Analysis of Patients Undergoing Major Lower Extremity Amputation in the Vascular Quality Initiative.

BACKGROUND: Despite an aggressive climate of limb salvage and revascularization, 7% of patients with peripheral artery disease undergo major lower extremity amputation (LEA). The purpose of this study was to describe the current demographics and early outcomes of patients undergoing major LEA in the Vascular Quality Initiative (VQI). METHODS: The VQI amputation registry was reviewed to identify patients who underwent major LEAs. Patient factors, limb characteristics, procedure type, and intraoperative variables were analyzed by the level of amputation. Factors associated with amputation level, 30-day complications, and mortality were analyzed using chi-squared analysis for significance with associated P values. Propensity score adjustment was used to balance statistically significant differences observed in subject characteristics by amputation level for the associated relative risk of a given outcome. RESULTS: Between 2013 and 2015, 2,939 major LEAs were recorded in the VQI amputation registry. The ratio of below-knee to above-knee amputation (BKA:AKA) was 1.29:1. The mean age was 66 years, 64% were male, 84% lived at home before admission, and 68% were ambulatory. Comorbidities included diabetes (67%), coronary artery disease (32%), end-stage renal disease (22%), and chronic obstructive pulmonary disease (23%). The mean preoperative ankle-brachial index (ABI) was 0.78. Overall, 43% had a history of prior ipsilateral revascularization. Indications for amputation were ischemic rest pain or tissue loss (58%), uncontrolled infection (31%), acute ischemia (9%), and neuropathic tissue loss (2%). The overall perioperative complication rate was 15%, 25% were discharged home, and the 30-day mortality was 5%. Patients who received an AKA versus BKA were more likely to be female (40.61% vs. 31.70%), more than age 70 (48.79% vs. 32.55%), underweight (18.63% vs. 9.18%), nonambulatory (40.22% vs. 25.18%), have an ABI <0.6 (58.00% vs. 45.26%), and carry nonprivate insurance (77.40% vs. 69.08%) (all P < 0.001). Patients undergoing AKA were less likely to have 30-day postoperative complications (12.24% vs. 17.87%) but had higher 30-day mortality (6.70% vs. 3.09%) than BKA patients (all P < 0.001). CONCLUSIONS: In the VQI registry, major LEA was performed predominantly for ischemic rest pain and tissue loss with a BKA:AKA ratio of 1.29:1. Patients undergoing AKA versus BKA were older, had lower ABI, lower rates of 30-day postoperative complications but higher rates of 30-day mortality. This registry offers an important real-world resource for studies pertaining to vascular surgery patients undergoing major lower extremity amputation.

Smoking Habits of Patients Undergoing Treatment for Intermittent Claudication in the Vascular Quality Initiative.

BACKGROUND: Society for Vascular Surgery practice guidelines for the medical treatment of intermittent claudication give a GRADE 1A recommendation for smoking cessation. Active smoking is therefore expected to be low in patients suffering from intermittent claudication selected for vascular surgical intervention. The aim of this study is to evaluate the prevalence of smoking in patients undergoing intervention for intermittent claudication at the national level and to determine the relationship between smoking status and intervention. METHODS: The Vascular Quality Initiative (VQI) registries for infra-inguinal bypass, supra-inguinal bypass, and peripheral vascular intervention (PVI) were queried to identify patients who underwent invasive treatment for intermittent claudication. Patient factors, procedure type (bypass versus PVI), and level of disease (supra-inguinal versus infra-inguinal) were evaluated for associations with smoking status (active smoking or nonsmoking) by univariate and covariate analysis. RESULTS: Between 2010 and 2015, 101,055 procedures were entered in the 3 registries, with 40,269 (40%) performed for intermittent claudication. Complete data for analysis were present in 37,632 cases. At the time of intervention, 44% of patients were active smokers, with wide variation by regional quality group (16-53%). In covariate analysis, active smoking at treatment was associated with age <70 years (prevalence ratio [PR] 2.42), male gender (PR 1.03), chronic obstructive pulmonary disease (PR 1.35), absence of prior cardiovascular procedures (PR 1.15), poor medication usage (PR 1.10), preoperative ankle-brachial index (ABI) <0.9 (PR 1.19), and supra-inguinal disease (PR 1.14). Invasiveness of treatment (PVI versus bypass procedures) was not significantly associated with smoking status. During follow-up, 36% of patients had quit smoking. Predictors of smoking cessation included age ≥70 years (RR 1.45), ABI ≥0.9 (RR 1.12), and bypass procedures (RR 1.22). CONCLUSIONS: At the time of treatment, 44% of patients undergoing intervention for intermittent claudication in the VQI were active smokers and there was a wide regional variation. Prevalence of active smoking was greater in the presence of younger age, fewer comorbidities, lower ABI, and supra-inguinal disease. Type of procedure performed, and in turn level of invasiveness required, did not appear to be influenced by smoking status. Elderly patients and those undergoing open procedures were more likely to quit smoking during follow up. These findings suggest opportunities for greater smoking cessation efforts before invasive therapies for intermittent claudication.

