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.

Use of tubularized bovine pericardium in left renal vein transposition for nutcracker syndrome.

Nutcracker syndrome is an extrinsic compression of the left renal vein by the superior mesenteric artery anteriorly and aorta posteriorly, resulting in hallmark manifestations of hematuria, proteinuria, and flank and/or pelvic pain. This report illustrates the case of a patient with a history of left flank pain and intermittent gross hematuria every 2 weeks. The patient denies any pelvic pain or gastrointestinal or lower extremity symptoms. Urinalysis revealed red blood cells, but no infection was noted. The cystoscopy findings were normal. Computed tomography urography showed left renal vein and duodenal compression between the aorta and superior mesenteric artery with a narrow aortic-superior mesenteric artery angle. The patient underwent left renal vein transposition to the distal inferior vena cava via a transabdominal approach. The left renal vein was transected at the inferior vena cava; however, the length was too short to create a tension-free anastomosis. Thus, a bovine pericardium sheet was tubularized and used as an interposition graft. The patient recovered well and is symptom-free. Left renal vein transposition is a well-described surgical technique in the treatment of nutcracker syndrome. The use of a vein or prosthetic graft has been described. This case demonstrates the use of an alternate conduit for reconstruction.

Laparoscopic nephrectomy, ex vivo renal artery aneurysm repair, and autotransplantation for symptomatic aneurysm with thromboembolism.

Renal artery aneurysms involving segmental branches pose a technical challenge to repair. Both endovascular and open repair techniques have been described. This case illustrates the clinical presentation of a patient with a symptomatic renal artery aneurysm with thromboembolic renal infarction managed with laparoscopic nephrectomy, ex vivo aneurysm resection, renal artery reconstruction, and autotransplantation.

Exploring the perception of venous disease within vascular surgery.

BACKGROUND: Biases and gender disparities influence career pathways within medicine, and vascular surgery is no exception. Venous disease comprises an estimated 1% to 3% of total health care expenditures. However, its value among vascular surgeons is poorly understood. This study aims to investigate the factors that influence vascular surgeons' current perceptions of superficial and deep venous disease treatments. METHODS: An anonymous survey was distributed electronically to practicing vascular surgeons in December 2021. The respondents were stratified by gender and practice breakdown. A venous-heavy practice was defined as a practice with venous work comprising ≥25% of the total volume. Changes in practice patterns over the respondent's career were also explored. Descriptive, univariate, and multivariate analyses were performed using STATA (StataCorp). RESULTS: A total of 315 practicing vascular surgeons responded, with 81.5% from the United States. Their mean age was 46.6 ± 9.6 years, and most identified as men (63.3%). The race and ethnicity breakdown was as follows: White (non-Hispanic), 63.0%; Asian or Asian Indian, 17.1%; Hispanic, Latinx, or Spanish, 8.4%; Black, 1.6%; and unknown, 9.9%. The practice settings were academic for 47.0%, private practice for 26.5%, hospital employed for 23.3%, and other for 3.2%. The female respondents were significantly younger (P < .0001), with fewer years in practice (P < .0001) and were more likely to perceive a gender bias within a career encompassing venous disease compared with the male respondents (P = .02). Of the 315 participants, 143 (45.4%) had a venous-heavy practice. No differences were found in age or gender between the venous-heavy and venous-light practices. Those with a venous-heavy practice had significantly more years in practice statistically (P = .02), had sought more venous training after graduation (P < .0001), were more likely to be in private practice (P < .0001), and were more likely to desire a practice change (P = .001) compared with those with a venous-light practice. Overall, 74.3% of respondents indicated that venous work might be less "valued" than arterial work in the field of vascular surgery. On multivariable regression, the predictors for the perception of venous work being less valued were female gender (odds ratio, 2.01; 95% confidence interval, 1.14-4.03) and completion of a vascular surgery fellowship (odds ratio, 2.0; 95% confidence interval, 1.15-3.57). CONCLUSIONS: Vascular surgeons overwhelmingly perceived the management of venous disease to be of less value than that of arterial disease, particularly by women and fellowship-trained vascular surgeons. The prevalence of venous disease, as measured by its proportion of the U.S. healthcare budget, cannot be overstated. Thus, efforts to elevate the importance of chronic venous disease within the scope of vascular surgery practices are essential to ensure patients are provided with appropriate specialty care.

