Mortality and major postoperative complications within 1 year after vascular surgery: a prospective cohort study.

INTRODUCTION: Patients undergoing vascular procedures are prone to developing postoperative complications affecting their short­term mortality. Prospective reports describing the incidence of long­term complications after vascular surgery are lacking. OBJECTIVES: We aimed to describe the incidence of complications 1 year after vascular surgery and to evaluate an association between myocardial injury after noncardiac surgery (MINS) and 1­year mortality. PATIENTS AND METHODS: This is a substudy of a large prospective cohort study Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION). Recruitment took place in 28 centers across 14 countries from August 2007 to November 2013. We enrolled patients aged 45 years or older undergoing vascular surgery, receiving general or regional anesthesia, and hospitalized for at least 1 night postoperatively. Plasma cardiac troponin T concentration was measured before the surgery and on the first, second, and third postoperative day. The patients or their relatives were contacted 1 year after the procedure to assess the incidence of major postoperative complications. RESULTS: We enrolled 2641 patients who underwent vascular surgery, 2534 (95.9%) of whom completed 1­year follow­up. Their mean (SD) age was 68.2 (9.8) years, and the cohort was predominantly male (77.5%). The most frequent 1­year complications were myocardial infarction (224/2534, 8.8%), amputation (187/2534, 7.4%), and congestive heart failure (67/2534, 2.6%). The 1­year mortality rate was 8.8% (223/2534). MINS occurred in 633 patients (24%) and was associated with an increased 1­year mortality (hazard ratio, 2.82; 95% CI, 2.14-3.72; P <0.001). CONCLUSIONS: The incidence of major postoperative complications after vascular surgery is high. The occurrence of MINS is associated with a nearly 3­fold increase in 1­year mortality.

Hemorrhage From Left Hepatic Artery Pseudoaneurysm as a Complication of Acute Pancreatitis in a Patient With Fibromuscular Dysplasia.

Hepatic artery pseudoaneurysms are a rare complication of pancreatitis, and their rupture and bleeding cause high mortality. We present the case of a 76-year-old woman with fibromuscular dysplasia who developed a new left hepatic artery pseudoaneurysm within a week of her first episode of acute pancreatitis and later suffered an acute pseudoaneurysm bleed successfully treated with transcatheter coil embolization. To the best of our knowledge, this is the first case reported of a patient with fibromuscular dysplasia with pancreatitis-related pseudoaneurysm formation. One must consider pseudoaneurysms and associated bleeding as complications of acute pancreatitis because prompt recognition can lead to timely management.

Rivaroxaban in patients with symptomatic peripheral artery disease after lower extremity bypass surgery with venous and prosthetic conduits.