Placement of Upper Extremity Arteriovenous Access in Patients with Central Venous Occlusions: A Novel Technique.

BACKGROUND: Central venous occlusion is a common occurrence in patients with end-stage renal disease. Placement of upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins is often not an option. Avoidance of lower extremity vascular access can decrease morbidity and infection. METHODS: The central venous lesions were crossed centrally via femoral access. The wire was retrieved in the neck extravascularly. A Hemodialysis Reliable Outflow catheter was then placed in the right atrium and completed with an arterial anastomosis. RESULTS: We describe a novel technique for placing upper extremity arteriovenous access in patients with occlusion of the brachiocephalic veins. This technique was utilized in 3 patients. The technical success was 100%. CONCLUSIONS: The placement of upper extremity arteriovenous access in patients with central venous occlusions is technically feasible.

Arteriovenous Hybrid Graft with Outflow in the Proximal Axillary Vein.

BACKGROUND: The patency of long-term hemodialysis access in end-stage renal disease patients remains a significant challenge. Often these patients are affected with limited venous outflow options, requiring limb abandonment, and creation of new access in the contralateral arm. Vascular surgeons are familiar with the exposure of the proximal axillary artery via an infraclavicular incision. The axillary vein is easily exposed through this technique. The use of the hybrid Gore graft can make the venous anastomosis easier. A hybrid graft with its venous outflow placed in the proximal axillary vein can extend the options of upper extremity access procedures. We reviewed our early experience with this technique. METHODS: A review of dialysis procedures at the Loma Linda VA was performed. All patients undergoing placement of arteriovenous grafts utilizing the Gore hybrid placed into the proximal axillary vein for outflow were identified. Outcomes in terms of primary and secondary patency rates were determined. RESULTS: Eight patients had placement of an arteriovenous hybrid graft in the proximal axillary vein via an infraclavicular incision. All patients had exhausted other options for hemodialysis access in the ipsilateral upper extremity. All grafts were used successfully for dialysis. The mean primary and secondary patency rates at 6 months were 37.5% and 62.5%, respectively. One patient developed steal syndrome, requiring proximalization of the graft. Seven out of the 8 patients required secondary procedures including thrombectomy (n = 16) and angioplasty (n = 17). CONCLUSIONS: Placement of a hybrid graft in the proximal axillary vein is an effective and suitable option for patients who have exhausted arteriovenous access sites in the arm. This procedure can easily be performed in an outpatient setting with a low complication rate and allowing for preservation of the contralateral upper extremity for future use.

Long-Term Outcome of Patients with Peripheral Arterial Disease and Tissue Loss Stratified to a Nonrevascularization Approach.

BACKGROUND: To evaluate the long-term outcome of patients presenting with peripheral artery disease (PAD) and tissue loss that were stratified in our limb preservation program to receive aggressive wound care without revascularization. METHODS: Veterans presenting with PAD and nonhealing wounds were prospectively enrolled into our Prevention of Amputation in Veterans Everywhere (PAVE) program. Patients were stratified according to management strategies, which include: revascularization, primary amputation, palliative limb care, and aggressive local wound care without revascularization (conservative group). This study focuses on the conservative cohort. Wound presentation, type of wound care provided, wound care-associated procedures, healing rates, revascularization, major amputation, wound recurrences, management of recurrent wounds, and patient survival were analyzed. RESULTS: Between January 2006 and November 2014, 601 patients were prospectively enrolled in our PAVE program. A total of 203 limbs in 183 patients with 231 wounds were allocated to the conservative group based on a validated pathway of care. Mean follow-up for this cohort was 33.6 months (range, 1.5-104). Complete wound healing was achieved in 148 limbs (73%). The mean time to healing was 4.1 months. Twenty-four limbs (11.8%) received "late revascularization" (beyond 6 months from enrollment). Overall limb preservation was 90% at 4 years, with 57% freedom from wound recurrence. In patients with recurrence over 80% were successfully managed without revascularization. Limb loss was attributed to infection in most cases. CONCLUSIONS: In this selected group, an initial approach with aggressive wound care without revascularization appears justified with good limb salvage. Long-term analysis demonstrated a notable incidence of wound recurrence (43%) albeit most recurrences can be successfully managed without the need for late revascularization and no increased incidence of limb loss.

