Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions.

OBJECTIVE: Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set. METHODS: We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups. RESULTS: Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category. CONCLUSIONS: Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Creating hemodialysis autogenous access in children and adolescents.

OBJECTIVE: End-stage renal disease (ESRD) in childhood and adolescence is rare, with relatively few published reports of pediatric ESRD vascular access. This study analyzes a 10-year experience creating arteriovenous fistulas (AVFs) in children and adolescents. Our goal is to review our strategy for creating functional autogenous vascular access in younger patients and report our results. METHODS: We retrospectively reviewed data and outcomes for consecutive vascular access patients aged ≤19 years during a 10-year period. Each patient had preoperative vascular ultrasound mapping by the operating surgeon in addition to physical examination. A distal forearm radiocephalic AVF was the first access choice when feasible, and a proximal radial artery inflow AVF was the next option. Demographic data, inflow artery, venous outflow target, and required transposition vs direct AVFs were variables included in the analysis. Primary and cumulative patency were calculated by Kaplan-Meier analysis. RESULTS: Thirty-seven AVFs were created in 35 patients. No grafts were used. Ages were 6 to 19 years (mean, 15 years), and 20 were male. Causes of ESRD included glomerular disease (n = 18) and urinary obstruction or reflux (n = 7), among others. Three had previous AVFs, and 10 were obese. The proximal radial artery supplied AVF inflow in 25 patients and the brachial artery in only seven. Eleven individuals required a transposition and one a vein translocation to the contralateral arm. No patients developed hand ischemia, although two later required banding procedures for high flow. Eleven patients had successful transplants. A single patient died, unrelated to the vascular access. Five AVFs failed. Of these, two had new successful AVFs created, two regained renal function, one was transplanted, and one declined other procedures. Primary and cumulative patency rates were 75% and 85% at 12 months, 70% and 85% at 24 months, and 51% and 85% at 36 months, respectively. Median follow-up was 16 months. CONCLUSIONS: Creating an AVF for hemodialysis is a successful vascular access strategy for pediatric and adolescent patients. Proximal radial artery AVFs provided safe and functional access when a distal AVF was not feasible. Cumulative AVF patency was 85% at 36 months.

Vascular surgeons are positioned to fight healthcare disparities.

Comprehensively managing vascular disease in the United States can seem overwhelming. Vascular surgery providers encounter daily stress-inducing challenges, including caring for sick patients who often, because of healthcare barriers, struggle with access to care, socioeconomic challenges, and a complex medical system. These individuals can present with advanced disease and comorbidities, and many have limited treatment options. Subsequently, it could seem as if the vascular surgeon's efforts have little opportunity to make a difference. This review describes a method to counter this sentiment through directed action, hope, and community building. Vascular surgeons are passionate about what they do and are built to fight healthcare disparities. This review also outlines the reasoning for attempting to create change and one approach to begin making a difference.

Vascular Surgery Training Positions and Applicant 10-Year Trends with Consideration for Further Expansion.

BACKGROUND: There is a significant shortage of vascular surgeons in the United States and projections for these practicing surgical specialists continue to worsen. Annual appraisal of our workforce recruitment and growth is imperative. MATERIALS AND METHODS: Retrospective data were analyzed using the National Resident Matching Program from 2012-2022 applicant appointment years (specialty code for vascular surgery 450). Simple linear trend analysis was performed for the number of positions available and the number of applicants, stratified by fellowship or residency. RESULTS: Over the 10-year study period, the total vascular surgery trainee positions expanded from 161 to 202. Integrated residency positions increased (41 positions in 2012 vs. 84 in 2022) while available fellowship positions remained stagnant (120 in 2012 vs. 118 in 2022). Total applicants rose as well, from 213 to 311. In 2022, unmatched applicants have increased for both paradigms (25 fellowship and 84 residency applicants) and 100% of programs filled. On average, the number of residency positions offered increased by 4 each year (P < 0.0001) and the number of fellowship positions increased by 0.5 each year (P = 0.1617). The number of integrated residency applicants increased by approximately 9 per year (P = 0.001), while the number of fellowships applicants increased by approximately 1.5 per year (P = 0.121). CONCLUSIONS: Applicants for both vascular tracks have increased since 2012 indicating successful recruitment; however, all 2022 programs filled, leaving many applicants unmatched. Residency positions have continued to expand while fellowship positions have not. With the demonstrated surge among applicants, the disproportionate lack of increasing training positions, and the existing shortage of vascular surgeons, there is an urgency to meet the increasing demand. A concerted effort should be made toward adding additional residency and fellowship positions where feasible.