Health care disparities involved in establishing functional arteriovenous fistula hemodialysis access.

OBJECTIVE: Race-related disparities in outcomes associated with cardiovascular disease are well-documented. Arteriovenous fistula (AVF) maturation can be a challenge in establishing functional access in the population of patients with end-stage renal disease requiring hemodialysis. We sought to investigate the incidence of adjunctive procedures required to establish fistula maturation and evaluate the association with demographic factors including patient race. METHODS: This study was a single-institution retrospective review of patients undergoing first-time AVF creation for hemodialysis from January 1, 2007, to December 31, 2021. Subsequent arteriovenous access interventions, such as percutaneous angioplasty, fistula superficialization, branch ligation and embolization, surgical revision, and thrombectomy, were recorded. The total number of interventions performed after index operation was recorded. Demographic data including age, sex, race, and ethnicity was recorded. The need for and number of subsequent interventions was evaluated using multivariable analysis. RESULTS: A total of 669 patients were included in this study. Patients were 60.8% male and 39.2% female. Race was reported as White in 329 (49.2%), Black in 211 (31.5%), Asian in 27 (4.0%), and other/unknown in 102 (15.3%). Of the patients, 355 (53.1%) underwent no additional procedures after initial AVF creation, 188 (28.1%) underwent one additional procedure, 73 (10.9%) had two additional procedures, and 53 (7.9%) had three or more additional procedures. As compared with the White reference group, Black patients were at higher risk of having maintenance interventions (relative risk [RR], 1.900; P ≤ .0001) and additional AVF creation interventions (RR, 1.332; P = .05), and total interventions (RR, 1.551; P ≤ .0001). CONCLUSIONS: Black patients were at significantly higher risk of undergoing additional surgical procedures, including both maintenance and new fistula creations, as compared with their counterparts of other racial groups. Further exploration of the root cause of these disparities is necessary to facilitate the achievement of equivalent high-quality outcomes across racial groups.

A rare case of angioinvasive aspergillosis aortic graft infection causing peripheral thromboembolism.

Angioinvasive aspergillosis is a fungal infection that rarely involves vascular grafts. This case illustrates a patient with a history of aortic arch Dacron graft reconstruction presenting with acute bilateral lower extremity ischemia. The patient underwent emergent open thromboembolectomy. The intraluminal contents had an atypical appearance for thromboembolism, and histologic examination was consistent with aspergillosis. Cardiac computed tomography and transesophageal echocardiography showed an aortic arch graft vegetation. Aortic graft excision and reconstruction were performed for control of the fungal source. Investigation into the etiology of thromboembolism should include consideration for septic emboli in patients with indwelling vascular grafts. When suspected, graft excision should be considered for definitive management.

Comparison of academic productivity and funding support between United States and international medical graduate vascular surgeons.