Distal Radial Artery Embolization: An Alternative Approach towards Access Preservation and Limb Salvage in Radiocephalic Arteriovenous Fistulae Complicated by Steal Syndrome.

The incidence of radiocephalic arteriovenous fistulae complicated by ischemic steal syndrome is low; however, its sequelae can be quite devastating. Traditional management includes open ligation of the distal radial artery. This series details 4 cases of successful embolization of the distal radial artery for flow interruption to treat ischemic steal syndrome and salvage functional dialysis access. For radiocephalic arteriovenous fistulae complicated by steal syndrome, distal radial artery endovascular coil embolization is a valuable treatment strategy.

Comparison of Nonpenetrating Titanium Clips versus Continuous Polypropylene Suture in Dialysis Access Creation.

BACKGROUND: Nonpenetrating titanium surgical clips (clips) offer a theoretical advantage of inducing less intimal hyperplasia at an anastomosis because of less endothelial injury. Whether this translates into improved outcomes when used in the creation of arteriovenous fistulas (AVFs) remains unclear. We sought to compare the maturation, patency, and failure rates of anastomoses created using traditional continuous polypropylene suture and clips. METHODS: All primary AVF created at a single Veterans Administration Medical Center were reviewed over a 6-year period. Anastomoses were created with either clips or suture based on surgeon preference. Patient characteristics and surgical outcomes were collected. Comparisons were made between the 2 groups. RESULTS: Over a 6-year period, 334 fistulas were created (29% suture and 71% clips) in 326 patients. The mean age was 64.8 ± 11 years with 98% males. Comorbidities included diabetes (70%), hypertension (96.1%), and tobacco use (52.9% previous or current). Approximately half the patients were predialysis. Comparison of patient characteristics showed no differences between the suture and clip groups. There was no significant difference in maturation rate (suture 79% versus clips 72%, P = 0.25), median time to maturation (suture 62 ± 35 versus clips 71 ± 13 days, P = 0.07), 1 year primary patency rate (suture 37.4% versus clips 39.6, P = 0.72), 1 year assisted primary patency rate (suture 82.4% versus clips 76.3%, P = 0.31), or overall failure rates (suture 62% versus clips 58%, P = 0.56). Median time to initial failure or reintervention was not significantly different in the clip group (suture 615 [range, 239-991] versus clips 812 [range, 635-989] days, P = 0.72). CONCLUSIONS: Compared to traditional polypropylene suture creation of upper extremity AVFs, nonpenetrating clips had equivalent maturation, 1-year patency, and overall failure rates. Neither clips nor suture offers any clear advantage in the creation of AVF.

Early vascular consultation in the setting of oncologic resections: benefit for patients and a continuing source of open vascular surgical training.

BACKGROUND: Oncologic surgeons have become more aggressive at tumor resections that often require complex open vascular interventions. Vascular surgeons may be consulted preoperatively to aid in these cases, or commonly called into the operating room for an urgent consult. These operations provide a challenge to the vascular surgeon and also an opportunity for open vascular surgical training of residents. We present our experience with vascular surgical interventions during oncologic resections. METHODS: A retrospective review of a prospectively maintained vascular registry was performed to identify patients undergoing vascular surgery in the setting of oncologic resections. Tumor histology, location, type of vascular intervention, vascular, and oncologic outcomes were recorded and reviewed. RESULTS: Over a 7-year period, 21 oncologic cases involving vascular surgeons were identified. Tumor types included sarcoma (9), adenocarcinoma (4), germ cell (4), paraganglioma (2), and others (2). Tumor locations included abdominal/pelvic (15), cervical (3), and extremity (3). Complete resection was achieved in 18 of the 19 patients; 2 patients underwent exploration alone for carcinomatosis. Vascular surgical procedures included bypass grafts in 7 patients, resection with primary repair in 5 patients, ligation/excision in 4 patients, and arterial mobilization in 3 patients. No major vascular complications occurred. Short-term patency rates were 100%. Survival rates following therapeutic resection were 90%, 80%, and 80% at 1, 3, and 5 years, respectively. Vascular surgeons were involved in the preoperative planning in 11 cases (52%). Patients with preoperative vascular consultation had significantly fewer vascular injuries, a nonsignificant trend toward lower blood loss, and a nonsignificant trend toward improved survival than those with urgent intraoperative vascular consultation. CONCLUSIONS: Vascular interventions can lead to favorable long-term outcomes during definitive oncologic resection of diverse tumor histologies and locations. Vascular surgeons must be prepared to participate, frequently urgently, in oncologic procedures. Standard open techniques employing all aspects of vascular exposures continue to be integral to vascular surgery training. Preoperative consultation between the oncologic and vascular surgeons may lead to improved outcomes.