Community-engaged research in vascular surgery: An approach to decrease amputation disparities and effect population-level change.

Community-engaged research (CEnR) is a powerful tool to create sustainable and effective change in health outcomes. CEnR engages community members as equal partners, amplifying their voices and priorities by including them throughout the research process. Such engagement increases the relevance and meaning of research, improves the translation of research findings into sustainable health policy and practice, and ultimately enhances mutual trust among academic, clinical, and community partners for ongoing research partnership. There are a number of key principles that must be considered in the planning, design, and implementation of CEnR. These principles are focused on inclusive representation and participation, community empowerment, building community capacity, and protecting community self-determination. Although vascular surgeons may not be equipped to address these issues from the ground up by themselves, they should work with a team who can help them incorporate these elements into their CEnR project designs and proposals. This may be best accomplished by collaborating with researchers and community-based organizations who already have this expertise and have established social capital within the community. This article describes the theory and principles of CEnR, its relevance to vascular surgeons, researchers, and patients, and how using CEnR principles in vascular surgery practice, research, and outreach can benefit our patient population, with a specific focus on reducing disparities related to amputation.

The association of racial and ethnic disparities and frailty in geriatric patients undergoing revascularization for peripheral artery disease.

Frailty is defined as a state of decreased physiologic reserve contributing to functional decline and adverse outcomes. Racial disparities in frail patients have been described sparsely in the literature. We aimed to assess whether race influences frailty status in geriatric patients undergoing revascularization for peripheral artery disease (PAD) with chronic limb-threatening ischemia (CLTI). A 5-year analysis of the National Surgical Quality Improvement Program database included all geriatric (65 years and older) patients who underwent revascularization for lower extremity PAD with CLTI. The frailty index was calculated using a 11-variable modified frailty index and a cutoff of 0.27 indicated frail status. The primary outcome was an association of race or ethnicity with frailty status. We included 7,837 geriatric patients who underwent a surgical procedure (open: 55.2%) for PAD with CLTI. Mean age of patients was 75.4 years, 63.8% were male, 24.1% (n = 1,889) were frail, and 21.8% (n = 1,710) were African American (AA). Overall complication rate was 11.2% (n = 909) and overall mortality rate was 1.9% (n = 148). AA patients were more likely to be frail than White patients (29.6% v 23.9%; P = .03). AA and Hispanic patients were more likely to have complications (P = .03 and P = .001) and require readmission (P = .015 and P = .001) compared with White and non-Hispanic patients, respectively. Frail AA and frail Hispanic patients were more likely to have 30-day complications and readmission compared with frail White and frail non-Hispanic patients, respectively. Race and ethnicity influence frailty status in geriatric patients with PAD and CLTI. These disparities exist regardless of age, sex, comorbid conditions, and type of operative procedure. Additional studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors to improve outcomes.

Creating reverse flow arteriovenous fistulas with a forearm cannulation target.