BACKGROUND: Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) have a high risk of adverse limb and cardiovascular events. The results from the VOYAGER PAD (efficacy and safety of rivaroxaban in reducing the risk of major thrombotic vascular events in subjects with symptomatic peripheral artery disease undergoing peripheral revascularization procedures of the lower extremities) trial have demonstrated that rivaroxaban significantly reduced this risk with an overall favorable net benefit for patients undergoing surgical revascularization. However, the efficacy and safety for those treated by surgical bypass, including stratification by bypass conduit (venous or prosthetic), has not yet been described. METHODS: In the VOYAGER PAD trial, patients who had undergone surgical and endovascular infrainguinal LER to treat PAD were randomized to rivaroxaban 2.5 mg twice daily or placebo on top of background antiplatelet therapy (aspirin 100 mg to be used in all and clopidogrel in some at the treating physician's discretion) and followed up for a median of 28 months. The primary end point was a composite of acute limb ischemia, major amputation of vascular etiology, myocardial infarction, ischemic stroke, and cardiovascular death. The principal safety outcome was major bleeding using the TIMI (thrombolysis in myocardial infarction) scale. The index procedure details, including conduit type (venous vs prosthetic), were collected at baseline. RESULTS: Among 6564 randomized patients, 2185 (33%) had undergone surgical LER. Of these 2185 patients, surgical bypass had been performed for 1448 (66%), using a prosthetic conduit for 773 patients (53%) and venous conduit for 646 patients (45%). Adjusting for the baseline differences and anatomic factors, the risk of unplanned limb revascularization in the placebo arm was 2.5-fold higher for those receiving a prosthetic conduit vs a venous conduit (adjusted hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.65-3.90; P < .001), and the risk of acute limb ischemia was three times greater (adjusted HR, 3.07; 95% CI, 1.84-5.11; P < .001). The use of rivaroxaban reduced the primary outcome for the patients treated with bypass surgery (HR, 0.78; 95% CI, 0.62-0.98), with consistent benefits for those receiving venous (HR, 0.66; 95% CI, 0.49-0.96) and prosthetic (HR, 0.87; 95% CI, 0.66-1.15) conduits (Pinteraction = .254). In the overall trial, major bleeding using the TIMI scale was increased with rivaroxaban. However, the numbers for those treated with bypass surgery were low (five with rivaroxaban vs nine with placebo; HR, 0.55; 95% CI, 0.18-1.65) and not powered to show statistical significance. CONCLUSIONS: Surgical bypass with a prosthetic conduit was associated with significantly higher rates of major adverse limb events relative to venous conduits even after adjustment for patient and anatomic characteristics. Adding rivaroxaban 2.5 mg twice daily to aspirin or dual antiplatelet therapy significantly reduced this risk, with an increase in the bleeding risk, but had a favorable benefit risk for patients treated with bypass surgery, regardless of conduit type. Rivaroxaban should be considered after lower extremity bypass for symptomatic PAD to reduce ischemic complications of the heart, limb, and brain.

Open surgical repair of giant hepatic artery aneurysm.

Hepatic artery aneurysms (HAAs) are visceral artery aneurysms with a significant risk of mortality upon rupture. HAAs can be treated with open or endovascular repair. The choice of treatment modality depends on aneurysm anatomy, adequacy of visceral collaterals, and overall health status of the patient. This case report describes the successful repair of a giant 14.9-cm HAA through open aneurysm resection and end-to-end anastomosis of the distal common hepatic artery to the gastroduodenal artery. The patient recovered postoperatively with no complications and normal liver function. This case report also reviews other giant HAAs that have been reported in literature.

Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease.

Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided-categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.

The Association of Cannabis Use Disorder with Acute Limb Ischemia and Critical Limb Ischemia.

OBJECTIVES: Heavy cannabis use has been associated with the development of acute myocardial infarction and stroke. The objective of this study was to determine if heavy, chronic cannabis use is associated with the development of acute limb ischemia (ALI) or critical limb ischemia (CLI). METHODS: We conducted a retrospective cohort study within the National Inpatient Sample (2006-2015). Patients without cannabis use disorder (CUD) were matched to patients with CUD in a 2:1 ratio using propensity scores. Our primary outcomes were incidence of ALI and CLI. Secondary outcomes included incidence of acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), frequency of open or endovascular interventions, length of stay, and total costs. Sensitivity analyses were performed with alternative models, including in the entire unmatched cohort with regression models utilizing survey weights to account for sampling methodology. RESULTS: We identified a cohort of 46,297 857 unmatched patients. Patients with CUD in the unmatched cohort were younger, with less cardiovascular risk factors, but higher rates of smoking and substance abuse. The matched cohort included 824,856 patients with CUD and 1,610,497 controls. Those with CUD had a higher incidence of ALI (OR 1.20 95% CI: 1.04-1.38 P=.016). Following multiple sensitivity analyses, there was no robust association between CLI and CUD. We observed no robust association of CUD with AMI, CMI, procedures performed, frequency of amputation, costs, or total length of stay. CONCLUSIONS: Cannabis use disorder was associated with a significantly higher incidence of admission for acute limb ischemia. CUD was not associated with an increased risk of critical limb ischemia following sensitivity analysis. Given CUD is often seen in younger, less co-morbid patients it provides an important target for intervention in this population.

Comparison of the Accuracy of Maxillary Positioning With Interim Splints Versus Patient-Specific Guides and Plates in Executing a Virtual Bimaxillary Surgical Plan.