Clinical outcomes of patients with peripheral artery disease and lower extremity wounds based on a predetermined intention-to-treat strategy.

Achieving healing in patients with peripheral artery disease and lower extremity wounds represent a significant clinical challenge. Important outcome measures that define a successful therapeutic approach include wound healing rate, time to heal, and recurrence with time. This article reviews our experience managing a peripheral artery disease patient cohort at a Veterans Affairs medical center based on the initial clinical evaluation stratification and prospective enrollment into a predetermined treatment strategy.

Carotid duplex ultrasound changes associated with left ventricular assist devices.

BACKGROUND: Carotid duplex ultrasound (CDUS) is often used as a screening test in cardiac patients. Significant cardiac dysfunction may affect the accuracy of CDUS because of alterations in the cardiac cycle. Left ventricular assist devices (LVADs) are frequently implanted as a bridge to cardiac transplant. A review of CDUS in patients with LVADs was performed to assess their influence on arterial waveforms and velocities. METHODS: Patients with LVADs undergoing carotid duplex in our Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)-accredited vascular laboratory were identified. The carotid waveforms were analyzed qualitatively and quantitatively. Common carotid artery (CCA) and internal carotid artery (ICA) peak-systolic and end-diastolic velocities (PSV and EDV) were recorded as ICA/CCA velocity ratios. In patients with prior CDUS, the changes between these values were analyzed before and after LVAD placement. RESULTS: Of the 14 patients with LVADs treated in our institution over the past 2 years, 4 had CDUS (8 ICAs). Mean age was 57 years, and 3 of the 4 patients were men. All patients were free of cerebrovascular symptoms. Qualitatively, there was significant blunting of the CCA and ICA waveforms noted in all 8 ICAs. The degree of stenosis was reported as ≤15% in 7 ICAs and 15-45% in 1 ICA. The mean ICA PSV was 61.8 cm/sec. Two patients (4 ICAs) had CDUS before and after LVAD placement. Comparing pre- and post-LVAD values, the mean ICA PSV decreased by 42% (54 cm/sec; P = 0.04) and EDV increased by 51% (17 cm/sec; P = 0.3). The PSV and EDV ratios were unchanged. Overall assessment of category of stenosis was unchanged in 2 ICAs (≤15%), one decreased from moderate to mild (45-70% to 15-45%), and one ICA changed from 45-70% to ≤15% based on the decreased ICA PSV. CONCLUSIONS: The presence of an LVAD has a significant influence on CDUS findings. There is a qualitative change in the ICA with blunting of the waveform, and a quantitative change with a decreased PSV and an increased EDV. Compared with pre-LVAD placement, there is a significant decrease in PSV which may affect the accuracy of CDUS using velocity-based criteria. Further study into the accuracy of CDUS in patients with LVADs is necessary.

Evaluation of superficial femoral artery remote endarterectomy for treatment of critical limb ischemia in patients with limited autogenous conduit.