OBJECTIVE: The demand for vascular surgeons in the United States stands to far exceed the current supply. International medical graduates (IMGs) are not only vital to meeting the country's growing health care needs, but also help to advance clinical research and medical education in the field of vascular surgery. Nearly 17% of practicing vascular surgeons in the United States are IMGs, yet little is known about their relative contributions to academic vascular surgery. Our study aims to compare the academic profiles and funding support for IMG vascular surgeons to that of their US medical graduate (USMG) counterparts. METHODS: A cross-sectional study was performed on all IMG and USMG academic vascular surgeons practicing in US-based hospitals with vascular surgery residency and/or fellowship programs. In addition to the baseline surgeon characteristics, academic profiles and research output were also collected. Furthermore, the National Institutes of Health (NIH) research reporting tool and open payments database were queried for any funding/payments to surgeons in both groups. Matching for year of vascular surgery training program graduation was performed where appropriate. RESULTS: A total of 908 academic vascular surgeons were included; 759 (83.6%) were USMGs and 149 (16.4%) were IMGs. The median year of graduation was comparable between the two groups, but USMGs had a significantly higher proportion of female surgeons (23.6% vs 10.7%; P = .0003). There were no significant differences in the academic profiles and leadership positions between the two groups. Although research productivity is similar between the two groups, IMG surgeons were more likely to have first or senior-authorship papers (47.1% vs 37.5%; P < .001). Additionally, faculty departments chaired/cheifed by a USMG were less likely to be staffed with IMG vascular surgeons (1.6 surgeons vs 3.1 surgeons; P < .0001). Following grant analysis, USMG surgeons received more NIH R01 grants (5.7% vs 1.3%; P = .026). R01-funded surgeons had significantly greater research output by number of publications (121.0 vs 47.5), citations (3872 vs 938), H-index (32.0 vs 17.5), and average journal impact factor (>10: 86.7% vs 33.3%) (all P < .001). CONCLUSIONS: The efforts to further diversify vascular surgery are vital to better serving an increasingly diverse US population, amid growing disparities in health care. Although IMGs account for a minority of academic vascular surgeons, and contribute significantly to their published research, they had less NIH R01 funding, warranting further investigation.

Programmatic engagement in diversity, equity, and inclusion in U.S. vascular surgery training programs.

OBJECTIVE: Given the diversity of populations that modern healthcare professionals treat, there has been an increasing call for academic medical centers to ensure that they themselves are diverse and inclusive. Historically, this has been measured by the composition of the workforce in terms of protected categories such as race/ethnicity, gender, and disability. However, these broad categories have only poorly reflected the actual ability of organizations to engage with a diverse workforce and patient population. The diversity and engagement survey (DES) is a specifically constructed and validated instrument designed to measure the integration of diversity, equity, and inclusion (DEI) within academic medical centers. The goal of the present study was to use the DES with vascular surgery program directors, to determine the predictors of low DEI in vascular surgery training programs. METHODS: An anonymous electronic survey was sent to all program directors and assistant program directors of vascular surgery training programs (residencies and fellowships) in the United States (n = 280). The survey consisted of 18 sections with 53 questions regarding details of the respondent, demographics, programmatic information, including information on faculty and trainee diversity, the resources available to enhance DEI within the program, institutional attitudes toward employees, and the DES itself. The total score from the DES section was used to the stratify institutions, which were classified as low DEI if in the bottom 25% percentile of the overall scores or as high DEI if scoring higher. Univariate analysis was used to determine whether any important differences were present in the demographics or survey responses between the institutions scoring as low vs high DEI. Multivariate logistic regression was also performed using the demographic variables and responses to the survey questions to determine their relationship to DEI status. RESULTS: There were a total of 102 complete responses to the survey (36.4% response rate). The proportion of women was higher (66.67%) than the men (33.30%) in the low DEI cohort, although women were only 28.4% of the overall cohort. A statistically significant difference was found between the high and low DEI institutions in the proportion of those who had responded yes, no, or preferred not to disclose whether they had experienced discrimination or hurtful comments (P < .001) with 71% of the respondents in the low DEI institutions reporting this experience compared with only 11% in high DEI institutions. Multivariate analysis also demonstrated that non-male gender (odds ratio, 5.10; P = .034) and experiences of discrimination (odds ratio, 6.51; P = .024) were associated with low DEI institutions. CONCLUSIONS: Non-male program directors and those who had experienced discrimination at their institution were significantly more likely to find that their institution had low DEI.

Concomitant Orthopedic Injury is the Strongest Predictor of Amputation in Extremity Vascular Trauma.

