A systematic review and meta-analysis on the influence of sociodemographic factors on amputation in patients with peripheral arterial disease.

OBJECTIVE: To identify disparities in sociodemographic factors that are associated with major lower limb amputation in patients with peripheral arterial disease (PAD). METHODS: A systematic review of the literature was performed to identify studies that reported major lower limb amputation rates in patients with PAD among different sociodemographic groups. Data that compared amputation rates on the basis of sex, race, ethnicity, income, insurance, geography, and hospital type were collected and described. Outcomes were then aggregated and standardized, and a meta-analysis was performed to synthesis data into single odds ratios (ORs). RESULTS: Forty-one studies were included in the review. There was no association found between males and females (OR, 0.95; 95% confidence interval [CI], 0.90-1.00). Compared with Whites, higher rates of amputation were seen among Blacks/African Americans (OR, 2.02; 95% CI, 1.81-2.26) and Native Americans (OR, 1.22; 95% CI, 1.04-1.45). No significant association was found between Whites and Asians, Native Hawaiians, or Pacific Islanders (OR, 1.15; 95% CI, 1.00-1.33). Hispanics had higher rates of amputation compared with non-Hispanics (OR, 1.36; 95% CI, 1.22-1.52). Compared with private insurance, higher rates of amputation were seen among Medicare patients (OR, 1.38; 95% CI, 1.27-1.50), Medicaid patients (OR, 1.59; 95% CI, 1.44-1.76), and noninsured patients (OR, 1.41; 95% CI, 1.02-1.95). Compared with the richest income quartile, higher rates of amputation were seen among the second income quartile (OR, 1.10; 95% CI, 1.05-1.15), third income quartile (OR, 1.20; 95% CI, 1.07-1.35), and bottom income quartile (OR, 1.36; 95% CI, 1.24-1.49). There was no association found between rural and urban populations (OR, 1.35; 95% CI, 0.92-1.97) or between teaching and nonteaching hospitals (OR, 1.01; 95% CI, 0.91-1.12). CONCLUSIONS: Our study has identified a number of disparities and quantified the influence of sociodemographic factors on major lower limb amputation rates owing to PAD between groups. We believe these findings can be used to better target interventions aimed at decreasing amputation rates, although further research is needed to better understand the mechanisms behind our findings.

Outcomes of the Gore® Excluder® Iliac Branch Endoprosthesis Using Self Expanding or Balloon-Expandable Stent Grafts for the Internal Iliac Artery Component.

OBJECTIVE: The GORE® EXCLUDER® Iliac Branch Endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Arizona) was developed to be used in combination with a self-expanding stent graft (SESG) for the internal iliac artery (IIA) bridging stent. Balloon-expandable stent grafts (BESGs) are an alternative for the IIA, offering advantages in sizing, device tracking, precision, and lower profile delivery. We compared the performance of SESG and BESG when used as the IIA bridging stent in patients undergoing EVAR with IBE. METHODS: This is a retrospective review of consecutive patients who underwent EVAR with IBE implantation at a single center from October 2016 to May 2021. Anatomic and procedural characteristics were recorded via chart review and computed tomography (CT) postprocessing software (Vitrea® v7.14). Devices were assigned to SESG vs. BESG groups based on the type of device landing into the most distal IIA segment. Analysis was performed per device to account for patients undergoing bilateral IBE. The primary endpoint was IIA patency, and secondary endpoint was IBE-related endoleak. RESULTS: During the study period, 48 IBE devices were implanted in 41 patients (mean age 71.1 years). All IBE devices were implanted in conjunction with an infrarenal endograft. There were 24 devices in each of the self-expanding internal iliac component (SE-IIC) and balloon-expandable internal iliac component (BE-IIC) groups. The BE-IIC group had smaller diameter IIA target vessels (11.6±2.0 mm vs. 8.4±1.7 mm, p<0.001). Mean follow-up was 525 days. Loss of IIA patency occurred in 2 SESG devices (8.33%) at 73 and 180 days postprocedure, and in zero BESG devices, however, this difference was not statistically significant (p=0.16). There was 1 IBE-related endoleak requiring reintervention during the study period. A BESG device required reintervention due to Type 3 endoleak at 284 days. CONCLUSIONS: There were no significant differences in outcomes between SESG and BESG when used for the IIA bridging stent in EVAR with IBE. The BESGs were associated with using 2 IIA bridging stents and were more often deployed in smaller IIA target arteries. Retrospective study design and small sample size may limit the generalizability of our findings. CLINICAL IMPACT: This series compares postoperative and midterm outcomes of self expanding stent grafts and balloon expandable stent grafts (BESG) when used as the internal iliac stent graft as part of a Gore® Excluder® Iliac Branch Endoprosthesis (IBE). With similar outcomes between the two stent-grafts, our series suggests that some of the advantages of BESG, device sizing, tracking, deployment, and profile, may be able to be leveraged without impacting the mid-term performance of the IBE.