BACKGROUND: Many patients with critical limb ischemia require infrageniculate bypass with a prosthetic graft due to the limited availability of autogenous vein. Prosthetic grafts have been shown to have inferior patency and subject the patient to increased infection rates when compared to bypass with autogenous conduit for lower extremity revascularization. In an effort to avoid the use of prosthetic material, we evaluated the use of remote superficial femoral artery endarterectomy (RSFAE) with distal autogenous revascularization in patients with critical limb ischemia and limited conduit. METHODS: This study is a retrospective review of a prospectively maintained database from January 2009 to September 2011. All patients undergoing RSFAE for critical limb ischemia were identified. Patients undergoing RSFAE with simultaneous distal revascularization constituted the study group. Outcome variables, including patency, time to healing, limb salvage, ambulatory status, and survival, were analyzed. RESULTS: Twenty-one patients underwent RSFAE at our institution. The study group was comprised of 5 patients undergoing RSFAE and adjunct distal revascularization for critical limb ischemia during the study period. Four patients (80%) presented with tissue loss, and 1 (20%) presented with ischemic rest pain. Three (60%) required simultaneous outflow sequential vein bypass and 2 (40%) required distal endovascular revascularization. The distal target vessels for bypass included the infrageniculate popliteal artery, posterior tibial artery, and peroneal artery. The mean operative time was 5.3 hours. The mean length of hospital stay was 8 days. Technical success was 100%, and there were no early reconstruction failures. There was 1 popliteal wound complication, and no groin wound complications during the study follow-up. At 6 months postoperatively, 4 of 5 reconstructions were patent. Two of 5 patients (40%) required percutaneous reintervention for restenosis at 10 and 11 months, respectively. Primary assisted patency was 80% with a mean follow-up of 12.6 months (range 8-22 months). The 4 patients with tissue loss achieved initial wound healing at a mean time of 4.8 months. The limb salvage rate was 80% and there have been no deaths. CONCLUSIONS: Remote superficial femoral artery endarterectomy with distal revascularization allows for autogenous reconstruction in patients with critical limb ischemia and compromised conduit by shortening bypass length. This procedure constitutes an appealing alternative to the use of synthetic material for lower extremity revascularization. Further study is needed to determine whether the long-term results are superior to distal composite bypass or polytetrafluoroethylene bypass alone.

Effects of prior abdominal surgery, obesity, and lumbar spine level on anterior retroperitoneal exposure of the lumbar spine.

OBJECTIVE: To evaluate the effects of prior abdominal surgery and obesity and the level of spine exposure on the technical aspects and complications of anterior retroperitoneal exposure of the lumbar spine (ARES). DESIGN: Retrospective review of prospective database. SETTING: Academic vascular surgery practice. PATIENTS: Patients undergoing ARES from 2001 to 2011. MAIN OUTCOME MEASURES: Influence of prior abdominal surgery, obesity, and level of exposure on time to spine exposure and incidence of vascular and perioperative complications. RESULTS: Four hundred seventy-six patients underwent ARES. Mean (SD) age was 47.7 (12.6) years; 46.6% had undergone prior abdominal surgery. Mean (SD) body mass index (BMI) was 28.3 (5.5); 61.6% of procedures included the L4-5 disk. Mean (SD) time to exposure was 70.0 (25.5) minutes. Vascular injury occurred in 23.3% (3.8% major). Perioperative complications occurred in 16.4% of cases. Prior abdominal surgery had no effect on time to exposure, vascular injury, and perioperative complications. A BMI of 30 or more had no effect on time to exposure compared with a lower BMI. A BMI of 30 or more led to higher rates of vascular injury (30.8% vs 19.7%; P = .007) and overall complications (21.4% vs 14.0%; P = .04). Exposures involving L4-5 led to increased time to exposure (77.0 vs 56.2 minutes; P < .001) and higher rates of vascular injury (29.7% vs 13.1%; P < .001) but had no effect on overall complications compared with exposures for other levels. CONCLUSION: Prior abdominal surgery should not be considered a contraindication to ARES. Caution is warranted in obese patients and exposures involving L4-5.

Preoperative carotid duplex findings predict carotid stump pressures during endarterectomy in symptomatic but not asymptomatic patients.

