The association of comorbid depression with mortality and amputation risk in patients with chronic limb-threatening ischemia.

OBJECTIVE: There is increasing evidence that depression is a risk factor for worse outcomes in patients with peripheral artery disease. The association of depression in patients with chronic limb-threatening ischemia (CLTI) is not well described, nor is the impact of medical treatment for depression in this patient population. The objective of this study was to investigate the prevalence of depression in patients with CLTI, its association on major amputation and all-cause mortality, and whether medical antidepressant treatment is associated with improvement in these outcomes in patients with depression. METHODS: A retrospective review of all adult patients (≥18 years old) diagnosed with CLTI from January 1, 2007, to December 31, 2018, at a single academic medical center was performed. Collected data included patient demographics, comorbidities, and diagnosis of depression within 6 months of initial CLTI diagnosis. We also collected data on use of antidepressant medications. Outcomes evaluated were need for major lower extremity amputation and all-cause mortality. Multivariable logistic regression models estimated the adjusted effects of comorbid depression and antidepressant medication use on major amputation and all-cause mortality. Kaplan-Meier survival curves illustrated the probabilities of survival and limb salvage over time, stratified by diagnosis of comorbid depression. Multivariable Cox proportional hazards models estimated the adjusted effects of comorbid depression on time to major amputation and all-cause mortality, and the adjusted effect of antidepressant treatment on time to all-cause mortality. RESULTS: A total of 2987 patients with CLTI were identified. Mean age was 68.6 years (standard deviation, 12.9 years); 56.5% were male, and 43.5% were female. Comorbid depression within 6 months of CLTI diagnosis was present in 7.1% of the cohort (212 patients). In multivariable analysis, comorbid depression was associated with a 68% increase in the odds of major amputation (adjusted odds ratio [aOR], 1.68; 95% confidence interval [CI], 1.19-2.37; P < .01), a 164% increase in the odds of all-cause mortality among patients not taking antidepressants (aOR, 2.64; 95% CI, 1.31-5.32; P = .03), and only a 6% increase in the odds of all-cause mortality among patients taking antidepressants (aOR, 1.06; 95% CI, 0.72-1.55; P = .99). The effect of comorbid depression on mortality varied significantly by whether or not the patient was taking an antidepressant medication (P = .02). CONCLUSIONS: Comorbid depression in the patient population with CLTI is associated with a worse prognosis for major lower extremity amputation overall, and a worse prognosis for all-cause mortality among patients not taking an antidepressant. Furthermore, antidepressant treatment in the presence of comorbid depression in this patient population is associated with an improvement in the odds of all-cause mortality, illustrating the potential importance of medical management of depression.

Fourth-Year Medical Students' Perceptions of Vascular Surgery: Can We Improve the Pipeline?

BACKGROUND: Since their inception, Integrated Vascular Surgery Residency (IVSR) programs have expanded widely and attracted highly competitive medical students by offering a more focused approach to learning both open surgical and endovascular techniques. However, despite substantial modifications to the training paradigm, a shortage of vascular surgeons is still projected through 2050. We aimed to gather and analyze fourth-year medical students' knowledge and perceptions of vascular surgery (VS) to further inform strategies for recruiting future vascular surgeons. METHODS: We sent anonymous electronic questionnaires to fourth-year medical students at 7 allopathic and 3 osteopathic medical schools, with questions detailing demographics, specialty preferences, and exposure to and perceptions of VS. Descriptive statistics were obtained, and responses were compared between students applying to surgical specialties (SS) and nonsurgical specialties (NSS). RESULTS: Two hundred eleven of 1,764 (12%) participants responded (56% female). 56% reported VS exposure, most commonly during the third year. 64 (30%) planned to apply to SS. 57% of respondents reported knowledge of the management of vascular disease, and 56% understood procedures performed by vascular surgeons. Ranking the importance of factors in choosing specialties, SS selected "experiences gained during medical school rotations" (P < 0.05), "types and/or variety of treatment modalities used in this field" (P < 0.001), and "interest in the pathology or disease processes treated" (P < 0.05) as highest priorities. NSS preferred "lifestyle (work-life balance) as an attending" (P < 0.001). Only 7% of all respondents believed vascular surgeons have a good work-life balance, with a larger percentage of SS (P < 0.001) agreeing. Stratified by gender, female students rated "limited ability of childbirth during residency and/or postponement of family plans" (P < 0.05), "gender-related concerns, such as discrimination at work or unfair career possibilities" (P < 0.001), and "fear of unfair competition" (P < 0.05) as potential negative aspects of VS careers. 55% of respondents believed the IVSR makes VS more appealing. CONCLUSIONS: Medical students perceive poor quality of life and work-life balance as deterring factors to a career in VS. Opportunities exist to educate students on the pathologies treated, procedures performed, and attainable quality of life available in our field. We should also continue to develop recruitment strategies to stimulate student interest and increase early exposure in VS.