BACKGROUND: Establishing a forearm arteriovenous fistula (AVF) offers preferred cannulation sites and preserves proximal access opportunities. When a radiocephalic AVF at the wrist is not feasible and the upper arm cephalic and median cubital veins are inadequate, an AV graft or more complex access procedure is often required. Creating a retrograde flow forearm AVF (RF-AVF) is a valuable alternative where the mid-forearm median antebrachial or cephalic vein is adequate, offering forearm cannulation zones with AVF outflow through deep and superficial collaterals. We report our technique and results. METHODS: We retrospectively reviewed our vascular access data base of consecutive patients during an 11-year study period where a RF-AVF established the only available cannulation target in the forearm. In addition to physical examination, all patients had ultrasound vessel mapping. RESULTS: A forearm access was established with a RF-AVF as the only opportunity for cannulation in 48 patients. Ages were 14-86 years (median = 62 years). Forty-four percent female, 63% diabetic, 13% obese, and 29% had previous access operations. Inflow was proximal radial artery in 47 individuals and one proximal ulnar. Nine AVFs (19%) failed at 2-66 months (median 14 months). One RF-AVF was ligated due to arm edema. Follow-up was 2-111 months (median = 23.5 months). Primary and cumulative patency rates were 62% and 91% at 12 months, and 46% and 85% at 24 months. Five patients were lost to follow-up with functioning RF-AVFs (mean 41 months). Twenty-three patients (48%) died during F/U of causes unrelated to access procedures (mean 25 months). CONCLUSIONS: Establishing a reverse flow forearm AVF offers a successful autogenous access option in the forearm for selected patients with an inadequate distal radial artery and/or cephalic vein at the wrist, avoiding more complex or staged procedures and preserving upper arm sites for future use. A proximal radial artery inflow procedure is recommended.

Venous thromboembolism as the first sign of malignancy.

BACKGROUND: Venous thromboembolism (VTE) is commonly associated with hypercoagulability in patients with cancer; however, there have been few investigations of VTE as the first sign of malignancy and even fewer performed in the United States. The aim of our study was to evaluate the incidence and predictors of unrecognized malignancy in patients presenting with VTE. METHODS: We performed a 1-year retrospective analysis of the Nationwide Readmission Database, including patients aged 18 years or older, presenting with a primary diagnosis of deep vein thrombosis (DVT) or a pulmonary embolism (PE). Patients known to have preexisting malignant diseases were excluded. Outcomes included the rate of newly diagnosed malignancy within 6 months from the discovery of VTE and demographic or associated illness predictors for the diagnosis of malignancy. A regression analysis was performed, based on which a VTE malignancy score was developed. RESULTS: A total of 116,048 patients were identified with VTE (49.8% DVT, 41.7% PE, 8.6% DVT and PE), 16% (n = 18,294) with malignancy. Of the remaining 97,754 patients, 31% were readmitted within 6 months. The incidence of newly diagnosed malignancy within 6 months was 2.4% (n = 2354). The most common malignancies were gastrointestinal in origin (29.2%). Demographic and diagnostic predictors for malignancy included age 65 years or older, female sex, inferior vena cava (IVC) thrombus, upper extremity thrombus, and a Charlson Comorbidity Index score of 5 or more. Receiver operating characteristic curve analysis found a cutoff VTE Malignancy score of 3 (sensitivity, 86%; specificity, 89%) to be predictive of an increased risk of a newly discovered malignancy within 6 months. CONCLUSIONS: VTE can be a risk indicator of underlying malignancy. Validation of a patient risk stratification score using multiple demographic or comorbid predictors for VTE on index admission may offer an opportunity for earlier diagnosis of occult malignancy.

Recruitment & Retainment of Vascular Surgeons: Prophylactic Measures to Improve the Current Workforce Crisis.