BACKGROUND: Carotid stump pressure (CSP) is frequently measured to determine the need for shunt use during carotid endarterectomy (CEA). We hypothesized that the preoperative carotid duplex examination correlates with preoperative symptoms and intraoperative CSP. METHODS: Patients undergoing CEA over a 7-year period were identified from our vascular registry. CEA was performed with selective shunting on the basis of intraoperative CSP <30 mm Hg regardless of symptoms or contralateral internal carotid artery (ICA) stenosis. The preoperative duplex was categorized by ipsilateral and contralateral ICA diameter-reduction stenosis (<15%, 15-45%, 45-70%, 70-99% [severe] and occluded), and the direction of vertebral artery flow. The relationships among preoperative duplex findings, symptom status, and CSP were evaluated using unpaired t-test and Chi-square analysis. RESULTS: A total of 303 CEAs were performed. Stump pressures were documented in 284 patients, which comprised the study population. Asymptomatic severe stenosis was the indication for CEA in 179 cases (59.1%). Symptomatic patients (Sx) had significantly lower stump pressures than asymptomatic (ASx) patients (40.72 ± 16.27 vs. 45.8 ± 17.64 mm Hg, p = 0.0167). Fifty-seven patients (19%) had contralateral severe ICA stenosis or occlusion. Contralateral ICA stenosis or occlusion had significantly lower CSP than those with lesser degrees of stenosis (39.24 ± 15 vs. 44.82 ± 17.62 mm Hg, p = 0.0267). Contralateral ICA severe stenosis or occlusion correlated with lower CSP in Sx patients (32.05 ± 8.24 vs. 42.92 ± 16.95 mm Hg, p = 0.038) but not in ASx patients (43.2 ± 16 vs. 46.29 ± 17.5 mm Hg, p = 0.39). CSP was <30 mm Hg in 63% of Sx patients and 24% of ASx patients (p = 0.012). Overall shunt usage was 84/2,842 (9.5%). Perioperative stroke and death rate was 2.7%. Perioperative stroke did not correlate with the presence of contralateral occlusion, or severity of contralateral stenosis. CONCLUSIONS: Symptomatic patients undergoing CEA have lower stump pressures than ASx patients overall and also in the presence of contralateral disease. The incidence of perioperative stroke was not predicted by severity of contralateral disease. A strategy of selective shunting seems appropriate even in Sx patients with contralateral severe stenosis or occlusion. Although a high-risk cohort for perioperative neurologic events exists and may include those with symptomatic disease and contralateral severe stenosis or occlusion, further study is warranted to define the patients who will clinically benefit from shunt placement.

Management of lower extremity wounds in patients with peripheral arterial disease: a stratified conservative approach.

BACKGROUND: Traditional wound care algorithms include aggressive detection of peripheral arterial disease (PAD) and treatment with revascularization for all patients with PAD and lower extremity wounds. Not every patient with PAD and a wound meets Transatlantic Inter-Society Consensus (TASCII) criteria for critical limb ischemia. We hypothesize that a conservative approach to selected patients with PAD and lower extremity wounds may be safe, provide acceptable limb salvage, and that failure of this approach does not translate into increased limb loss. METHODS: Veterans referred with PAD and nonhealing ulcers/wounds were prospectively enrolled into our Prevention of Amputation Care Team program. Patients were stratified according to management strategies which included revascularization, primary amputation, palliative limb care, and aggressive local care without revascularization (conservative group). Patients were assigned to conservative management group on the basis of transcutaneous oxygen measurement (TcpO2) and ankle-brachial index (ABI). Healing rates, need for "late" revascularization, major amputation rates, and survival of this conservative group were analyzed in terms of ABI and ankle pressures. RESULTS: Between January 2006 and March 2009, a total of 190 lower extremity wounds in 178 patients with PAD were analyzed. Forty-nine patients with 52 wounds (27.9%) were deemed candidates for conservative treatment. During mean follow-up of 14.5 months, complete wound healing was documented in 33 patients (35 wounds: 67%). Mean time to complete wound healing was 4.5 months. Predictors of healing included mean ABI (0.62 vs. 0.42 [p < 0.001]) and ankle pressures >70 mm Hg (p = 0.025). Sixteen patients (17 wounds: 33%) were not healed at the time of analysis. Of these, three patients (four wounds: 8%) showed active healing and 13 (13 wounds: 25%) failed conservative management. Nine patients (9 wounds: 17%) underwent late revascularization. There was one case of amputation (2%) and six cases of mortalities (12.2%). There was no increase in the rates of limb loss and mortality in patients who failed conservative management and underwent "late" revascularization. CONCLUSIONS: Conservative management of lower extremity nonhealing wounds in selected patients with PAD is successful in over two-thirds of the patients. The failure of conservative management does not increase mortality or amputation rates. When the TcPO2 is >30 mm Hg, the ABI and the TASC II definition of critical limb ischemia predict wound healing and should be key factors in considering conservative therapy.

Rupture of an abdominal aortic aneurysm following nonaccidental blunt abdominal trauma.