The Impact of Perioperative Morbidities, Lack of Discharge Aspirin, and Lack of Discharge Statin on Long Term Survival Following EVAR.

OBJECTIVE: Adverse perioperative events and discharge medications both have the potential to impact survival following endovascular abdominal aortic aneurysm repair (EVAR). We hypothesize that variables such as blood loss, reoperation in the same hospital admission, and lack of discharge statin/aspirin have significant effect on long term survival following EVAR. Similarly, other perioperative morbidities, are hypothesized to affect long term mortality. Quantifying the mortality effect of perioperative events and treatment emphasizes to physicians the critical nature of preoperative optimization, case planning, operative execution and postoperative patient management. METHODS: All EVAR in the Vascular Quality Initiative between 2003 and 2021 were queried. Exclusions were: ruptured/symptomatic aneurysm; concomitant renal artery or supra-renal intervention at the time of EVAR; conversion to open aneurysm repair at the time of initial operation; and undocumented mortality status at the 5 year mark postoperatively. 18,710 patients met inclusion criteria. Multivariable Cox regression time dependent analysis was performed to investigate the strength of mortality association of the exposure variables. Standard demographic variables and pre-existing major co-morbidities were included in the regression analysis to account for disproportionate, deleterious co-variables amongst those experiencing the various morbidities. Kaplan-Meier survival analysis was performed to provide survival curves for the key variables. RESULTS: Mean follow up was 5.99 years and 5-year survival for included patients was 69.2%. Cox regression revealed increased long term mortality to be associated with the following perioperative events: reoperation during the index hospital admission (HR 1.21, P = .034), perioperative leg ischemia (HR 1.34, P = .014), perioperative acute renal insufficiency (HR 1.24, P = .013), perioperative myocardial infarction (HR 1.87, P < .001), perioperative intestinal ischemia (HR 2.13, P < .001), perioperative respiratory failure (HR 2.15, P < .001), lack of discharge aspirin (HR 1.26, P < .001), and lack of discharge statin (HR 1.26, P < .001). The following pre-existing co-morbidities correlated with increased long term mortality (P < .001 for all) : body mass index under 20 kg/m2, hypertension, diabetes, coronary artery disease, reported history congestive heart failure, chronic obstructive pulmonary disease, peripheral artery disease, advancing age, baseline renal insufficiency and left ventricular ejection fraction less than 50%. Females were more likely to have EBL >300 mL, reoperation, perioperative MI, limb ischemia and acute renal insufficiency than males (P < .01 for all). Female sex trended but was not associated with increased long term mortality risk (HR 1.06, 95% CI .995-1.14, P = .072). CONCLUSIONS: Survival after EVAR is improved with optimal operative planning to facilitate evading the need for reoperation and ensuring patients without contra-indication are discharged with aspirin and statin medications. Females and patients with pre-existing co-morbidity are at particularly higher risk for perioperative limb ischemia, renal insufficiency, intestinal ischemia and myocardial ischemia necessitating appropriate preparation and preventative measures.

Investigation of Renal Decline and New Onset Dialysis Following Endovascular Aneurysm Repair in the Vascular Quality Initiative.