BACKGROUND: Although the risk of extremity amputation related to an isolated vascular injury is low, it increases significantly with concomitant orthopedic injury. Our study aims to evaluate and quantify the impact of risk factors associated with trauma-related extremity amputation in patients with vascular injury. We sought to determine whether there are other potential predictors of amputation. METHODS: A retrospective review of patients with extremity vascular injury presenting to a single level 1 academic trauma center between January 1, 2007, and December 31, 2018, was performed. All patients diagnosed with major vascular injury to the upper or lower extremity were included. Data on patient demographics, medical comorbidities, anatomic location of vascular injury, and the presence of soft tissue or orthopedic injury were collected. The main outcome measure was major amputation of the affected extremity. Major amputation included below-the-knee amputation, above-the-knee amputation, as well as any amputation of the upper extremity at or proximal to the wrist. RESULTS: We identified 250 extremities with major vascular injury in 234 patients. Of these, 216 (86.4%) were male and 34 (13.6%) female. The mean age was 32.2 years (range 18-79 years) and mean follow-up was 6.9 (standard deviation: 3.3) years. Just over half of injuries, 130 (52.0%) involved the lower extremity. Forty extremities (29 lower and 11 upper), or 16.0%, of total injured extremities, required major amputation during the follow-up period. Concomitant orthopedic injury was present in 106 of 250 (42%) injured extremities. Using univariable logistic regression models, variables with a significant association with major amputation included older age, higher body mass index, blunt mechanism of injury, concomitant orthopedic injury, soft tissue injury, and nerve injury, and the need for fasciotomy (P < 0.05). In multivariable analyses, blunt mechanism of injury (odds ratio [OR] (confidence ratio {CI}): 6.51 (2.29, 18.46), P < 0.001) and concomitant orthopedic injury (OR [CI]: 7.23 [2.22, 23.55], P = 0.001) remained significant predictors of amputation. CONCLUSIONS: Concomitant orthopedic injury and blunt mechanism in the setting of vascular injury are associated with a higher likelihood of amputation in patients with extremity vascular injury. Further development of a vascular extremity injury protocol may be needed to enhance limb salvage. Findings may guide patient discussion regarding limb-salvage decision-making.

Factors associated with successful median arcuate ligament release in an international, multi-institutional cohort.

OBJECTIVE: Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. METHODS: The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. RESULTS: For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. CONCLUSIONS: No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.

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 vascular surgery in-training examination predicts performance on qualifying examination.

OBJECTIVE: Vascular surgery trainees participate in the vascular surgery in-training examination (VSITE) during each year of their training. Although the VSITE was developed as a low-stakes, formative examination, performance on that examination might correlate with the pass rates for the Vascular Surgery Board written qualifying examination (VQE) and oral certifying examination (VCE) and might, therefore, guide both trainees and program directors. The present study was designed to examine the ability of the VSITE to predict trainees' performance on the VQE and VCE. METHODS: All first-time candidates of the Vascular Surgery Board VQE and VCE were analyzed from 2016 to 2020, including those from both the integrated and independent training pathways. VSITE scores from the final year of training were associated with the VQE scores and the probability of passing the VQE and VCE both. Linear and logistic regression models were used to determine the ability of VSITE results to predict the VQE scores and the probability of passing each board examination. RESULTS: VSITE scores available for the 559 candidates (69.3% male; 30.7% female) who had completed the VQE and 369 candidates (66.7% male; 33.3% female) who had completed both the VQE and the VCE. The linear regression model results for the final year of training showed that the VSITE scores explained 34% of the variance in the VQE scores (29% for the integrated and 37% for the independent trainees). Logistic regression demonstrated that the final year VSITE scores were a significant predictor of passing the VQE for both integrated and independent trainees (P < .001). A VSITE score of 500 during the final year of training predicted a VQE passing probability of >90% for each group of candidates. The probability of passing the VQE decreased to 73% for candidates from integrated programs, 61% for candidates from independent programs, and 64% for the whole cohort when the score was 400. The VSITE scores were a significant predictor of passing the VCE only for the candidates from independent programs (odds ratio, 1.01; 95% confidence interval, 1.00-1.02; P < .01), for whom a VSITE score of 400 correlated with an 82% probability of passing the VCE. CONCLUSIONS: VSITE performance is predictive of passing the VQE for trainees from both integrated and independent training paradigms. Vascular surgery trainees and training programs should optimize their preparation and educational efforts to maximize performance on the VSITE during their final year of training to improve the likelihood of passing the VQE. Further analysis of the predictive value of VSITE scores during the earlier years of training might allow the board certification examinations to be administered earlier in the final year of training.