BACKGROUND: The vascular surgery workforce is in jeopardy with the current and increasing shortages. This study explores target populations for recruitment and aims to identify potential modifiable and nonmodifiable risk factors associated with reduced job satisfaction among practicing vascular surgeons to improve retention and prevent early retirement. METHODS: A cross-sectional national survey of surgeons (n = 1,043) was conducted from September 2016 to May 2017. Data included, demographic and occupational characteristics, as well as psychological, work-life balance, work-environment, and job-satisfaction variables. Surgeons were grouped into general surgery (n = 507), obstetrics and gynecology (n = 272), surgical subspecialties (n = 212), and vascular surgery (n = 52). Vascular surgeons were recategorized as more satisfied and less satisfied, and potential risk factors for job dissatisfaction were identified. RESULTS: As compared with general surgeons, obstetrics and gynecology, as well as other surgical subspecialties, vascular surgery tended to be male-dominated with higher rates of non-white, minority groups (P < 0.05). Less vascular surgery respondents were found in the Midwest (P < 0.001). Vascular surgeons worked more hours on average than other surgical fields and were less satisfied with work (P < 0.05). Potential job dissatisfaction risk factors among vascular surgeons include: unhealthy work-life balance, poor camaraderie/coworker dissatisfaction, insufficient hospital support, hostile hospital culture, discontent with supervision, minimal patient diversity, dissatisfaction with work in general, and unhappiness with career choice (P < 0.05). CONCLUSIONS: Recruiting new vascular surgery trainees while simultaneously preventing early retirement and attrition is critical to combatting the current workforce crisis. Potential interventions include (1) re-branding of the field with prioritization of work-life balance, (2) increasing hospital administration's support, (3) creating a collaborative work environment, and (4) facilitating personal accomplishment in work.

Recruitment of General Surgery Residents into Vascular Surgery.

BACKGROUND: Vascular surgery fellowship applications among general surgery residents have declined. Given this steady downward trend in vascular applicants in conjunction with a predicted critical shortage of vascular surgeons, a call to action for increased recruitment is needed. To improve recruitment efforts, a subgroup analysis of general surgery residents was performed to explore factors that influence interest in vascular surgery. METHODS: A cross-sectional national survey of residents (n = 467) was conducted from September 2016 to May 2017. In addition to collection of demographic and occupational characteristics, assessment of psychological, work-life balance, and job-satisfaction variables were obtained. Residents were grouped based on their interest in pursuing a fellowship. Chi-squared and Fisher's exact test was performed to determine significant variables. RESULTS: Residents were grouped into "interest in non-vascular fellowship" (n = 350), "interest in vascular fellowship" (n = 21), and "not interested in fellowship" (n = 96). Significant variables between the groups included age, geographic location, residency size, and type of institution (p < 0.05). Those interested in vascular surgery tended to be older. Residents not interested in fellowship were more commonly located in the Midwest and at smaller, community residencies. No significant difference was found between mental wellness and work-life balance variables. Those residents interested in a vascular surgery fellowship were more dissatisfied with their current salary as compared to other residents (p = 0.021). CONCLUSIONS: There is a predicted critical shortage in the vascular surgery workforce making recruitment of the best and brightest residents into the specialty vital to its future. In order to invigorate and broaden our group of vascular surgeons, focused recruitment of younger, Midwest, general surgery residents at smaller, community programs may provide the most yield. Publicizing the strengths of a vascular surgery career including the diversity of patients, continuity of care, proficiency in technical skill, and higher monetary rewards should be emphasized in recruiting these target populations.

Autogenous Vascular Access in American Indians.