INTRODUCTION: The purpose of this study is to identify variables significantly associated with renal function decline after elective endovascular infra-renal abdominal aortic aneurysm repair and to identify the rate and risks of subsequent progression to dialysis. Specifically, we investigate the long-term impact of supra-renal fixation, female gender, and physiologically stressful perioperative events on renal function following endovascular aneurysm repair (EVAR). METHODS: Review of all EVAR cases in the Vascular Quality Initiative between 2003 and 2021 was conducted to investigate variable associations with three primary outcomes: postoperative acute renal insufficiency (ARI); greater than 30% decline in glomerular filtration rate (GFR) in patients beyond 1 year of follow up; and new onset dialysis requirement at any point in follow up. Binary logistic regression analysis was performed for the events of acute renal insufficiency and new onset dialysis requirement. Cox proportional hazard regression was performed regarding long term GFR decline. RESULTS: Postoperative ARI occurred in 3.4% (1692/49 772) of patients. Significant (P < .05) association with postoperative ARI was noted for: age (OR 1.014/year, 95% CI 1.008-1.021); female gender (OR 1.44, 95% CI 1.27-1.67); hypertension (OR 1.22, 95% CI 1.04-1.44); chronic obstructive pulmonary disease (OR 1.34, 95% CI 1.20-1.50); anemia (OR 4.24, 95% CI 3.71-4.84); reoperation at index admission (OR 7.86, 95% CI 6.47-9.54); baseline renal insufficiency (OR 2.29, 95% CI 2.03-2.56); larger aneurysm diameter; increased blood loss; and higher volumes of intra-operative crystalloid. Risk factors (P < .05) correlating with a decline of 30% in GFR at any time beyond 1 year were: female gender (HR 1.43, 95% CI 1.24-1.65); body mass index (BMI) less than 20 (HR 1.34, 95% CI 1.03-1.74); hypertension (HR 1.38, 95% CI 1.15-1.64); diabetes (HR 1.34, 95% CI 1.17-1.53); COPD (HR 1.21, 95% CI 1.07-1.37); anemia (HR 1.92, 95% CI 1.52-2.42); baseline renal insufficiency (HR 1.31, 95% CI 1.15-1.49); absence of discharge ace-inhibitor (HR 1.27, 95% CI 1.13-1.42); long term re-intervention (HR 2.43, 95% CI 1.84-3.21) and larger AAA diameter. Patients who experienced long term GRF decline had a significantly higher long-term morality. New onset dialysis following EVAR occurred in .47% (234/49 772) of those meeting inclusion criteria. Higher rate (P < .05) of new onset dialysis was associated with age (OR 1.03/year, 95% CI 1.02-1.05); diabetes (OR 1.376, 95% CI 1.005-1.885); baseline renal insufficiency (OR 6.32, 95% CI4.59-8.72); Reoperation at index admission (OR 2.41, 95% CI 1.03-5.67); postoperative ARI (OR 23.29, 95% CI 16.99-31.91); absence of beta blocker (OR 1.67, 95% CI 1.12-2.49); long term graft encroachment on renal arteries (OR 4.91, 95% CI 1.49-16.14). CONCLUSIONS: New onset dialysis following EVAR is a rare event. Perioperative variables influencing renal function following EVAR include blood loss, arterial injury, and reoperation. Supra-renal fixation is not associated with postoperative acute renal insufficiency or new onset dialysis in long term follow up. Renal protective measures are recommended for patients with baseline renal insufficiency undergoing EVAR as acute renal insufficiency following EVAR portends a 20-fold increased risk of new onset dialysis in long term follow up.

Risk Factors Associated with Spinal Cord Ischemia During Aortic Aneurysm Repair.

BACKGROUND: The risk of spinal cord ischemia (SCI) with aortic aneurysm repair can cause significant neurological morbidity. Prevention of SCI is critical. We sought to identify risk factors that predispose to SCI that may guide strategies to mitigate the occurrence of SCI during and following these procedures. METHODS: This study includes all adults who underwent atraumatic, unruptured, thoracic, and suprarenal aortic aneurysm repairs (endovascular or open) at our institution over 11 years (2010-2020). Our database included patient demographics, aneurysm anatomic features, and operative characteristics and an extreme gradient boost (XGB) machine method was used to develop a predictive model for SCI. The model was trained on an 80% randomly stratified cohort of the data and tested on the remaining 20% testing cohort. Shapley values were used to determine the most important predictive factors of SCI and decision trees were used to identify risk factor threshold values and highest risk factor combinations. RESULTS: Information was collected for 174 adult patients undergoing thoracic and suprarenal aortic repair from 2010 to 2020. Fifty eight percent of the patients were male. Ninety seven (55.7%) patients had open aortic repair and 87 (44.3%) had endovascular repair. Twenty seven (15%) of all patients had major complications and were considered to have SCI. The XGB model converged over the training cohort with a testing cohort accuracy of 0.841 [Sensitivity = 75%, Specificity = 68%] and area under the curve of receiver operating characteristic of 0.774. The XGB model identified older age (> 65 years), history of neurologic disease, hyperlipidemia, diabetes, coronary artery disease, heart failure, poor renal function, < 6 months since last aortic repair, chronic anticoagulant use, preoperational anemia (Hemoglobin < 9), thrombocytopenia (platelet < 90,000), coagulopathy (prothrombin time > 15s and activated partial thromboplastin time > 40s), hypotension (mean arterial pressure < 70 mm Hg), longer operations (> 100 min), aneurysms longer than 5 cm, and anatomic location of aneurysm caudal to T-11 as risk factors for SCI in all types of aortic repair. Diabetic and heart failure patients undergoing longer operations (> 100 min) with thrombocytopenia or aneurysms longer than 5 cm were at the highest risk. CONCLUSIONS: The XGB model accurately identified risk factors of SCI with aortic aneurysm repair that may guide patient selection, timing of surgery, and strategies to minimize the risk of SCI.