Racial and ethnic disparities in 3-year outcomes following infrainguinal bypass for chronic limb-threatening ischemia.

OBJECTIVE: Black and Hispanic patients have had higher rates of chronic limb-threatening ischemia (CLTI) and experienced worse perioperative outcomes after lower extremity bypass compared with White patients. The underlying reasons for these disparities have remained unclear, and data on 3-year outcomes are limited. Therefore, we examined the differences in 3-year outcomes after open infrainguinal bypass for CLTI stratified by race/ethnicity and explored the potential factors contributing to these differences. METHODS: We identified all CLTI patients who had undergone primary open infrainguinal bypass in the Vascular Quality Initiative registry from 2003 to 2017 with linkage to Medicare claims through 2018 for the 3-year outcomes. Our primary outcomes were the 3-year rates of major amputation, reintervention, and mortality. We also recorded the 30-day major adverse limb events (MALE) defined as major amputation or reintervention. We used Kaplan-Meier estimation methods and multivariable Cox regression analyses to evaluate the outcomes stratified by race/ethnicity and identify contributing factors. RESULTS: Of the 7108 patients with CLTI, 5599 (79%) were non-Hispanic White, 1053 (15%) were Black, 48 (1%) were Asian, and 408 (6%) were Hispanic patients. Compared with White patients, Black patients had higher rates of 3-year major amputation (Black vs White, 32% vs 19%; hazard ratio [HR], 1.9; 95% confidence interval [CI], 1.7-2.2), reintervention (Black vs White, 61% vs 57%; HR, 1.2; 95% CI, 1.1-1.3), and 30-day MALE (Black vs White, 8.1% vs 4.9%; HR, 1.3; 95% CI, 1.2-1.4) but lower mortality (Black vs White, 38% vs 42%; HR, 0.9; 95% CI, 0.8-0.99). Hispanic patients also experienced higher rates of amputation (Hispanic vs White, 27% vs 19%; HR, 1.6; 95% CI, 1.3-2.0), reintervention (Hispanic vs White, 70% vs 57%; HR, 1.4; 95% CI, 1.2-1.6), and MALE (Hispanic vs White, 8.7% vs 4.9%; HR, 1.5; 95% CI, 1.3-1.7. However, mortality was similar between the two groups (Hispanic vs White, 38% vs 42%; HR, 0.88; 95% CI, 0.76-1.0). The low number of Asian patients prevented a meaningful assessment of amputation (Asian vs White, 20% vs 19%; HR, 0.93; 95% CI, 0.44-2.0), reintervention (Asian vs White, 55% vs 57%; HR, 0.79; 95% CI, 0.51-1.2), MALE (Asian vs White, 8.5% vs 4.9%; HR, 0.71; 95% CI, 0.46-1.1), or mortality (Asian vs White, 36% vs 42%; HR, 0.83; 95% CI, 0.52-1.3). In the adjusted analyses, the association of Black race and Hispanic ethnicity with amputation and reintervention was explained by differences in the demographic characteristics (ie, age, sex) and baseline comorbidities (ie, tobacco use, diabetes, renal disease). CONCLUSIONS: Compared with White patients, Black and Hispanic patients had higher 3-year major amputation and reintervention rates. However, mortality was lower for Black patients than for the White patients and similar between Hispanic and White patients. Disparities in amputation and reintervention were partly attributable to differences in demographic characteristics and the higher prevalence of comorbidities in Black and Hispanic patients with CLTI. Future work is necessary to determine whether interventions to improve access to care and reduce the burden of comorbidities in these populations will confer limb salvage benefits.

Racial Disparities in the Risk for Thromboembolic Events in COVID-19 Patients during the Height of the SARS-CoV-2 Pandemic and Impact on Outcomes.