PURPOSE: An extension of digital technology is to provide patient-specific hardware to reposition the first jaw in a bimaxillary case without the use of an intermediate splint. The purpose of our study was to determine if there were significant differences in maxillary repositioning using interim splints versus patient-specific guides and implants (PSIs) in executing a bimaxillary virtual surgical plan (VSP). MATERIALS AND METHODS: This is a retrospective cohort study of patients who underwent bimaxillary orthognathic surgery with interim splints or PSIs planned with VSP at our institution. The difference in maxillary positions from the VSP to the postoperative cone-beam computed tomography (CBCT) was evaluated in both groups. The primary predictor variable was the method by which the maxilla was repositioned (interim splint vs PSI). The primary outcome variable was the postoperative 3D position of the maxillary incisors and right and left first molars in the anteroposterior, transverse, and vertical dimensions. Differences in the planned and postoperative positions of the above landmarks in all three planes of space between the two groups were statistically analyzed. RESULTS: A total of 82 patients were included. 13 patients had their maxillae repositioned with an interim splint between the unoperated mandible and the mobile maxilla, and 69 patients had their maxilla repositioned using custom drill/cutting guides and a PSI. The mean difference between the planned and actual position of the maxilla in the PSI group was smaller than in the splint group. In the PSI group alone, vertical changes were accurate whether the maxilla was being superiorly or inferiorly repositioned. CONCLUSION: The use of a PSI provides more accurate maxillary repositioning during bimaxillary surgery than the use of an interim splint.

Medical Therapy Following Urgent/Emergent Revascularization in Peripheral Artery Disease Patients (Canadian Acute Limb Ischemia Registry [CANALISE I]).

BACKGROUND: Following severe limb ischemia requiring urgent/emergent revascularization, peripheral arterial disease patients suffer a high risk of recurrent atherothrombosis. METHODS: Patients discharged from Hamilton General Hospital (Hamilton, Ontario) between April 2016 and September 2017 following severe limb ischemia requiring urgent/emergent revascularization were identified via the Local Health Integration Network CorHealth database, with supplemental information from chart review. RESULTS: A total of 158 patients admitted for urgent/emergent revascularization were identified (148 alive at discharge). Among patients without a pre-existing indication for anticoagulation, 38.8% (n = 47) were discharged on single-antiplatelet therapy, 27.3% (n = 33) on dual-antiplatelet therapy, 19.8% (n = 24) on anticoagulants plus antiplatelet therapy, 6.6% (n = 8) on anticoagulants alone, and 2.6% (n = 3) on unknown therapy. Patients who received angioplasty with stenting were more likely be discharged on dual-antiplatelet therapy (hazard ratio [HR]: 7.14; 95% confidence interval [CI]: 2.87-17.76; P < 0.01); patients who received an embolectomy/thrombectomy were more likely be discharged on an anticoagulant alone (HR: 2.61; 95% CI: 1.00-6.81; P = 0.049); and patients who received peripheral bypass grafting were more likely be discharged on single-antiplatelet therapy (HR: 2.28; 95% CI: 1.11-4.69; P = 0.024). Neither statins (60.8% vs 56.3%; P = 0.23) nor renin-angiotensin-aldosterone system inhibitors (48.7% vs 50.6%; P = 0.58) were prescribed at higher rates at discharge, compared with the rate at admission. CONCLUSIONS: Substantial heterogeneity exists in antithrombotic prescription following urgent/emergent revascularization. No intensification of non-antithrombotic vascular protective medications occurred during hospitalization. Clinical trials and health system interventions to optimize medical therapy in peripheral arterial disease patients are urgently needed.