Extent of mural thrombus is not associated with increased 5-year mortality following elective AAA repair.

BACKGROUND: Mural thrombus in abdominal aortic aneurysm (AAA) has been associated with increased rates of aneurysm growth as well as adverse cardiovascular events. The extent of mural thrombus in thoracoabdominal aortic aneurysms has recently been linked to 1-year mortality following endovascular repair and has been hypothesized as a marker for reduced cardiac reserve. This study investigates whether the extent of mural thrombus in infra-renal AAA is associated with 5-year mortality following elective repair. METHODS: Retrospective review of all patients undergoing elective infra-renal AAA repair at a single academic medical center between 2007 and 2016 was performed. The following variables at the time of surgery were investigated for association with 5-year mortality: age, sex, ethnicity, insurance status and co-morbidities, repair type, renal insufficiency, end-stage renal disease on dialysis, history of smoking, coronary artery disease, congestive heart failure, diabetes mellitus, hypertension, stroke, chronic obstructive pulmonary disease, body mass index category, AAA diameter, and ratio of aortic thrombus to total aneurysm diameter. RESULTS: Amongst 427 patients undergoing infra-renal AAA repair during the study period, 232 met extensive inclusion criteria. Univariate analysis found mean age (76 vs 72, p < 0.01), age cohort over 72 years (OR = 1.9, p = 0.04), renal insufficiency (OR = 3.1, p < 0.01), ESRD (OR = 6.5, p < 0.01), AAA diameter 6 cm or greater (OR = 2.3, p < 0.01), and mean AAA diameter (61.36 vs 56.99 mm, p < 0.01) all predictive of 5-year mortality. Multivariate analysis revealed renal insufficiency (p < 0.01) and AAA diameter 6 cm or greater (p = 0.03) to be significantly associated with 5-year mortality. The extent of mural thrombus was identical between 5-year survivors and non-survivors. The mean inner to outer AAA diameter was 0.65 in the survivor cohort and 0.64 in the mortality cohort. Inner to outer ratio of < 0.5 was identified in 23% of 5-year survivors and 27% of the mortality group. CONCLUSIONS: In our experience, the extent of mural thrombus in AAA does not influence long-term survival after elective repair. AAA repair may provide protection against circulating components of mural thrombus which have the potential to promote atherosclerotic-related adverse events. Patients with renal insufficiency and larger AAA have increased risk of mortality 5 years after elective repair.

The Effect of Smoking Status on Perioperative Morbidity and Mortality after Open and Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: This study quantifies the extent to which active tobacco smoking is deleterious toward outcomes following open and endovascular abdominal aortic aneurysm (AAA) repair. METHODS: Open and endovascular AAA repairs between January 2003 and June 2020 in the Vascular Quality Initiative were queried. Rupture, symptomatic status, and lack of 90 day follow-up were exclusions. Patients were then placed into 1 of 6 groups: open AAA with active smoking (n = 3,788), open AAA with prior smoking (n = 4,614), open AAA never smokers (817), endovascular AAA active smokers (n = 14,173), endovascular AAA former smokers (n = 25,831), and endovascular AAA never smokers (n = 6,064). Comparison of baseline characteristics, comorbidities, and adverse outcomes across each of the 6 cohorts was performed with open AAA in active smokers serving as the reference. Subanalysis investigating open AAA repair in active smokers relative to open AAA in patients confirmed in Vascular Quality Initiative to have quit smoking between 30 and 90 days before surgery was performed. Smoking cessation for a minimum of 30 days before surgery was required to fall into the former smoker category. RESULTS: In comparing open AAA in active smokers to open AAA in former and never smokers, the active smokers experienced significantly higher rates of pneumonia (P < 0.001). Combined additive morbidity and mortality was highest (54%) in active smokers (P < 0.001) relative to all cohorts other than open AAA former smokers (P = 0.21). Smoking status did not impact morbidity or mortality incidence across individuals undergoing endovascular aneurysm repair. Binary logistic regression for all AAA patients (open and endovascular combined) revealed those with any history of smoking to be more likely to experience 90 day mortality (adjusted odds ratio [OR] 2.5 [2.2-2.9], P < 0.001) relative to never smokers. Active smokers were similarly more likely to experience 90 day mortality than prior/never smokers combined (OR 1.23 [1.07-1.38], P < 0.001). Mortality within 90 days was significantly more likely (P < 0.001) with aging, female gender, larger aneurysms, preoperative history of congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, peripheral artery disease, and body mass index less than 20 and more than 35 mg/kg2. Diabetes and coronary artery disease were also associated with 90 day mortality (P = 0.045 and 0.049, respectively). Quitting smoking between 30 and 90 days before open repair reduced combined additive morbidity and mortality relative to active smokers (OR 1.34, P = 0.038). CONCLUSIONS: Smoking cessation 30 days before open AAA repair reduces perioperative morbidity and mortality. Smoking status does not impact morbidity and mortality in patients undergoing endovascular AAA repair. When combining all patients (open and endovascular), higher rates of 90 day mortality are associated with any history of smoking, aging, female gender, and advanced pre-existing comorbidities on a multivariable analysis.