BACKGROUND: American Indians (AI) or Alaska Natives, or in combination with another race, comprised 6.8 million individuals in 2010 and the population is expected to exceed 10 million in the current census. Diabetes is more common in AIs than in other races in the United States and is responsible for 69% of new onset end stage renal disease in AI patients. The incidence of obesity is also higher among AIs. As both diabetes and obesity make creating a successful autogenous vascular access more challenging, we reviewed our experience creating arteriovenous fistulas in AI patients. METHODS: Our vascular access database was reviewed for consecutive new AI patients undergoing creation of a hemodialysis vascular access during a 10-year period. Each patient underwent ultrasound vessel mapping by the operating surgeon in addition to history and physical examination. The goal for initial cannulation was 4-6 weeks after access creation. Minimal AVF flow volume for cannulation was 500 mL/min with an outflow vein diameter of 6 mm. RESULTS: 235 consecutive new AI patients were identified. All patients had an autogenous access constructed. The median age was 56 years (range, 15-89 years). Diabetes was present in 85% and 42% were female. Obesity was noted in 27% of the patients and 37% had previous vascular access operations. Primary patency at 12 and 24 months was 62% and 46%, respectively. Cumulative patency at 12 and 24 months was 96% and 94%, respectively. Female gender and previous access operations were associated with lower primary (P = 0.002 and 0.02, respectively) and cumulative patency (P = 0.01 and 0.04, respectively). Obesity was associated with lower cumulative access patency (P = 0.02). Overall, 74% of the access operations used the radial or ulnar artery for AVF inflow. Distal radial artery inflow AVFs were associated with longer patient survival (P = 0.01) and individuals with proximal radial inflow had longer survival when compared to brachial artery AVFs. Previous access operations were associated with shorter patient survival (P = 0.04). CONCLUSIONS: Safe and functional arteriovenous fistulas can be created for American Indians despite a higher prevalence of vascular access risk factors such as diabetes and obesity.

Analysis of Early Lower Extremity Re-amputation.

BACKGROUND: Data is scarce regarding the need for early re-amputation to a higher anatomic level. This study seeks to define outcomes and risk factors for re-amputation. METHODS: Patients undergoing primary major lower extremity amputation were identified within the 2012-2016 ACS-NSQIP database. Demographics, outcomes, and peri-operative characteristics were compared, and multivariable logistic regression model was used to determine association with early re-amputation. RESULTS: Over a 4-year period, 8306 below knee amputations and 6367 above knee amputations were identified. Thirty-day re-amputation occurred in 262 patients (1.8%) and was associated with increased length of stay (12.9 vs. 7.3 days, P < 0.001), higher rates of readmission (64.9% vs. 13.6%, P < 0.001), and overall complications (69.5% vs. 39.3%, P < 0.01). On multivariable analysis, advanced age (OR 1.02, CI 1.01-1.03), smoking (OR 1.75, CI 1.32-2.33), dialysis dependence (OR 1.67, CI 1.23-2.26), preoperative septic shock (OR 2.53, CI 1.29-4.97), and bleeding disorders (OR 1.72, CI 1.34-2.22) were associated with early re-amputation. CONCLUSIONS: Thirty-day re-amputation rates are low, but are associated with significant morbidity, prolonged hospitalization, and frequent readmissions.

Frailty Syndrome in Patients With Lower Extremity Amputation: Simplifying How We Calculate Frailty.

BACKGROUND: Frailty syndrome is an established predictor of adverse outcomes after surgical procedures. Our study aimed to compare the simplified National Surgical Quality Improvement Program 5-factor-modified frailty index (mFI-5) to its prior 11-factor-modified frailty index (mFI-11) with respect to the predictive ability for mortality, postoperative complications, and unplanned 30-d readmission in patients undergoing lower limb amputation. METHODS: The National Surgical Quality Improvement Program (2005-2012) databank was queried for all geriatric patients (>65 y) who underwent above-knee and below-knee amputations. We calculated each mFI by dividing the number of factors present for a patient by the total number of available factors. To assess the correlation between the mFI-5 and mFI-11, we used Spearman's rho rank coefficient. We then compared the two indices for each outcome (30-d complication, 30-d mortality, and 30-d readmission) and C-Statistic using predictive models. RESULTS: A total of 8681 patients were included with mean age of 76 ± 9 y, complication rate 35.8%, mortality rate 10.2%, and readmission rate 15.9%. There was no difference in type of amputation in frail and nonfrail. Correlation between the mFI-5 and mFI-11 was above 0.9 for all outcome measures. Both mFI-5 and mFI-11 indexes had strong predictive ability for mortality, postoperative complications, and 30-d readmissions. CONCLUSIONS: In patients undergoing major lower limb amputation, we found mFI-5 and the mFI-11 were equally effective in predicting postoperative outcomes. Frailty remained a strong predictor of postoperative complications, mortality, and 30-d readmission.

