Long-Term Outcomes of Vein Adjuncts in Distal Infrainguinal Bypass.

INTRODUCTION: Autologous vein is recommended for infrainguinal bypass due to improved freedom from occlusion compared to prosthetic graft. In patients without adequate vein, vein adjunct at the distal anastomosis has been suggested to improve patency in small studies. This study aimed to determine if performance of a distal vein adjunct was associated with improved freedom from occlusion in below knee popliteal and tibial bypasses compared to prosthetic bypass alone. METHODS: A retrospective review of the Vascular Quality Initiative Infrainguinal Bypass database was conducted. Patients undergoing prosthetic-only and prosthetic with vein adjunct were compared. Inclusion criteria included age >18 years, and bypass to below knee popliteal or tibial vessels. Exclusion criteria included autologous vein conduits and prior interventions. Groups were further divided into below knee popliteal and tibial subgroups. RESULTS: A cohort of 3,939 patients underwent bypass to the below knee popliteal artery, with 287 (7.3%) receiving vein adjunct. More patients were male (68.8 vs 57.8%, p<.001) and had higher rates of CHF (21.1 vs 16.0%, p=.040) within the below knee popliteal group. Two-year bypass occlusion was decreased in patients receiving vein adjuncts (11.6 vs 17.1%, p=.004). A cohort of 2,378 patients underwent tibial bypass, with 473 (19.9%) receiving vein adjunct. Within the tibial group, patients were similar in age, BMI, race, comorbidities, and indications. Bypass occlusion (24.8 vs. 17.6%, p=.005) and amputation (20.5 vs. 15.9%, p=.048) rates at two years were worse for patients who did not receive a distal vein adjuncts to tibial arteries. CONCLUSION: Distal vein adjuncts are associated with improved freedom from occlusion, amputation, MALEs, and overall survival when compared to bypasses performed with prosthetic graft alone for tibial bypasses within the VQI. Vein adjunct was not associated with improved freedom from occlusion in below knee popliteal bypasses. Consideration should be given to utilization of a distal vein adjunct to improve prosthetic bypass longevity and limb salvage for patients requiring tibial bypasses.

Racial Disparity in Length of Stay Following Implementation of a Bariatric Enhanced Recovery Program.

INTRODUCTION: Enhanced Recovery Programs (ERPs) mitigate racial disparities in postoperative length of stay (LOS) for colorectal populations. It is unclear, however, if these effects exist in the bariatric surgery population. Therefore, this study aimed to evaluate the racial disparities in LOS before and after implementation of bariatric surgery ERP. METHODS: A retrospective cohort study was performed using data from a single institution. Patients undergoing minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass from 2017 to 2019 (pre-ERP) or 2020-2022 (ERP) were included. Chi-square, Kruskal-Wallis, and analysis of variance were used to compare groups, and estimated LOS (eLOS) was assessed via multivariable regression. RESULTS: Seven hundred sixty four patients were identified, including 363 pre-ERPs and 401 ERPs. Pre-ERP and ERP cohorts were similar in age (median 44.3 years versus 43.8 years, P = 0.80), race (53.4% Black versus 56.4% Black, P = 0.42), and preoperative body mass index (median 48.3 versus 49.4, P = 0.14). Overall median LOS following bariatric surgery decreased from 2 days pre-ERP to 1 day following ERP (P < 0.001). Average LOS for Black and White patients decreased by 0.5 and 0.48 days, respectively. However, overall eLOS remained greater for Black patients compared with White patients despite ERP implementation (eLOS 0.21 days, P = 0.01). CONCLUSIONS: Implementation of a bariatric surgery ERP was associated with decreased LOS for both Black and White patients. However, Black patients did have slightly longer LOS than White patients in both pre-ERP and ERP eras. More work is needed to understand the driving mechanism(s) of these disparities to eliminate them.

Treatment Location Variation for Chronic Limb-Threatening Ischemia in Patients With Kidney Failure.

INTRODUCTION: End-stage kidney disease (ESKD) is an established risk factor for chronic limb-threatening ischemia (CLTI). Procedural location for ESKD patients has not been well described. This study aims to examine variation in index procedural location in ESKD versus non-ESKD patients undergoing peripheral vascular intervention for CLTI and identify preoperative risk factors for tibial interventions. METHODS: Chronic limb-threatening ischemia (CLTI) patients were identified in the Vascular Quality Initiative (VQI) peripheral vascular intervention dataset. Patient demographics and comorbidities were compared between patients with and without ESKD and those undergoing index tibial versus nontibial interventions. A multivariable logistic regression evaluating risk factors for tibial intervention was conducted. RESULTS: A total of 23,480 procedures were performed on CLTI patients with 13.6% (n = 3154) with ESKD. End-stage kidney disease (ESKD) patients were younger (66.56 ± 11.68 versus 71.66 ± 12.09 y old, P = 0.019), more often Black (40.6 versus 18.6%, P < 0.001), male (61.2 versus 56.5%, P < 0.001), and diabetic (81.8 versus 60.0%, P < 0.001) than non-ESKD patients. Patients undergoing index tibial interventions had higher rates of ESKD (19.4 versus 10.6%, P < 0.001) and diabetes (73.4 versus 57.5%, P < 0.001) and lower rates of smoking (49.9 versus 73.0%, P < 0.001) than patients with nontibial interventions. ESKD (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.52-1.86, P < 0.001), Black race (OR 1.19, 95% CI 1.09-1.30, P < 0.001), and diabetes (OR 1.82, 95% CI 1.71-2.00, P < 0.001) were risk factors for tibial intervention. CONCLUSIONS: Patients with ESKD and CLTI have higher rates of diabetes and tibial disease and lower rates of smoking than non-ESKD patients. Tibial disease was associated with ESKD, diabetes, and Black race.