Sex Disparities in Arteriovenous Fistula Maturation Outcomes.

BACKGROUND: The end-stage kidney disease life-plan aims to individualize hemodialysis (HD) access selection in patients requiring renal replacement therapy. Paucity of data on risk factors for poor arteriovenous fistula (AVF) outcomes limits the ability of physicians to guide their patients on this decision. This is especially true for female patients, who are known to have worse AVF outcomes when compared to male patients. The goal of this study was to identify risk factors associated with poor AVF maturation outcomes in female patients that will help guide individualized access selection. METHODS: A retrospective review of 1,077 patients that had AVF creation between 2014 and 2021 at an academic medical center was performed. Maturation outcomes were compared between 596 male and 481 female patients. Separate multivariate logistic regression models were created for the male and female cohorts to identify factors associated with unassisted maturation. AVF was considered mature if it was successfully used for HD for 4-week sessions without need for further interventions. Unassisted fistula was defined as an AVF that matured without any interventions. RESULTS: The male patients were more likely to receive more distal HD access; 378 (63%) male versus 244 (51%) female patients had radiocephalic AVF, P < 0.001. Maturation outcomes were significantly worse in female patients; 387 (80%) AVFs matured in females and 519 (87%) in male patients, P < 0.001. Similarly, the rate of unassisted maturation was 26% (125) in female patients versus 39% (233) in male patients, P < 0.001. Mean preoperative vein diameters were similar in both groups; 2.8 ± 1.1 mm in male versus 2.7 ± 0.97 mm in female patients, P = 0.17. Multivariate logistic regression analysis of the female patients revealed that Black race (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.4-0.9, P = 0.045), radiocephalic AVF (OR: 0.6, 95% CI: 0.4-0.9, P = 0.045), and preoperative vein diameter <2.5 mm (OR: 1.4, 95% CI: 10.33-0.901.1-1.7, P = 0.014) were independent predictors of poor unassisted maturation in this cohort. In male patients, preoperative vein diameter <2.5 mm (OR: 1.4, 95% CI: 1.2-1.7, P < 0.001) and need for HD prior to AVF creation (OR: 0.6, 95% CI: 0.3-0.9, P = 0.018) were independent predictors of poor unassisted maturation. CONCLUSIONS: Black women with marginal forearm veins may have worse maturation outcomes, and upper arm HD access should be considered when advising patients on their end-stage kidney disease life-plan.

Early Follow-Up after Arteriovenous Fistula Creation is Associated with Improved Access-Related Outcomes.

BACKGROUND: Up to 60% of arteriovenous fistulas (AVF) require intervention to assist maturation, which prolongs the time until it can be used for hemodialysis (HD). Current guidelines recommend early postoperative AVF examination to detect and address immaturity to decrease time to maturation. This study evaluates how the timing of postoperative follow-up to assess AVF maturity affects patients' outcomes. METHODS: All patients who underwent AVF creation between 2017 and 2021 in an academic medical center were retrospectively reviewed, excluding patients lost to follow-up or not on HD. Outcomes were compared between patients that had delayed follow-up to assess AVF maturity, >8 weeks post surgery, versus early follow-up, <8 weeks post-surgery. AVF evaluation for maturity consisted of physical examination and duplex ultrasound. Primary endpoints were time to first cannulation (interval from AVF creation to first successful cannulation) and time to catheter-free dialysis (interval from AVF creation to central venous catheter removal). RESULTS: A total of 400 patients were identified: 111 in the delayed follow-up group and 289 in the early follow-up group. The median time to follow-up was 78 days (interquartile range [IQR], 66-125) in the delayed follow-up group versus 39 days (IQR, 36-47) in the early follow-up group, (P < 0.0001). The maturation rate was 87% in the delayed follow-up group versus 81% in the early follow-up group, (P = 0.1) and both groups had similar rates of interventions to assist maturation (66% vs. 57%, P = 0.2). The early follow-up group had a significantly shorter median time to first cannulation (50 vs. 88 days; P < 0.0001) and shorter time to catheter-free HD (75 vs. 118 days; P <0.0001). At 4 months after AVF creation, the incidence of first cannulation was 74% in the early follow-up group versus 63% in the delayed follow-up group (P = 0.001). Similarly, the incidence of catheter-free dialysis was 65% in the early follow-up group versus 50% in the delayed follow-up group at 4 months postoperatively, (P = 0.036). CONCLUSIONS: Early postoperative follow-up for evaluation of fistula maturation is associated with reduced time to first successful cannulation of AVF for HD and reduced time to catheter-free dialysis.

Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia.

OBJECTIVES: Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality. METHODS: A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed. RESULTS: The mean patient age was 69 ± 17 years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10 years) as independent predictors of perioperative mortality. CONCLUSIONS: Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.

Hemodynamic instability in the immediate postoperative setting after transcarotid artery revascularization.

OBJECTIVE: Transcarotid artery revascularization (TCAR) is a relatively recent development in the management of carotid artery occlusive disease, the utilization of which is becoming more prevalent. This study aims to evaluate the timing, prevalence, and types of hemodynamic instability after TCAR. METHODS: We performed a retrospective review of all TCAR procedures performed at two tertiary care academic medical centers within a single hospital system from 2017 through 2019. Demographics, comorbidities, preoperative patient factors, procedural details, and postoperative data were collected. Patients were assessed over 24 hours postoperatively for stroke, death, myocardial infarction (MI), and hemodynamic instability at 3, 6, 9, 12, and 24 hour intervals. Hemodynamic instability was defined as any vital sign abnormality which required pharmacological intervention with antihypertensive, vasopressor, and/or anti-arrhythmic agents. The incidence and timing of postoperative complications and hemodynamic instability were recorded. RESULTS: During the study period, 76 patients 80 TCAR procedures. Out of 80 procedures, 64 (80.0%) were receiving home antihypertensive medication and 28 (35.0%) were symptomatic lesions preoperatively. Intraoperatively, one patient (1.3%) received atropine, 26 (32.5%) received glycopyrrolate, 76 (95%) underwent predilatation, and 16 (20.0%) underwent postdilatation. Postoperatively, a total of 22 cases (27.5%) required medication for acute control of blood pressure or heart rate, which reached a peak of 19 patients (23.8%) within the first 3 hours, and tapered to nine patients (11.3%) by the 24 hour mark. A total of three patients (3.75%) required initiation of pharmacological management after the three-hour mark. Six patients (7.5%) underwent stroke code workup, 4 (5.0%) of whom were confirmed to have stroke on CT. Average time to neurologic event was 3.9 hours. No patients experienced MI or death. Median ICU and hospital days for unstable patients were two and three, respectively, compared to one and one for stable patients. CONCLUSIONS: Hemodynamic instability is common after TCAR and reliably presents at or before postoperative hour 3. Hypo- followed by hyper-tension were the most common manifestations of hemodynamic instability. Regardless, unstable patients and stroke patients were more likely to require longer periods of time in the ICU and in the hospital overall. This may have implications for postoperative ICU resource management when deciding to transfer patients out of a monitored setting. Further study is required to establish relationships between pre- and intra-operative risk factors and outcomes such as hemodynamic instability and/or stroke. At present, one should proceed with careful evaluation of preoperative medications, strict management of postoperative hemodynamics, and clear communication among team members should all be employed to optimize outcomes.

Reducing lower extremity hospital-acquired pressure injuries: a multidisciplinary clinical team approach.