BACKGROUND: The primary objective of this study is to assess the risk of thromboembolic events (TEs) in hospitalized patients with coronavirus disease 2019 (COVID-19) and study the impact of TEs on hospital course and mortality risk during the initial height of the severe acute respiratory syndrome coronavirus-2 pandemic. METHODS: A retrospective review of all adult inpatients (≥ 18 years old) with COVID-19 infection at a single academic institution from March 15, 2020 to July 1, 2020 was performed. Collected data included patient demographics, comorbidities, hospital admission type, TEs, laboratory values, use of anticoagulants/antiplatelet agents, hospital length of stay, and in-hospital mortality. A logistic regression was used to estimate associations between risk factors and TEs. RESULTS: A total of 826 inpatients with COVID-19 were identified. Of these, 56% were male, average age was 60.9 years, and race/ethnicity was reported as Hispanic in 51%, non-Hispanic Black in 25%, and non-Hispanic White in 18%. A total of 98 TEs were documented in 87 patients (10.5%). Hypertension, coronary artery disease, and chronic limb threatening ischemia were associated with an increased incidence of thromboembolism (P < 0.05). Hispanic patients had higher incidence of thromboembolism compared to White non-Hispanic patients (odds ratio {[OR] confidence interval [CI]}: 2.237 [1.053, 4.754], P = 0.036). As D-dimer increased, the odds of TE increased by 5.2% (OR [CI]: 1.052 [1.027, 1.077], P < 0.001). Patients with TEs had longer hospital stay (median 13 vs. 6 days, P < 0.001), higher likelihood of intensive care unit admission (63% vs. 33%, P < 0.001), and higher in-hospital mortality (28% vs. 16%, P = 0.006). Arterial TEs were associated with higher in-hospital mortality than venous TEs (37% vs. 15%, P = 0.027). CONCLUSIONS: During the initial height of the severe acute respiratory syndrome coronavirus-2 pandemic, TEs were relatively frequent in hospitalized patients with COVID-19. Racial disparities were seen with an increased proportion of minority patients admitted with respect to percentages seen in the general population. There was also a significantly increased incidence of TEs in Hispanic patients. TEs were associated with significantly longer hospital stay and higher in-hospital mortality. Patients with arterial TEs fared worse with significantly higher mortality than those with venous events. Inconsistencies in anticoagulation management early in the pandemic may have contributed to poor outcomes and more contemporary management outcomes need to be investigated.

A Contemporary Comparison of Cyanoacrylate, Radiofrequency, and Endovenous Laser Ablation on Healing of Active Venous Ulceration.

BACKGROUND: The goal of this study is to compare the healing rates of active lower extremity venous ulcers for patients receiving one of 3 ablation methods, compare their complications, and identify factors affecting successful healing and prevention of recurrence. METHODS: For this study, data were collected retrospectively on 146 patients at a single institution, tertiary referral center, with an active venous ulcer who underwent ablation therapy via cyanoacrylate (VenaSeal), radiofrequency (RFA), or endovenous laser ablation (EVLA) from 2010 to 2020. RESULTS: The study showed a nonsignificant difference in days to ulcer healing postintervention between ablative techniques, with 80.8 days for cyanoacrylate ablation (n = 15), 70.07 for RFA (n = 44), and 67.04 days for EVLA (n = 79). A similar, nonsignificant trend was observed for ulcer recurrence, with a rate of 35.7% (5/14) for cyanoacrylate ablation, 26.7% (20/75) for EVLA, and 23.1% (9/39) for RFA. The same nonsignificant trend occurred with deep venous thrombosis following the procedure in 6.3% (1/16) of cyanoacrylate ablation, 4.8% (4/84) of EVLA, and 2.2% (1/46) of RFA cases. The rate of endovenous glue induced thrombosis was also higher (6.3%) for cyanoacrylate than endovenous heat induced thrombosis in EVLA (3.6%) and RFA (2.2%). Cox proportional hazard was significant for compliance with compression therapy (hazard ratio [HR] 2.12, confidence interval [CI] 95% = 1.10-4.20, P = 0.031) and a lack of working with a wound clinic (HR 0.50, CI 95% = 0.33-0.75, P = 0.001) were associated with the decreased time to healing of ulcer but was not influenced by the presence of other comorbidities of smoking or diabetes mellitus. CONCLUSIONS: This study indicates a trend toward cyanoacrylate ablation having longer healing times and more complications compared to other ablation methods when used in patients with active venous ulcers. Compliance with compression treatment is predictive of venous ulcer healing and working with a wound clinic had significantly longer healing times.