Efficacy and safety of sonographer discretion to terminate a venous duplex ultrasound for diagnosis of deep vein thrombosis in coronavirus disease 2019 patients.

OBJECTIVE: Sonographers performing venous duplex ultrasound (VDUS) of patients with coronavirus disease 2019 (COVID-19) have an increased risk of exposure owing to their close contact with these patients for an extended period. The objective of the present study was to evaluate the efficacy of a modified COVID-19 VDUS protocol to reduce sonographer exposure to COVID-19 patients. METHODS: We performed a single-center retrospective review. Patients who had undergone VDUS under the modified COVID-19 protocol between March 1, 2020, and June 30, 2020, with a confirmed or presumed COVID-19 diagnosis at the VDUS were included. The modified COVID-19 protocol was defined as the ability of the sonographer to terminate the examination on detection of an acute deep vein thrombosis (DVT). The primary outcome measures were the number of anatomic deep venous segments recorded by the sonographer, which was used as a surrogate measure for sonographer exposure time, and the number of acute DVTs found on follow-up examinations in segments not visualized at the index VDUS. RESULTS: A total of 160 lower extremity VDUS (LEVDUS) scans and 72 upper extremity VDUS (UEVDUS) scans were performed using the modified COVID-19 protocol. The index VDUS had found an acute DVT for 44 of 160 patients (27.5%) who had undergone LEVDUS and 26 of 72 (36.6%) who had undergone UEVDUS. On follow-up imaging, 7 of 38 LEVDUS scans (17.9%) and 1 of 10 UEVDUS scans (10%) had demonstrated a new acute DVT. Malignancy and surgery 30 days before imaging were significantly associated with acute lower extremity DVT, and mechanical ventilation and extracorporeal membrane oxygenation were associated with acute upper extremity DVT. On the index VDUS, the average was 10.6 of 12 total visualized segments on LEVDUS and 6.4 of 10 total segments on UEVDUS. Of the index VDUS scans, 35.6% of the LEVDUS and 78.6% of the UEVDUS scans had been abbreviated. The index VDUS scans that were positive for acute DVT had had significantly fewer visualized segments for both lower (8.4 vs 11.5; P < .0001) and upper (4.2 vs 7.6) extremities (P < .0001). On the follow-up examinations, only one of eight new acute DVTs had been found in a patient whose index VDUS had been abbreviated and the corresponding segment not assessed. These findings did not affect the patient's clinical course. CONCLUSIONS: The modified COVID-19 VDUS protocol reduced sonographers' potential exposure time to COVID-19. Additionally, the clinical efficacy was maintained, with no missed DVTs, despite the abbreviation of the VDUS examinations.

Peripheral artery reconstructions using cryopreserved arterial allografts in infected fields.