Avoiding hemodialysis access-induced distal ischemia.

Timely creation and maintenance of a safe and reliable vascular access is essential for hemodialysis patients with end-stage renal disease. Hemodialysis access-induced distal ischemia (HAIDI) is a recognized complication of arteriovenous fistulas and grafts that may result in serious or even devastating consequences. Avoiding such complications is clearly preferred over treatment of HAIDI once established. Proper recognition of patients at increased risk of HAIDI includes careful pre-operative evaluation of the patient's medical and surgical history along with physical examination and imaging to determine a plan for creating a functional permanent access while minimizing the risk of distal ischemia. Our aim is to review identifying characteristics of individuals at risk of HAIDI and provide recommendations regarding pre-operative assessment. Vascular access options and techniques are suggested for establishing a functional vascular access without distal ischemia for such patients.

Racial and ethnic disparities in lower extremity amputation: Assessing the role of frailty in older adults.

BACKGROUND: Frailty is a state of decreased physiologic reserve contributing to functional decline and is associated with adverse surgical outcomes, particularly in the elderly. Racial disparities have been reported previously both in frail individuals and in limb-salvage patients. Our goal was to assess whether race and ethnicity are disproportionately linked to frailty status in geriatric patients undergoing lower-limb amputation, leading to an increased risk of complications. METHODS: A 3-year analysis was conducted of the National Surgical Quality Improvement Program database and included all geriatric (age ≥65 years) patients who underwent amputation of the lower limb. The frailty index was calculated using the 11-factor modified frailty index with a cutoff limit of 0.27 defined for frail status. Outcomes were 30-day complications, mortality, and readmissions. Multivariate regression analysis was performed. RESULTS: A total of 4,218 geriatric patients underwent surgical amputation of a lower extremity (above knee: 41%; below knee: 59%). Of these patients, 29% were frail, 26% were African American, and 9% were Hispanic. Being African American (odds ratio: 1.6 [1.3-1.9]) and Hispanic (odds ratio: 1.1 [1.05-2.5]) was independently associated with frail status. Frail African Americans had a higher likelihood of 30-day complications (odds ratio: 3.2 [1.9-4.4]) and 30-day readmissions (odds ratio: 2.9 [1.8-3.6]) when compared with nonfrail individuals. Similarly, frail Hispanics had higher 30-day complications (odds ratio: 2.6 [1.9-3.1]) and 30-day readmissions (odds ratio: 1.4 [1.1-2.7]) compared with nonfrail Hispanics/Latinos. CONCLUSION: African American and Hispanic geriatric patients undergoing lower-limb amputation are at increased risk for frailty status and, as a result, increased associated operative complications. These disparities exist regardless of age, sex, comorbid conditions, and location of amputation. Further studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors, decrease frailty, and improve outcomes.

Present-day analysis of early failure after forefoot amputation.

BACKGROUND: Forefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation. METHODS: We queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation. RESULTS: In the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2-3.6) were independent predictors of more proximal amputation. CONCLUSION: Early below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.

Thirty-day outcomes after fenestrated endovascular repair are superior to open repair of abdominal aortic aneurysms involving visceral vessels.