Female gender increases risk of stroke and readmission after carotid endarterectomy and carotid artery stenting.

OBJECTIVE: Carotid endarterectomy (CEA) has historically demonstrated a higher rate of perioperative adverse events for female patients. However, recent evidence suggests similar outcomes for CEA between genders. In contrast, fewer studies have examined gender in carotid artery stenting (CAS). Using contemporary data from the American College of Surgeons National Surgical Quality Improvement Program database, we aim to determine if gender impacts differences in postoperative complications in patients who undergo CEA or CAS. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2017 using Current Procedural Terminology and International Classification of Diseases codes for retrospective review. Patients with carotid intervention (CEA or CAS) were stratified into asymptomatic vs symptomatic cohorts to determine the effect of gender on 30-day postoperative outcomes. Symptomatic patients were defined as those with perioperative transient cerebral ischemic attack or stenosis of carotid artery with cerebral infarction. Descriptive statistics were calculated. Risk-adjusted odds of 30-day postoperative outcomes were calculated using multivariate regression analysis with fixed effects for age, race, and comorbidities. RESULTS: There were 106,568 patients with CEA or CAS (104,412 CEA and 2156 CAS). The average age was 70.9 years, and female patients accounted for 39.9% of the population. For asymptomatic patients that underwent CEA or CAS, female gender was associated with significantly higher rates of cerebrovascular accident (CVA)/stroke (13%; P = .005), readmission (10%; P = .004), bleeding complication (32%; P = .001), and urinary tract infection (54%; P = .001), as well as less infection (26%; P = .001). In the symptomatic cohort, female gender was associated with significantly higher rates of CVA/stroke (32%; P = .034), bleeding complication (203%; P = .001), and urinary tract infection (70%; P = .011), whereas female gender was associated with a lower rate of pneumonia (39%; P = .039). Subset analysis found that, compared with male patients, female patients <75 years old have an increased rate of CVA/stroke (21%; P = .001) and readmission (15%; P < .001), whereas female patients ≥75 years old did not. In asymptomatic and symptomatic patients that underwent CEA, female gender was associated with significantly higher rates of CVA/stroke (13%; P = .006 and 31%; P = .044, respectively), but this finding was not present in patients undergoing CAS. CONCLUSIONS: In patients undergoing carotid intervention, female gender was associated with significantly increased rates of postoperative CVA/stroke in the asymptomatic and symptomatic cohorts as well as readmission in the asymptomatic cohort. Female gender was associated with higher rates of CVA/stroke following CEA, but not CAS. We recommend that randomized control trials ensure adequate representation of female patients to better understand gender-based disparities in carotid intervention.

Effect of Stent-Graft Active Fixation and Oversizing on Aortic Neck Dilation After Endovascular Aneurysm Exclusion For Infrarenal Aortic Aneurysm.