OBJECTIVE: Cryopreserved human arterial allografts are a recognized acceptable alternative for vascular reconstruction when other traditional conduits are either unavailable or contraindicated. We reviewed our experience using cryopreserved arterial allografts for peripheral artery reconstructions in contaminated and infected surgical fields. METHODS: A single-center, retrospective review was conducted of 57 patients who underwent a peripheral vascular reconstruction using a cryopreserved arterial allograft from January 2002 through July 2017. Indications for repair included removal of infected prosthetic bypass (n = 29), revascularizations in contaminated fields (n = 11), primary arterial repair in the setting of infection (n = 10), and infected vascular closure devices (n = 7). Aorta-based repairs were excluded. Demographics, index procedural details, postoperative complications, and conduit patency were analyzed. Primary end points included conduit-related mortality and graft failure as measured by reinfection, hemorrhage, or aneurysmal degeneration. Mean follow-up for the study is 27.8 months (range, 2-125 months). RESULTS: A total of 57 peripheral vascular reconstructions using cryopreserved arterial allografts were performed during the 15-year period. Among the 22 women and 35 men treated, the mean age was 61 years. The vascular beds involved included iliofemoral (n = 39), femoropopliteal or femoral-distal (n = 10), axillosubclavian or brachial (n = 2), mesenteric (n = 3), and carotid (n = 3) arteries. Adjunctive muscle flap coverage of the allograft conduit was performed in the majority of cases (61%; n = 35). The 30-day mortality was 9%; one death was directly related to conduit insertion. The 30-day conduit-related complication rate was 14% and included hemorrhage from the graft requiring return to the operating room (n = 4) and graft infection (n = 4). The late conduit-related complication rate was 15.8% and included graft infection (n = 1), graft thrombosis (n = 3), major amputation resulting from conduit failure (n = 1), pseudoaneurysm degeneration requiring repair (n = 2), graft hemorrhage (n = 1), and symptomatic graft stenosis (n = 1). CONCLUSIONS: A cryopreserved arterial allograft is a useful alternative conduit for peripheral vascular reconstruction in infected or contaminated surgical fields when other autologous or prosthetic conduits are either unavailable or contraindicated. In the immediate postoperative period, these repairs demonstrate acceptable resistance to graft failure and reinfection, particularly in conjunction with adjunctive rotational muscle flap coverage. Late conduit-related complications appear to be infrequent.

Impact of Body Mass Index on Outcomes after Mesenteric Revascularization for Chronic Mesenteric Ischemia.

BACKGROUND: Historically, patients with chronic mesenteric ischemia (CMI) are underweight with a low body mass index (BMI). However, with the recent obesity epidemic many of these patients now are overweight with a high BMI. We evaluated the impact of BMI on outcomes after mesenteric revascularization for CMI. METHODS: A retrospective chart review of patients undergoing open or endovascular mesenteric revascularization for CMI between January 2000 and June 2015 was performed. Demographics, comorbidities, BMI, Society for Vascular Surgery-combined comorbidity score, treatment modality, postoperative complications, reintervention, and all-cause mortality were analyzed. The primary end point for the study was all-cause mortality at 5 years. Patients were stratified using the World Health Organization BMI criteria. Univariate, Kaplan-Meier survival, and multivariate analyses were performed. RESULTS: In the study period, 104 unique patients underwent mesenteric revascularization for CMI, for 77 of whom BMI information was available. Of these 77, 30 patients were treated by endovascular revascularization, and 47 patients were treated by open revascularization. Overall, 27 (35.1%) were overweight or obese with a BMI ≥25. Median follow-up time was 41 months. High BMI patients were less likely to have weight loss at the time of surgery (P = 0.004). Stratified by BMI <25 versus BMI ≥25, 5-year survival for patients treated by open revascularization was 90% versus 50% (P = 0.02); survival for patients treated by endovascular revascularization was 27% vs. 53% (P = 0.37). Multivariate survival analysis identified active smoking, hypertensive chronic kidney disease, open repair with the use of venous conduit instead of prosthetic conduit (P < 0.001), and history of peripheral arterial disease (PAD) (P = 0.002), as independent predictors of increased all-cause mortality. CONCLUSIONS: BMI needs to be considered in assessing and counseling patients on outcomes of mesenteric revascularization for CMI, as a BMI over 25 is associated with poorer long-term survival after open revascularization. Smoking, hypertensive chronic kidney disease, PAD, and open repair with the use of venous conduit are independent predictors of long-term mortality after mesenteric revascularization independent of BMI.