INTRODUCTION: Après une ischémie grave d'un membre ayant nécessité une revascularisation urgente/nouvelle revascularisation, les patients atteints d'une maladie artérielle périphérique ont un risque élevé de récidive d'athérothrombose. MÉTHODES: Nous avons recensé les patients qui ont obtenu leur sortie de la Hamilton General Hospital (Hamilton, Ontario) entre avril 2016 et septembre 2017 à la suite d'une ischémie grave d'un membre ayant nécessité une revascularisation urgente/nouvelle revascularisation via la base de données Local Health Integration Network CorHealth et grâce aux renseignements complémentaires issus de la revue des dossiers. RÉSULTATS: Nous avons recensé un total de 158 patients admis pour une revascularisation urgente/nouvelle revascularisation (148 patients en vie à la sortie de l'hôpital). Parmi les patients chez lesquels l'anticoagulation n'avait pas antérieurement été indiquée, 38,8 % (n = 47) avaient reçu à leur sortie de l'hôpital un simple traitement antiplaquettaire; 27,3 % (n = 33), une bithérapie antiplaquettaire; 19,8 % (n = 24), des anticoagulants plus un traitement antiplaquettaire; 6,6 % (n = 8), des anticoagulants seuls; 2,6 % (n = 3), un traitement inconnu. Les patients qui avaient subi une angioplastie et une pose d'endoprothèse étaient plus susceptibles d'obtenir à leur sortie de l'hôpital une bithérapie antiplaquettaire (rapport de risque [RR] : 7,14; intervalle de confiance [IC] à 95 % : 2,87-17,76; P < 0,01); les patients qui avaient subi une embolectomie, ou thrombectomie, étaient plus susceptibles d'obtenir à leur sortie de l'hôpital un anticoagulant seul (RR : 2,61; IC à 95 % : 1,00-6,81; P = 0,049); les patients qui avaient subi un pontage périphérique étaient plus susceptibles d'obtenir à leur congé de l'hôpital un simple traitement antiplaquettaire (RR : 2,28; IC à 95 % : 1,11-4,69; P = 0,024). Comparativement à l'admission, ni les statines (60,8 % vs 56,3 %; P = 0,23) ni les inhibiteurs du système rénine­angiotensine­aldostérone (48,7 % vs 50,6 %; P = 0,58) n'avaient été prescrits à des taux plus élevés à la sortie de l'hôpital. CONCLUSIONS: Nous observons une hétérogénéité substantielle de l'ordonnance des antithrombotiques après la revascularisation urgente/nouvelle revascularisation. L'hospitalisation n'a donné lieu à aucune augmentation des médicaments de protection vasculaire non antithrombotiques. Des essais cliniques et des interventions du système de santé qui permettent d'optimiser le traitement médical des patients atteints d'une maladie artérielle sont d'une urgente nécessité.

A National Canadian Survey of Antithrombotic Therapy After Urgent and Emergent Limb Revascularization.

Patients with peripheral artery disease who undergo urgent or emergent lower extremity revascularization have the highest risk of major adverse cardiac and limb events. Although available evidence suggests that antithrombotic therapy reduces this risk, optimal antithrombotic therapy is unclear. In this report, we aim to describe current practice patterns for use of antithrombotic therapies after urgent/emergent peripheral artery revascularization. A self-administered online survey was distributed to all active vascular surgeons registered through the Canadian Society of Vascular Surgery (n = 149) between March 19 and April 29, 2019. The overall response rate was 53% (79/149). More than half of the respondents use a medical specialist service in aiding decision-making (52% (95% confidence interval [CI], 40.9%-63.0%). When concerned for high rethrombosis risk, respondents most commonly favoured initiation of either aspirin plus full dose anticoagulation (60% [95% CI, 49.2%-70.8%]) or dual antiplatelet therapy (58% (95% CI, 47.1%-68.9%]). Intraoperative findings and patient characteristics prompting concern for high rethrombosis risk include residual proximal/distal occlusive disease (75% [95% CI, 65.5%-84.5%]), poor-quality venous conduit (76% [95% CI, 66.6%-85.4%]), distal/infrapopliteal synthetic conduit (77% [95% CI, 67.7%-86.3%]), and history of multiple previous failed vascular interventions (98% [95% CI, 94.9%-100%]). More than 90% of respondents believe significant uncertainty exists in antithrombotic decision-making after urgent/emergent peripheral revascularization. Substantial uncertainty exists regarding antithrombotic therapy after urgent/emergent revascularization. In patients at high perceived rethrombosis risk, vascular surgeons preferentially choose aspirin with full-dose anticoagulation or dual antiplatelet therapy. Because of the clinical uncertainty in this domain, trials to determine optimal antithrombotic therapy in this high-risk population are required.