OBJECTIVE: Optimal methods of reducing incidence of hospital-acquired pressure injuries (HAPIs) remain to be determined. We assessed changes in yearly incidence of lower extremity HAPIs before and after an intervention aimed at reducing these wounds. METHOD: In 2012, we implemented a three-pronged intervention to reduce the incidence of HAPIs. The intervention included: a multidisciplinary surgical team; enhanced nursing education; and improved quality data reporting. Yearly incidence of lower extremity HAPIs was tracked. RESULTS: Pre-intervention, incidence of HAPIs was 0.746%, 0.751% and 0.742% in 2009, 2010 and 2011, respectively. Post-intervention, incidence of HAPIs was 0.002%, 0.051%, 0.038%, 0.000% and 0.006% in 2013, 2014, 2015, 2016 and 2017, respectively. Mean incidence of HAPIs was reduced from 0.746% before the intervention to 0.022% after the intervention (p<0.001). CONCLUSION: An intervention by a multidisciplinary surgical team enhanced nursing education, and improved quality data reporting reduced the incidence of lower extremity HAPIs.

The effect of nutrition on stroke risk: A systematic review.

Background: An estimated 33% reduction in cardiovascular events can be achieved when incorporating whole grains, fruits, vegetables, poultry, nuts, and vegetable oils in the diet along with reduced consumption of refined carbohydrates, processed meats, and sugar sweetened beverages. We performed a systematic review to analyze the impact of nutritional intervention on stroke risk, as there is no current consensus concerning dietary recommendation for primary and secondary stroke prevention. Methods: A literature search of the PubMed database from January 2010 to June 2020 was performed using combinations of the following search terms: carotid disease, carotid artery disease, carotid stenosis, carotid intima-media thickness (CIMT), diet, nutrition, micronutrition, embolic stroke, and stroke. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 checklist. Results: 28 studies met our inclusion criteria. Multiple studies showed an inverse relationship between consumption of vegetables and fruits and stroke risk. Vitamin B12 or a combination of B Vitamins was the most common supplement studied in stroke prevention. Only one RCT showed the use of B12 (500 micrograms/day) correlated with lower CIMT at follow up in healthy vegetarians. Discussion: The key findings from this systematic review indicate that adopting a diet rich in fruits and vegetables earlier in life may lower stroke risk compared with meats and fat intake. B vitamins also appear to confer some protection against stroke. However, not enough data exists to support the use of multivitamins, calcium, soy products and other supplements for primary or secondary stroke prevention.

The Role of Duplex Ultrasound in Assessing AVF Maturation.

BACKGROUND: Arteriovenous fistulas (AVFs) are favored for hemodialysis (HD) access. However, in many instances, AVFs fail to mature. We examined the utility of postoperative color duplex ultrasound (CDU) in assessing AVF maturation and determining the need for balloon-assisted maturation (BAM). METHODS: A total of 633 patients underwent AVF creation at a single institution from 2015 to 2018. A total of 339 patients (54%) underwent CDU at a median of 8 weeks postoperatively. We collected the following parameters: vein diameter, volume flow (VF), peak systolic velocities in arterial inflow and venous outflow, and presence of stealing branches. A peak systolic velocity ratio (SVR) of ≥2 correlated with ≥50% stenosis in venous outflow, and SVR ≥3 correlated with ≥50% stenosis at the anastomosis. AVFs were considered mature when they were successfully cannulated on dialysis. A generalized linear mixed model (GLMM) was created to compare duplex criteria associated with successful use of AVF (maturation) to those AVFs that required further intervention or failed to mature. Fistulography images, the current gold standard, were compared with findings from CDU studies to determine validity of the duplex ultrasound. RESULTS: Of the 339 AVFs with postoperative CDU, 31.3% matured without interventions, 38.3% required BAM, 9.7% thrombosed, and the remaining patients were not yet on HD. Based on GLMM analysis, the probability of AVF maturation increases if CDU demonstrated one of the following: the vein diameter is ≥ 6 (odds ratio [OR] = 38.7), no evidence of stenosis in the venous outflow tract (OR = 35.6), no stealing branches (OR = 21.6) and VF ≥ 675 (OR = 5.0). Fistulography was performed in 195 patents. Sensitivity and specificity for each are as follows: vein diameter (84.3%, 28.6%), stenosis (59.3%, 78.8%), and stealing branches (20.7%, 92.7%). CONCLUSIONS: Postoperative CDU should be considered routine to correct anatomical findings that might limit AVF maturation and identify the need for further interventions.