A 78-year-old woman presented to our trauma center with an initial, erroneous history of a ground-level fall. Further investigation revealed that the patient had been assaulted by her husband immediately prior to presentation. The initial abdominal examination was benign, and the patient was hemodynamically stable. The patient was found to have a large subdural hematoma (SDH). Following open evacuation of the SDH, the patient developed ongoing hemodynamic instability. Further evaluation with computed tomography of the abdomen and pelvis uncovered the diagnosis of a 6 cm abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. The patient underwent emergent repair of the ruptured AAA. There were no other significant intra-abdominal injuries, and the patient had an uneventful recovery. This case highlights the need for thorough evaluation of the trauma patient and recognition of the possibility of coexistent AAA in the elderly trauma patient. We believe that this is the first reported case of a ruptured AAA following nonaccidental blunt abdominal trauma.

The role of the vascular surgeon in anterior retroperitoneal spine exposure: preservation of open surgical training.

OBJECTIVE: Open vascular surgical procedures have decreased since the advent of endovascular repair. Advances in spinal fusion techniques and artificial disc replacement have led to an increase in the need for anterior retroperitoneal exposure of the lumbar spine (ARES). Vascular surgeons participate as "exposure surgeons" for these cases due to their unique skills in dealing with retroperitoneal structures. We report a single center experience with this procedure and focus on injury pattern and preservation of open surgical training. METHODS: Patients undergoing ARES over an 8-year period were identified from our vascular registry. A two-team approach involving a vascular surgeon and spine surgeon has been routinely employed. ARES was performed for anterior lumbar interbody fusion or total disc replacement. The intraoperative techniques of vascular manipulation were reviewed. The need for suture repair of vascular structures and the incidence and timing of serious vascular injury was recorded. RESULTS: Four-hundred and five ARES procedures were performed. The levels exposed included L5-S1 alone (128), L4-5 (54), 4-5 and 5-S1 (139), and other combinations in 84 cases. The exposure involved the L4-5 disc in 243 cases (60%). Exposure of L4-5 was accomplished above the left common iliac artery (CIA) in 44%, between the left CIA and common iliac vein (CIV) in 45%, and below the left CIV in 11%. Minor vascular injuries (all venous) needing suture repair occurred in 24% of cases overall. Minor vascular injuries occurred during both exposure (43%) and instrumentation (57%). Minor vascular injuries were significantly more frequent in cases involving the L4-5 disc than in those not involving L4-5 (31.7% vs 11.1%, P < .001). Serious, life-threatening, vascular injuries occurred in 12 patients (3%), all during instrumentation, and included left CIV laceration (seven cases), right CIV laceration (two cases), and inferior vena cava laceration, distal aortic plaque disruption and left CIA laceration in one case each. There was no association between body mass index, prior surgery, or type of instrumentation and the occurrence of minor or major vascular injuries. Postoperative vascular complications included three deep vein thromboses; two of which occurred in patients with CIV laceration. CONCLUSION: Vascular expertise is important in anterior retroperitoneal lumbar spine exposure. Minor venous injuries frequently occur during exposure and instrumentation. Significant vascular injuries, while rare, occur during instrumentation, therefore the vascular surgeon should remain present throughout the entire procedure. The vascular manipulations required during exposure of the L4-5 disc offer an excellent opportunity for open vascular surgical experience. Vascular surgeon involvement in these cases allows for prompt repair of vascular injuries and provides opportunities for the vascular surgery resident to augment his/her open surgical training.

Management of symptomatic spontaneous isolated visceral artery dissection: is emergent intervention mandatory?

Spontaneous dissection of a visceral artery without associated aortic dissection is rare, although more cases have recently been reported because of the advancement of diagnostic techniques. The risk factors, causes, and natural history of spontaneous isolated visceral artery dissection are unclear. Treatment with open surgery, endovascular stenting, or anticoagulation therapy has been proposed; however, there is no consensus on the optimal management. We present three cases of spontaneous and isolated dissection of visceral arteries. Dissection involved the superior mesenteric artery in one and the celiac artery in two. All three patients presented with acute abdominal pain but lacked any peritoneal irritation. The patients were treated nonoperatively with anticoagulants or antiplatelets. No surgical or endovascular intervention was performed. Follow-up imaging studies demonstrated improvement of the dissection in two patients and no change in one patient. All patients were symptom-free over a mean follow-up of 17 months. Nonoperative treatment with close observation is an acceptable strategy in the management of spontaneous isolated dissection of visceral arteries. Emergent intervention is not mandatory in symptomatic patients without evidence of acute bowel ischemia or hemorrhage.