Rivaroxaban and Aspirin in Peripheral Artery Disease Lower Extremity Revascularization: Impact of Concomitant Clopidogrel on Efficacy and Safety.

BACKGROUND: The VOYAGER PAD trial (Vascular Outcomes Study of ASA Along With Rivaroxaban in Endovascular or Surgical Limb Revascularization for Peripheral Artery Disease) demonstrated superiority of rivaroxaban plus aspirin versus aspirin to reduce major cardiac and ischemic limb events after lower extremity revascularization. Clopidogrel is commonly used as a short-term adjunct to aspirin after endovascular revascularization. Whether clopidogrel modifies the efficacy and safety of rivaroxaban has not been described. METHODS: VOYAGER PAD was a phase 3, international, double-blind, placebo-controlled trial in patients with symptomatic PAD undergoing lower extremity revascularization randomized to rivaroxaban 2.5 mg twice daily plus 100 mg aspirin daily or rivaroxaban placebo plus aspirin. The primary efficacy outcome was a composite of acute limb ischemia, major amputation of a vascular cause, myocardial infarction, ischemic stroke, or cardiovascular death. The principal safety end point was TIMI (Thrombolysis in Myocardial Infarction) major bleeding, with International Society on Thrombosis and Haemostasis major bleeding a secondary safety outcome. Clopidogrel use was allowed at the discretion of the investigator for up to 6 months after the qualifying revascularization. RESULTS: Of the randomized patients, 3313 (50.6%) received clopidogrel for a median duration of 29.0 days. Over 3 years, the hazard ratio for the primary outcome of rivaroxaban versus placebo was 0.85 (95% CI, 0.71-1.01) with clopidogrel and 0.86 (95% CI, 0.73-1.01) without clopidogrel without statistical heterogeneity (P for interaction=0.92). Rivaroxaban resulted in an early apparent reduction in acute limb ischemia within 30 days (hazard ratio, 0.45 [95% CI, 0.14-1.46] with clopidogrel; hazard ratio, 0.48 [95% CI, 0.22-1.01] without clopidogrel; P for interaction=0.93). Compared with aspirin, rivaroxaban increased TIMI major bleeding similarly regardless of clopidogrel use (P for interaction=0.71). With clopidogrel use >30 days, rivaroxaban was associated with more International Society on Thrombosis and Haemostasis major bleeding within 365 days (hazard ratio, 3.20 [95% CI, 1.44-7.13]) compared with shorter durations of clopidogrel (P for trend=0.06). CONCLUSIONS: In the VOYAGER PAD trial, rivaroxaban plus aspirin reduced the risk of adverse cardiovascular and limb events with an early benefit for acute limb ischemia regardless of clopidogrel use. The safety of rivaroxaban was consistent regardless of clopidogrel use but with a trend for more International Society on Thrombosis and Haemostasis major bleeding with clopidogrel use >30 days than with a shorter duration. These data support the addition of rivaroxaban to aspirin after lower extremity revascularization regardless of concomitant clopidogrel, with a short course (≤30 days) associated with less bleeding. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02504216.

Single Institution Experience with Hybrid Endovascular and Surgical Repairs Involving the Distal Aortic Arch.