Anatomically Coiled Internal Carotid Artery Resulting in Severe Dysphagia and Burning Mouth Syndrome.

This is a report of a 65-year-old female presenting with symptoms of dysphagia due to a coiled left internal carotid artery, treated with resection and primary repair. Dysphagia lusoria is more commonly caused by aortic arch anomalies, aberrant subclavian or common carotid arteries. Internal carotid tortuosity as a cause of severe dysphagia and burning mouth syndrome is highly unusual. A literature review examines the etiology, natural history, and treatment options.

Maturation Rates of Arteriovenous Fistulas Using Small Veins in the Era of Endovascular Interventions.

BACKGROUND: Traditional practice suggests the abandonment of veins smaller than 3 mm in diameter for arteriovenous fistula (AVF) creation because of a low rate of maturation. This study aims to show that with balloon-assisted maturation (BAM), undersized veins can be used to create functional AVFs with a high rate of success. METHODS: All patients who underwent AVF creation between 2014 and 2018 at a tertiary academic medical center were retrospectively reviewed. The patients without preoperative vein mapping, those who failed to follow-up, and the patients who were not on dialysis were excluded. A fistula was considered to be mature if it was successfully cannulated for dialysis. A total of 596 patients were identified for analysis. The cohort was divided into the small-vein group (SVG, <2.5 mm) and large-vein group (LVG, ≥2.5 mm) based on preoperative vein size. Categorical variables were analyzed with the chi-squared test for their association with maturation status. Continuous variables were analyzed with the Wilcoxon rank sum test. A P-value less than 0.05 was considered significant. RESULTS: In the study cohort, 61.9% of the patients were male, with an average age of 62.8 ± 13.7 years, and an average preoperative vein size of 2.9 ± 1.1 mm. With similar demographic distribution, the participants in the SVG (n = 216) had significantly smaller preoperative vein size of 1.9 ± 0.4 mm than the patients in the LVG (n = 380), 3.5 ± 0.8 mm (P = 0.001). There were significantly more radio-cephalic AVFs created in the SVG (77.8% versus 48.7%, P < 0.0001). The overall maturation rate was 83.1% (n = 495), 219 fistulas (36.7%) matured primarily and 276 (46.3%) required interventions. Ninety-one percent of the patients required only 1 or 2 BAMs to achieve maturation. The SVG achieved a maturation rate of 75.9% as compared with 87.1% in the LVG (P = 0.002). A significantly higher number of patients in the SVG required BAM for maturation as compared with the LVG (67.7% versus 49.9%, P = 0.0002); however, there was no difference in the average number of BAMs required for fistula maturation between the groups (1.5 ± 0.8 for the SVG vs. 1.4 ± 0.7 for the LVG). In multivariable logistic regression analysis, vein size ≥2.5 mm (odds ratio (OR) = 2.11, confidence interval (CI): 1.36-3.27, P = 0.0009) and male sex (OR = 2.30, CI: 1.49-3.57, P = 0.0002) were independent predictors of maturation. CONCLUSIONS: Small veins can be used for AVF creation with lower but still favorable maturation rates using BAM interventions, especially in male patients. This practice can increase the creation of autogenous dialysis access and potentially reduce complications related to prosthetic dialysis access.

Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

Maximizing proximal seal zone in fenestrated endografting: Evolution in the approach to graft configuration.