Dual true and false lumen stent graft technique for endovascular repair of isolated common iliac artery aneurysm in chronic type A10 dissection.

A 52-year-old man presented with a chronic type A10 aortic dissection with subsequent aneurysmal degeneration of the left common iliac artery measuring up to 4.6 cm. He had previously undergone hemiarch replacement, which was complicated by renal failure. Owing to the presence of the growing aneurysm, he was unable to be listed for renal transplantation. He declined open operative repair. A novel dual true and false lumen stent graft technique using thoracic endografts was performed to successfully exclude the aneurysm. Follow-up imaging demonstrated aneurysm sac regression, with the patient subsequently undergoing renal transplantation.

Lumbar Drains for Vascular Procedures: An Institutional Protocol Review and Guidelines.

BACKGROUND: Aortic disease requiring open or endovascular repair may result in spinal cord injury in approximately 2%-10% of patients. Cerebrospinal fluid diversion using lumbar drains (LDs) has been validated as a protective measure to mitigate this complication. METHODS: This single-institution retrospective study analyzed the implementation of a standardized protocol and subsequent educational intervention for LDs for aortic vascular procedures over a 4-year period. RESULTS: In 2016-2019, 45 patients had LDs placed for open or endovascular procedures; group 1 included 19 patients with LDs placed before protocol implementation, and group 2 included 26 patients with LDs placed as per the institutional protocol. Demographics and procedural details in both groups were similar. However, there was a significant difference in the number of patients who had emergent versus planned placement of the LD (group 1, 89.5%; group 2, 50%; P < 0.01), volume of cerebrospinal fluid drained (group 1, 453 mL; group 2, 197 mL; P < 0.01), and compliance with 10 mL/hour drainage recommendation (group 1, 68.4%; group 2, 100%; P < 0.01). In group 1, 5 (31.6%) patients experienced neurological complications compared with only 1 (3.8%) in group 2. LD-related complications occurred 3 patients (15.8%) in group 1, whereas none occurred in group 2. Survey results suggested increased health care worker protocol familiarity with educational interventions. CONCLUSIONS: Implementation of an institutional protocol for LDs for open or endovascular procedures is feasible and beneficial. Educational modules improve familiarity among all health care providers, which can improve patient care and complication avoidance.

Hypertrophic cranial pachymeningitis and orbital apex syndrome secondary to infection of the eye: illustrative case.

BACKGROUND: Hypertrophic cranial pachymeningitis is a rare inflammatory disorder characterized by thickening of the dura mater and multiple cranial neuropathies. Although an infectious etiology may be present, often no specific cause is discovered. OBSERVATIONS: The authors described a 71-year-old man with progressive right eye vision loss, ptosis, and complete ophthalmoplegia with imaging findings suggestive of hypertrophic cranial pachymeningitis. Extensive studies, including cerebrospinal fluid studies, showed negative results. Blood serum, cell-free evaluation, and paraffin-embedded dural tissue testing had positive results for Pseudomonas aeruginosa, which allowed treatment tailored to the organism and a salutary clinical outcome. LESSONS: The constellation of neurological and radiological findings may make a diagnosis difficult in an inflammatory setting. The most precise methodology for establishing a diagnosis involves sampling the dura and testing it for infectious pathology. However, if results are inconclusive, further cell-free serum sampling with next-generation sequencing is a viable option for identifying pathogens with infectious concerns. This case highlighted the importance of multimodality studies for identifying a targetable pathogen.