BACKGROUND: A hybrid approach of aortic arch and descending aorta pathology, involving surgical debranching of the great vessels after endovascular stenting, has been increasingly used as an alternative to entirely open surgical repair. This study reviews and reports our single-center experience with hybrid aortic arch repair over the span of a decade. METHODS: A total of 43 patients who underwent hybrid arch repair from 2005 to 2015 were identified. Key endpoints included the presenting pathology, perioperative details, and postoperative outcomes. RESULTS: The mean age was 64.9 years at the commencement of surgery (61.4% men [n = 27] and 38.6% women [n = 16]). Presenting pathologies included aneurysms (77%), dissections (16%), pseudoaneurysms (5%), and transections (2%). While most procedures were multistaged, single-stage interventions were completed for 16.3% (n = 7) of patients. Emergent surgeries were performed in 23.3% of cases; the remaining 76.7% of cases were elective. The proximal extents of endovascular repair were zone 0 (n = 4), zone 1 (n = 12), zone 2 (n = 20), and zone 3 (n = 1). The remaining 6 patients had had aberrant or anomalous distal origins of a great vessel that required debranching. Technical success rates of surgical revascularizations and subsequent endovascular stenting were both 100%. The 30-day perioperative event rates for mortality, stroke, and cardiac events were 7.0% (n = 3), 4.7% (n = 2), and 9.3% (n = 4), respectively. At the end of 2-year follow-up, total mortality and stroke rates were 11.6% (n = 5) and 7.0% (n = 3), respectively. The 2-year primary patency of the revascularizations was 97.8%, and the associated primary-assisted patency was 100%. Secondary interventions were necessary for 32% (n = 12) of the patients, 67% of which (n = 8) were warranted because of endoleaks. The remaining secondary interventions were required to resolve device migration (n = 1), stent graft stenosis (n = 1), and disease progression (n = 2). CONCLUSIONS: Hybrid approaches are viable alternatives to entirely open surgical treatments of acute and chronic aortic arch pathology and may be particularly attractive for high-risk patients. Surgical revascularizations appear durable, but endovascular reintervention is not uncommon and highlights the need for careful surveillance after repair.

A comparison of duplex ultrasound findings after cyanoacrylate embolization versus endovenous laser ablation of the great saphenous vein.

BACKGROUND: Whereas numerous studies have demonstrated noninferiority of cyanoacrylate embolization (CAE) relative to endovenous laser ablation (EVLA), little is known about the natural history of the vein or the glue that is implanted. This study provides the first description of duplex ultrasound changes of the great saphenous vein (GSV) after CAE relative to EVLA as well as a pragmatic view of outcomes in clinical practice. METHODS: Patients treated with CAE and EVLA at our institution were matched by time of procedure and vein size. GSV diameter was measured at the saphenofemoral junction, midthigh, and knee. Duplex ultrasound imaging was repeated after treatment in the same noninvasive laboratory with an identical protocol. Clinical data were collected by retrospective chart review. RESULTS: Of 481 eligible patients, 119 underwent postoperative duplex ultrasound imaging. Although there was a trend toward decreased vein diameter over time in CAE patients relative to their preoperative vein diameter, this failed to reach statistical significance at the midthigh (P = .32) or at the knee (P = .511). In EVLA patients, as follow-up interval increased, the vein was less frequently visualized on ultrasound at the midthigh (P = .046) and knee (P = .038). At >2 years of follow-up, >80% of EVLA patients had no visible vein segment. Anatomic recurrence was observed in 10.5% of CAE patients and 8.2% of EVLA patients, which was not statistically significantly different (P = .60). The majority of recurrence was observed in the presence of incompetent tributaries. CONCLUSIONS: After CAE of the GSV, our results indicate that the glue cast remains for at least 3 years. Although our results suggest that the glue is broken down over time, this process is much slower than expected. In contrast, after EVLA, the vein tissue is remodeled and is no longer visible with time. In our study, which represents a pragmatic clinical population with a large (median, 9.2 mm) vein diameter, we again demonstrate no statistically significant difference in recurrence rates. Whereas CAE offers an attractive treatment option for GSV incompetence, the glue cast remains for a prolonged time, and longer follow-up studies than those currently available are indicated.

Myocardial Injury After Noncardiac Surgery (MINS) in Vascular Surgical Patients: A Prospective Observational Cohort Study.

OBJECTIVE: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. BACKGROUND: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. METHODS: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. RESULTS: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%-22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%-20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%-3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46-25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1-29.1) and without an ischemic feature (12.2%; 95% CI, 5.3-25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6-82.4). CONCLUSIONS: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

Blunt innominate artery trauma requiring repair and carotid ligation.