OBJECTIVE: Although few studies have reported outcomes after branched or fenestrated endovascular aortic aneurysm repair (FEVAR) of abdominal aortic aneurysms involving visceral vessels (AAA-Vs), no multi-institutional study has compared FEVAR with open surgery (OS) for AAA-Vs. Our objective was to compare 30-day outcomes after FEVAR vs OS for AAA-Vs. METHODS: Patients who underwent FEVAR (n = 535) and OS (n = 1207) for elective AAA-Vs were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2008 to 2013 database. Thoracoabdominal aneurysms were excluded. Univariable and multivariable logistic regression analyses were performed. RESULTS: There were more men (82% vs 72%; P < .0001), diabetic patients (16% vs 11%; P = .005), patients with dependent functional status (4% vs 2%; P = .002), and nonsmokers (70% vs 56%; P < .0001) in the FEVAR group vs OS. There was no difference in rates of chronic obstructive pulmonary disease, cardiac history, peripheral artery disease, hypertension, and dialysis (P > .05). FEVAR had fewer major postoperative pulmonary complications (3.0% vs 19.0%; P < .0001), less renal failure requiring dialysis (1.9% vs 6.4%; P < .0001), less frequent cardiac arrest or myocardial infarction (2.2% vs 5.8%; P = .001), less bleeding with major transfusion (17.4% vs 50.2%; P < .0001), and decreased incidence of return to the operating room (4.5% vs 9.6%; P < .0001) and death (2.4% vs 4.7%; P = .02). The median length of stay was also significantly shorter for FEVAR (2 days vs 7 days; P < .0001). On multivariable analyses, OS was associated with higher risk than FEVAR for 30-day death (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-5.0), pulmonary complications (OR, 8.8; 95% CI, 5.1-15.0), cardiac complications (OR, 3.4; 95% CI, 1.8-6.6), renal failure needing dialysis (OR, 3.8; 95% CI, 1.9-7.7), and return to the operating room (OR 2.5; 95% CI, 1.6-4.0). CONCLUSIONS: FEVAR is associated with a lower risk for 30-day mortality and adverse events compared with OS for AAA-Vs.

Superior Lower Extremity Vein Graft Bypass Patency among Married Patients with Peripheral Artery Disease.

BACKGROUND: Outcome disparities associated with lower extremity bypass (LEB) for peripheral artery disease (PAD) have been identified but are poorly understood. Marital status may affect outcomes through factors related to health risk behaviors, adherence, and access to care but has not been characterized as a predictor of surgical outcomes and is often omitted from administrative data sets. We evaluated associations between marital status and vein graft patency following LEB using multivariable models adjusting for established risk factors. METHODS: Consecutive patients undergoing autogenous LEB for PAD were identified and analyzed. Survival analysis and Cox proportional hazards models were used to evaluate patency stratified by marital status (married versus single, divorced, or widow[er]) adjusting for demographic, comorbidity, and anatomic factors in multivariable models. RESULTS: Seventy-three participants who underwent 79 autogenous vein LEB had complete data and were analyzed. Forty-three patients (58.9%) were married, and 30 (41.1%) were unmarried. Compared with unmarried patients, married patients were older at the time of their bypass procedure (67.3 ± 10.8 years vs. 62.2 ± 10.6 years; P = 0.05). Married patients also had a lower prevalence of female gender (11.6% vs. 33.3%; P = 0.02). Diabetes, hypertension, hyperlipidemia, and smoking were common among both married and unmarried patients. Minimum great saphenous vein conduit diameters were larger in married versus unmarried patients (2.82 ± 0.57 mm vs. 2.52 ± 0.65 mm; P = 0.04). Twenty-four-month primary patency was 66% for married versus 38% for unmarried patients. In a multivariable proportional hazards model adjusting for proximal and distal graft inflow/outflow, medications, gender, age, race, smoking, diabetes, and minimum vein graft diameter, married status was associated with superior primary patency (hazard ratio [HR] = 0.33; 95% confidence limits [0.11, 0.99]; P = 0.05); other predictive covariates included preoperative antiplatelet therapy (HR = 0.27; 95% confidence limits [0.10, 0.74]; P = 0.01) and diabetes (HR = 2.56; 95% confidence limits [0.93-7.04]; P = 0.07). CONCLUSIONS: Marital status is associated with vein graft patency following LEB. Further investigation into the mechanistic explanation for improved patency among married patients may provide insight into social or behavioral factors influencing other disparities associated with LEB outcomes.