INTRODUCTION: Aortic neck dilation post endovascular aneurysm repair (EVAR) has been implicated in the long-term development of endoleak and the subsequent re-intervention. Optimal endograft sizing is a vital aspect to successful repair. This study looked at percentage of graft oversizing as well as type of fixation on aortic neck dilation. METHODS: We retrospectively evaluated all EVARs completed at Loyola's University from 2006 to 2015 after IRB approval. Patients without follow-up scans within a year were excluded. We collected demographics, comorbidities, graft type, size, aortic neck diameter, maximum sac size diameters from the pre-operative and follow-up scans. We reviewed and collected data on 432 patients but analyzed 154. We measured the largest aortic diameter on axial images 1 cm above and 1 cm below the lowest renal artery. Change in supra and infrarenal aortic measurements were evaluated by calculating the mm difference from each scan compared to the pre-operative scan. Linear mixed effects models were used to estimate patients' mean differences over time. RESULTS: We compared three groups of neck fixation grafts. Those with active suprarenal fixation had a significant change in suprarenal aortic diameter at four-year follow-up (1.86 mm, CI:0.65-3.06), compared to those with active infrarenal (0.22 mm, CI: -0.67 to -1.11) or passive suprarenal fixation (1.52 mm, CI: -0.11 to -3.15) (Fig. 1). Those with active suprarenal fixation were the only ones to have significant increase in suprarenal aortic diameter (P = 0.0026). Degree of oversizing was also divided into three groups. Oversizing by <10% had less impact on the suprarenal aorta than >15% oversizing at 4 years (0.41 mm, CI: -0.31 to -1.14 vs. 3.26 mm, CI: 1.63-4.88, P < 0.001) (Fig. 2). Oversizing had a more pronounced effect on the infrarenal aorta: 3.01 mm, CI: 2.18-3.83; 5.95 mm, CI: 3.26-8.64; and 5.05 mm, CI: 3.41-6.69 for <10%, 10-15%, and >15% oversizing at four years, respectively. CONCLUSION: Stent-grafts with active fixation below the renal arteries as well as oversizing by <10% seem to have the least effect on aortic neck dilation over time. These factors should be considered when performing EVARs, as aortic neck dilation could lead to endoleak and need for further intervention. Further research defining the optimal stent-graft type, self-expanding versus balloon expandable, type of fixation and degree of oversizing.

Representation of women in vascular surgery science and societies.

OBJECTIVE: Medical schools and surgical residencies have seen an increase in the proportion of female matriculants, with 30% of current vascular surgery trainees being women over the past decade. There is widespread focus on increasing diversity in medicine and surgery in an effort to provide optimal quality of patient care and the advancement of science. The presence of gender diversity and opportunities to identify with women in leadership positions positively correlates with women choosing to enter traditionally male-dominated fields. The purpose of this study was to evaluate the representation of women in regional and national vascular surgical societies over the last 20 years. METHODS: A retrospective review of the meeting programs of vascular surgery societies was performed. Data were collected on abstract presenters, moderators, committee members and chairs, and officers (president, president-elect, vice president, secretary, and treasurer). The data were divided into early (1999-2009) and late (2010-2019) time periods. RESULTS: Five regional and five national societies' data were analyzed, including 139 meetings. The mean percentage of female abstract presenters increased significantly from 10.9% in the early period to 20.6% in the late period (P < .001). Female senior authors increased slightly from 8.7% to 11.5%, but this change was not statistically significant (P = .22). Female meeting moderators increased significantly from 7.8% to 17.2% (P < .001), as well as female committee members increased from 10.9% to 20.3% (P = .003). Female committee chairs increased slightly from 10.9% to 16.9%, but this difference was not statistically significant (P = .13). Female society officers increased considerably from 6.4% to 14.8%. (P = .002). Significant variation was noted between societies, with five societies (three regional and two national) having less than 10% women at the officer level in 2019. There was a wide variation noted between societies in the percentage of female abstract presenters (range, 7.6%-34.9%), senior authors (3.9%-17.9%), and meeting moderators (5.4%-40.7%). CONCLUSIONS: Over the past two decades, there has been a significant increase in the representation of women in vascular surgery societies among those presenting scientific work, serving as meeting moderators, and serving as committee members. However, the representation of women among committee chairs, senior authors, and society leadership has not kept up pace with the increase noted at other levels. Efforts to recruit women into the field of vascular surgery as well as to support the professional development of female vascular surgeons are facilitated by the presence of women in leadership roles. Increasing the representation of women in vascular society leadership positions may be a key strategy in promoting gender diversity in the vascular surgery field.