OBJECTIVE: Fenestrated endografting for juxtarenal and pararenal abdominal aortic aneurysms affords the ability to seal stent grafts in normal aorta at and above the renal arteries. The Zenith fenestrated graft (ZFEN; Cook Medical, Bloomington, Ind) is custom-made to surgeon specifications, subject to certain manufacturing limitations. The most common configuration in the pivotal trial and in commercial use after approval has been as a scallop for the superior mesenteric artery (SMA) and two small fenestrations for the renal arteries (configuration A). An alternative configuration to maximize the seal zone length, consisting of a large fenestration for the SMA and two small fenestrations for the renal arteries (configuration B) has been routinely adopted at our institutions to potentially prevent type IA endoleak. METHODS: The present retrospective cohort study examined 100 consecutive ZFEN grafts designed for patients at two university centers from 2012 through 2019. The proximal seal length, measured from the top of the graft to the beginning of the aneurysm, was determined from the preoperative computed tomography angiograms. Alternative configurations were evaluated to determine whether they would have provided a longer proximal seal length. RESULTS: The two most common configurations were B (n = 45) and A (n = 38). For the cases in which A had been chosen but B could have been built, 5.8 ± 1.9 mm of seal zone length was lost. For the cases in which B was chosen but A could have been built, 5.8 ± 2.8 mm of seal zone length was gained. Owing, in part, to the increased proximal seal length with configuration B, this configuration has been used more frequently in the past 4 years of the present study compared with the first four (53% vs 25%; P = .004). Of 95 patients who had completed surgery and follow-up, type IA endoleaks were observed in 12 (13%) on completion angiography, all of which had resolved on follow-up imaging without intervention. No SMA was compromised by misalignment of the large fenestration in configuration B. CONCLUSIONS: A significantly longer proximal seal length can be obtained using a ZFEN with a large fenestration for the SMA and two small fenestrations for the renal arteries. Whenever possible, surgeons should consider this configuration to maximize the proximal seal length and potentially reduce the risk of proximal endoleak. An additional advantage of this approach is that stenting of the SMA to prevent shuttering will be unnecessary or impossible, making the procedure more technically facile.

Infections of Prosthetic Grafts and Patches Used for Infrainguinal Arterial Reconstructions.

BACKGROUND: Prosthetic grafts are often used as alternative conduits in patients with peripheral vascular disease who do not have an adequate autologous vein for bypass. Prosthetic grafts, unfortunately, carry an increased risk of infection and are associated with increased morbidity and mortality. The goal of this study was to identify potential risk factors and subsequent outcomes associated with lower extremity prosthetic graft infections. METHODS: Two hundred seventy-two lower extremity prosthetic bypasses and patches were performed at an academic medical center between 2014 and 2016. A retrospective review of patients' demographics, comorbidities, indication for surgery, type of procedures performed, and procedural characteristics was conducted. Outcomes, including limb loss and mortality, were analyzed. RESULTS: Forty-three (15.8%) patients with graft infections were identified during a median follow-up of 668 days (interquartile range [IQR] = 588). The median time to graft infection was 43 days (IQR = 85) with Staphylococcus being the most common bacteria cultured. Infections were associated with a 30.2% rate of limb loss and a 34.9% rate of mortality. The risk of infection was 2.4 times greater among those with a history of redo surgery (95% confidence interval [CI] of the hazard ratio [HR]: 1.3, 4.3) and 2.1 times greater in women (95% CI: 1.1, 3.8), by multivariable statistics. A 1 g/dL increase in albumin level was associated with a 33.5% decrease in hazard of infection (HR: 0.67, 95% CI: 0.46, 0.96) in the multivariable model. The estimated cumulative incidence of infection for female patients with hypertension and mean albumin of 3.36 undergoing redo surgery was 19.4% at 30 days after surgery (95% CI: 10.6, 35.6) and 39.9% at 1 year (95% CI: 26.8, 59.3). CONCLUSIONS: Female gender, redo surgery, and malnutrition are associated with increased risk of prosthetic graft infections leading to a high rate of limb loss and mortality. Endovascular interventions and bypasses with vein conduits should be considered in these patients.

Improving the Power of the American Society of Anesthesiology Classification System to Risk Stratify Vascular Surgery Patients Based on National Surgical Quality Improvement Project-Defined Functional Status.