Implications of Intraoperative Vascular Surgery Assistance for Hospitals and Vascular Surgery Trainees.

Importance: Vascular surgeons possess a skill set that allows them to assist nonvascular surgeons in the operating room. Existing studies on this topic are limited in their scope to specific procedures or clinical settings. Objective: To describe the broad spectrum of cases that require intraoperative vascular surgery assistance. Design, Setting, and Participants: A retrospective medical record review of patients undergoing nonvascular surgery procedures that required intraoperative vascular surgery assistance between January 2010 and June 2014 at a single urban academic medical center (Northwestern Memorial Hospital, Chicago, Illinois). Trauma patients and inferior vena cava filter placements were excluded. Exposures: Intraoperative vascular surgery assistance stratified by need for vascular reconstruction, anatomic location, urgency of consultation, and timing of consultation. Main Outcomes and Measures: A composite primary end point of death, myocardial infarction, or unplanned return to the operating room within 30 days of the index operation. Results: We identified 299 patients involving 12 different surgical subspecialties that met the study criteria. The cohort included 148 men (49.5%) and had a mean (SD) age of 56.4 (15) years. Most consultations occurred preoperatively (n = 224; 74.9%; odds ratio, 0.04; 95% CI, 0.02-0.08; P < .001) and were elective (n = 212; 70.9%; odds ratio, 0.06; 95% CI, 0.03-0.12; P < .001 ). The indications for vascular surgery assistance were 156 spine exposure (52%), 43 vascular control without hemorrhage (14.4%), 43 control of hemorrhage (14.4%), and 57 vascular reconstruction (19%). Vascular repairs consisted of 13 bypasses (4.3%), 18 patch angioplasties (6.0%), and 79 primary repairs (26.4%). All procedures required open surgical exposure by the vascular surgeon. The incidence of death, myocardial infarction, or unplanned return to the operating room was 11.4% for the cohort with a mortality rate of 1.7%. Patients who required vascular repair had a higher incidence of death, myocardial infarction, or unplanned return to the operating room (17.4% vs 7.9%; P = .01). These cases resulted in an additional 1371.46 work relative value units per year. Conclusions and Relevance: Vascular surgeons provide crucial operative support across multiple specialties. Although vascular reconstruction is not needed in most patients, it may be associated with increased risk of death, myocardial infarction, or unplanned return to the operating room. The high proportion of emergent cases that require vascular repair demonstrates the importance of having vascular surgeons immediately available at the hospital. To continue providing this valuable service, vascular surgery trainees need to continue to learn the full breadth of open anatomic exposures and vascular reconstruction.

Two Cases of Aortic Intimal Intussusception During Endovascular Repair of an Acute Type B Dissection.

PURPOSE: To raise awareness of a previously undescribed complication of thoracic endovascular aortic repair (TEVAR) for aortic dissection that can lead to acute aortic occlusion and to highlight that early recognition, excision of the intimal flap, and open aortic repair can be lifesaving. CASE REPORT: Two patients underwent TEVAR for acute type B dissections complicated by abdominal malperfusion syndrome. During stent-graft deployment, the intimal flap circumferentially detached from its origin proximally with subsequent intussusception, leading to acute aortic occlusion. Both complications were recognized intraoperatively with immediate conversion to open aortic reconstruction and intimal flap excision. The first patient required an infrarenal aortobi-iliac bypass, while the second had an open aortic fenestration and bovine pericardial patch repair of the aortotomy. Their postoperative courses were uneventful. Follow-up imaging revealed excellent stent-graft approximation without endoleak and thrombosis of the false lumen. CONCLUSION: Aortic intimal flap detachment and intussusception is a rare but potentially fatal complication of TEVAR for acute complicated aortic dissection. Quick diagnosis and a low threshold for conversion to open repair are critical in achieving a successful outcome.