Outcomes After Use of Aortouniiliac Endoprosthesis Versus Modular or Unibody Bifurcated Endoprostheses for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

OBJECTIVES: Outcomes after endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAAs) have been widely published. There is, however, controversy on the role of the use of aortouniiliac endoprosthesis (AUI) versus modular or unibody bifurcated endoprosthesis (MUB) for repair of rAAAs. We study and compare 30-day outcomes after use of AUI and MUB for all rAAAs focusing specifically on patients with instability. MATERIALS AND METHODS: Patients who underwent EVAR for rAAA (n = 425) using AUI (n = 55; 12.9%) and MUB (n = 370; 87.1%) were identified from the American College of Surgeons' National Surgical Quality Improvement Program (2005-2010) database. Univariable and multivariable logistic regression analyses were performed. RESULTS: No significant difference ( P > .5) was seen in comorbidities between patients who underwent EVAR with AUI or MUB; there was also no change in endoprosthesis use from 2005 to 2010 ( P = .7). Patients who underwent EVAR with AUI more commonly had a history of peripheral arterial procedure (10.9% vs 4.6%; P = .053) and preoperative transfusion of >4 U packed red blood cells (18.2% vs 6.8%; P = .004). Use of AUI versus MUB was associated with more 30-day wound complications (16.4% vs 6.2%; P = .01), return to operating room (38.2% vs 20.0%; P = .003), and mortality (34.5% vs 21.4%; P = .03). On multivariable analysis, use of AUI was associated with an increased risk of 30-day mortality (odds ratio: 2.4; 95% confidence interval: 1.1-5.3). On subanalysis of the cohort for only the patients with unstable rAAA (n = 159; AUI = 29 and MUB = 130), 30-day mortality for AUI versus MUB was still higher but not statistically significant (44.8% vs 32.3%; P = .2). CONCLUSION: Endovascular repair for ruptured AAA using aortouniliac endoprosthesis is associated with higher 30-day mortality than using modular or unibody bifurcated endoprosthesis.

Gender-specific Differences in Great Saphenous Vein Conduit. A Link to Lower Extremity Bypass Outcomes Disparities?

BACKGROUND: Inferior lower extremity bypass (LEB) outcomes have been reported among women with peripheral arterial disease (PAD), but the mechanisms responsible for this disparity are unknown. Great saphenous vein (GSV) is considered the conduit of choice for LEB; GSV diameter is associated with graft patency and therefore is often used as a criterion for suitability for use as bypass conduit. We hypothesized that gender-based differences in GSV may contribute to LEB outcomes disparities. To explore this hypothesis, we performed a gender-based analysis of GSV anatomic characteristics among patients with PAD who were studied with duplex ultrasound vein mapping during evaluation for LEB. METHODS: Consecutive patients undergoing ultrasound vein mapping for planned LEB were analyzed. Minimum above- and below-knee GSV diameters were obtained in addition to demographic, procedural, and clinical data. Associations between gender and GSV diameter were evaluated using multivariate mixed models adjusting for anatomic location and within-patient correlation. RESULTS: One hundred five patients were analyzed. Mean patient age was 65 ± 11 years, 25% were women, and 78% were white. Mixed model estimates of minimum GSV diameters were 3.14 ± 0.09 mm above knee and 2.74 ± 0.09 below knee for men versus 3.23 ± 0.14 above-knee and 2.49 ± 0.14 below knee for women. A gender-based interaction between anatomic location and GSV diameter was identified, with women having a greater difference between above- and below-knee GSV diameters (or taper; mean difference of 0.73 ± 0.12 vs. 0.41 ± 0.17 mm; P = 0.017). CONCLUSIONS: GSV taper (difference between above- and below-knee diameters) is greater in women and may contribute to inferior patency after LEB with vein conduit, particularly for below-knee target vessels. Further research is necessary to evaluate specific hemodynamic effects of graft taper and links with other clinical endpoints. In addition to minimum diameter, vein graft taper may warrant consideration when planning LEB.