Traumatic dissection of the innominate artery is a rare clinical entity. Management of a patient with motorsensory compromise and dissection extending to the subclavian and right common carotid arteries is quite rare and can be quite involved. Here we present such a case and discuss the unique peri-operative decision-making in the context of what is reported in the literature. Restoration of motorsensory function is critical and in this case, requiring a multi-disciplinary team.

Product analysis and initial reliability testing of the total mesorectal excision-quality assessment instrument.

BACKGROUND: Product analysis of rectal cancer resection specimens before specimen fixation may provide an immediate and relevant evaluation of surgical performance. We tested the interrater reliability (IRR) of a product analysis tool called the Total Mesorectal Excision-Quality Assessment Instrument (TME-QA). METHODS: Participants included two gold standard raters, five pathology assistants, and eight pathologists. Domains of the TME-QA reflect total mesorectal excision principles including: (1) completeness of mesorectal margin; (2) completeness of mesorectum; (3) coning of distal mesorectum; (4) physical defects; and (5) overall specimen quality. Specimens were scored independently. We used the generalizability theory to assess the tool's internal consistency and IRR. RESULTS: There were 39 specimens and 120 ratings. Mean overall specimen quality scores for the gold standard raters, pathologists, and assistants were 4.43, 4.43, and 4.50, respectively (p > 0.85). IRR for the first nine items was 0.68 for the full sample, 0.62 for assistants alone, 0.63 for pathologists alone, and 0.74 for gold standard raters alone. IRR for the item overall specimen quality was 0.67 for the full sample, 0.45 for assistants, 0.80 for pathologists, and 0.86 for gold standard raters. IRR increased for all groups when scores were averaged across two raters. CONCLUSIONS: Assessment of surgical specimens using the TME-QA may provide rapid and relevant feedback to surgeons about their technical performance. Our results show good internal consistency and IRR when the TME-QA is used by pathologists. However, for pathology assistants, multiple ratings with the averaging of scores may be needed.

Infected aortic stent graft with Propionibacterium acnes.

An infected aortic endograft is an uncommon event, and when it happens it can be of significant morbidity and mortality to the patient. We present here a case of a patient with an infected aortic endograft following percutaneous translumbar sac embolization for a type II endoleak leading to sac expansion. The cultured pathogen was Propionibacterium acnes, a commonly occurring skin bacterium that leads to the clinical condition "acne vulgaris." The patient underwent graft explantation and reconstruction with autogenous femoral vein. To our knowledge, there are no previously published reports of aortic graft infections with P acnes.

Mortality and reintervention following elective abdominal aortic aneurysm repair.

BACKGROUND: The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches. METHODS: MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR) of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs EVAR were calculated for short- and long-term mortality and reintervention rates. RESULTS: The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair. CONCLUSIONS: Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group. Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach to AAAs can be supported by the meta-analysis.

Exploring how surgeon teachers motivate residents in the operating room.

BACKGROUND: Motivation in teaching, mainly studied in disciplines outside of surgery, may also be an important part of intraoperative teaching. We explored techniques surgeons use to motivate learners in the operating room (OR). METHODS: Forty-four experienced surgeon teachers from multiple specialties participated in 9 focus groups about teaching in the OR. Focus groups were transcribed and subjected to qualitative thematic analysis by 3 reviewers through an iterative, rigorous process. RESULTS: Analysis revealed 8 motivational techniques. Surgeons used motivation techniques tacitly, describing multiple ways that they facilitate resident motivation while teaching. Two major categories of motivational techniques emerged: (1) the facilitation of intrinsic motivation; and (2) the provision of factors to stimulate extrinsic motivation. CONCLUSIONS: Surgeons unknowingly but tacitly and commonly use motivation in intraoperative teaching and use a variety of techniques to foster learners' intrinsic and extrinsic motivation. Motivating learners is 1 vital role that surgeon teachers play in nontechnical intraoperative teaching.