BACKGROUND: Recently published reports have shown that the American Society of Anesthesiology (ASA) classification system has limited applicability in vascular surgery patients. Most patients undergoing vascular procedures are designated as ASA class III, limiting discrimination in preoperative risk assessment. The 2006 National Surgical Quality Improvement Project (NSQIP), containing over 170,000 surgical cases, demonstrated that functional status is an important predictor of mortality. We propose that dividing ASA class III into 2 subgroups, based on NSQIP-defined functional status, improves the predictive value of the ASA scheme. METHODS: The 2006 NSQIP database was queried for ASA class III patients undergoing vascular surgery procedures. Patients were divided into groups IIIA and IIIB based on independent or dependent (partial or complete) functional status, respectively. Difference in 30-day survival between subgroups was evaluated using Kaplan-Meier and logistic regression analyses. Differences in postoperative morbidity and length of stay were compared using the unpaired t-test. RESULTS: ASA class III patients having undergone vascular surgery procedures numbered 11,555 (68%). Of those 9,913 (85.7%) patients were independent (IIIA), and 1,642 (14.3%) were dependent (IIIB). Mean 30-day mortality was 1.3% in subgroup IIIA, and 6.5% in IIIB (logrank P < 0.001, χ2, 137.8). Mean lengths of stay between subgroups IIIA and IIIB were 5.4 and 13.2 days (P < 0.001). The risk of NSQIP-defined postoperative complications was 0.16 in IIIA and 0.32 in IIIB (P < 0.001). CONCLUSIONS: A 5-fold difference in mortality was observed between patients who were functionally independent and dependent. A significant increase in length of stay and incidence of postoperative complications was also observed in subgroup IIIB. Subdividing ASA class III vascular surgery patients markedly improves the value of the ASA classification system. Given the "high-risk" nature of patients with vascular disease, the addition of functional status to the preoperative assessment will assist in predicting outcomes in this patient population.

Bilateral extracranial internal carotid artery aneurysms: Case report and review of literature.

This is a report of a 62-year-old male with bilateral extracranial internal carotid artery aneurysms, treated with resection, and interposition bypass. Bilateral presentation of carotid aneurysms is an uncommon finding in an already rare disease. We review the etiology, natural history, and treatment options.

The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry.

OBJECTIVE: Data on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS. METHODS: We evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes. RESULTS: There were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs. 4.2% for CEA), death (1.1% for CAS vs. 0.7% for CEA), stroke (2.1% for CAS vs. 3.1% for CEA), and MI (0.3% for CAS vs. 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs. 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs. 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs. 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs. 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs. 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs. 2.0%; P = .0095) and symptomatic (1.7% vs. 4.9%; P = .0012) patients. CONCLUSIONS: Although CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.

Intraoperative vascular mapping improves patient eligibility for arteriovenous fistula creation.

BACKGROUND: We assessed the utility of intraoperative vein mapping performed by the operating surgeon for evaluating vessel suitability for arteriovenous fistula (AVF) creation. METHODS: In a retrospective review of 222 AVFs, vein diameter measurements were compared between intraoperative and preoperative mapping in the same anatomical location. AVF creation was based on intraoperative vein diameter ≥2 mm, using a distal to proximal and superficial veins first approach. Potential selection of access type based on preoperative findings alone was analyzed. RESULTS: The mean diameter of the veins used for AVF creation measured 3.6 ± 0.8 mm on intraoperative duplex versus 2.5 ± 0.9 mm when the same veins were measured on preoperative duplex. Based on preoperative mapping alone, 23% of patients would have received a more proximal AVF and 5% would have needed a graft. AVFs created more distally based on intraoperative findings had similar maturation rates compared to the rest of the cohort, 79% versus 84% (p = 0.2). CONCLUSIONS: Intraoperative vein mapping can be used to evaluate vessel suitability for AVF and compared to pre-operative vein mapping may increase the eligibility of distal veins for fistula creation while reducing the need for AV grafts.

Transradial access for balloon-assisted maturation of arteriovenous fistulas.

Balloon-assisted maturation (BAM) of arteriovenous fistulas has conventionally been performed via direct fistula access. The transradial approach has not been well described for BAM, although its use has been reported throughout the cardiology literature. The purpose of the present study was to assess the outcomes of transradial access for its use with BAM. A retrospective review of 205 patients with transradial access for BAM was performed. One sheath was inserted into the radial artery distal to the anastomosis. We have described the procedural details, complications, and outcomes. The procedure was considered technically successful if transradial access had been established and the AVF had been ballooned with at least one balloon without major complications. The procedure was considered clinically successful if no further interventions had been required for AVF maturation. The average time for BAM via transradial access was 35 ± 20 minutes, with 31 ± 17 mL of contrast used. No access-related perioperative complications, including access site hematoma, symptomatic radial artery occlusion, or fistula thrombosis, had occurred. The technical success rate was 100%, and the rate of clinical success was 78%, with 45 patients requiring additional procedures to achieve maturation. Transradial access is an efficient alternative to trans-fistula access for BAM. It is technically easier and allows for better visualization of the anastomosis.

Lessons Learned: A Disruption in Care Leads to Increased Rates of Proximal Amputations.

BACKGROUND: In March 2020, due to the COVID-19 pandemic, hospitalizations in New York state were restricted to emergency purposes. Non-COVID related cases involving lower extremity wounds were only admitted for acute infections and limb salvage. Patients with these conditions were placed at higher risk for eventual limb loss. PURPOSE: To understand the impact of COVID-19 on amputation rates. METHODS: A retrospective review of lower limb institution-wide amputations was conducted at Northwell Health from January 2020 to January 2021. The amputation rates during the COVID-19 shutdown period were compared to the pre-pandemic, post-shutdown, and reopening period. RESULTS: The pre-pandemic period had 179 amputations, of which 8.38 % were proximal. 86 amputations were performed during shutdown, with a greater proportion being proximal (25.58 %, p=0.0009). Following the shutdown period, amputations returned to baseline. The proportion of proximal amputations during post-shutdown was 18.5 % and during reopening was 12.06 %. Patients had 4.89 times higher odds of undergoing a proximal amputation during the shutdown period. CONCLUSIONS: The effect of COVID-19 on amputation rates demonstrates an increase in proximal amputation during the initial shutdown. This study suggests an indirect negative effect of COVID-19 hospital restrictions on surgeries during the initial shutdown period.

Intraparotid facial varix.

A 72-year-old man had presented with a 4-day history of progressive left-sided facial swelling associated with pain. The physical examination revealed left facial fullness over the parotid gland without tenderness to palpation. His vital signs and laboratory test findings were within normal limits. A computed tomography scan demonstrated a left facial varix measuring 3.4 cm × 2.8 cm within an unremarkable-appearing parotid gland. Parotidectomy vs close observation were discussed, and the patient decided to pursue nonoperative management. Ultimately, his symptoms were self-limited, and the swelling had resolved within 6 months after the diagnosis. Interval computed tomography demonstrated a thrombosed left facial varix measuring 1.3 cm × 1.1 cm.

Acute aortic occlusion from a Candida fungus ball.

Fungal arterial infections are well-described entities resulting in direct invasion of the arterial wall or embolic occlusion of small and medium-sized arteries. However, acute occlusion of large vessels such as the aorta by fungal material is exceedingly rare. A 53-year-old woman presented with acute bilateral lower extremity ischemia. She had a history of fungal endocarditis requiring two prosthetic mitral valve replacements; the last episode was 7 months before the current admission. Imaging studies revealed that she had an acute infrarenal aortic occlusion, with evidence of multiple end-organ emboli. After transfemoral thromboembolectomy, perfusion was restored to her lower extremities with minor neurologic sequelae. She ultimately responded to intravenous antifungal agents.