Ankle-brachial index use in peripheral vascular interventions for claudication.

OBJECTIVE: The ankle-brachial index (ABI) has been recommended as the first-line noninvasive test to establish a diagnosis of peripheral arterial disease in patients with claudication (grade 1, level A evidence). The ABI can also be used to monitor disease progression and assess the benefits of treatment after peripheral vascular intervention (PVI). The Upper Midwest Region of the Vascular Quality Initiative has a unique balance of participation from vascular surgeons, interventional radiologists, and cardiologists performing PVI. We sought to identify the use of ABI and assess the functional outcomes of patients who had undergone PVI for claudication. METHODS: We conducted a review of the Upper Midwest Region of the Vascular Quality Initiative to identify PVI performed for claudication from native artery atherosclerotic occlusive disease in nondiabetic patients from 2010 to 2020. Patients who had undergone PVI with infection, tissue loss, rest pain, bypass graft stenosis, or aneurysmal disease were excluded. The primary outcomes included the ABI, ambulation status, and functional status before and after PVI. RESULTS: A total of 3787 patients (58.0% male, 42.0% female; mean age, 68.4 years) who had undergone 3830 procedures were identified. Of the 3787 patients, 2665 (69.5%) had had the ABI measured: 1803 (47.1%) before PVI only, 190 (4.9%) after PVI only, and 862 (22.5%) before and after PVI. In addition, 975 patients (25.5%) had never had the ABI performed. Statistical analysis of the entire cohort found no change in ambulation status (P = .33-.95 for all comparisons) or functional status (P = .42-.61 for all comparisons) regardless of the use of the ABI. However, a significant number of patients who had never had the ABI measured had decreased from full functional status before PVI to only being functional with light work after PVI (P = .015). CONCLUSIONS: Despite the grade 1, level A evidence, ABI had been used before and after PVI for only 22.5% of the patients who had undergone PVI for claudication. In addition, we found overall functional status had decreased significantly after PVI for those patients who had never had an ABI performed. Accurately identifying patients with claudication due to PAD using the ABI remains critically important before PVI. Given the lack of overall improvement in ambulation after PVI found in the present study, identifying the patients who will benefit from PVI to treat claudication remains elusive.

Emergency department visits after acute aortic syndromes.

OBJECTIVE: Recent reports document a high rate of readmission after hospitalization for acute aortic syndromes (AAS) that include acute aortic dissections, intramural hematomas, or penetrating aortic ulcers. We examined the rate of return to the emergency department (ED) to better understand the utilization of emergent health care services after AAS. METHODS: Consecutive patients with AAS admitted to the vascular surgery service from 2004 to 2020 were included. Patients with type A dissections, arch involvement, or chronic aortic pathology were excluded. The primary outcome was ED visits within 90 days of the original hospitalization. RESULTS: The study included 79 subjects (62% men, 38% women; mean age: 64 ± 14 years) with AAS (82% aortic dissections, 11% intramural hematomas, and 6% penetrating aortic ulcers). A total of 54 ED visits related to the AAS occurred within 90 days of the original discharge, each of which incurred a computed tomography angiogram. Twenty-eight (35%) subjects had a mean of 2 ± 2 ED visits, whereas 51 (65%) subjects had no ED visits. Ninety percent (25 of 28) of the first ED visits occurred within 1 month of discharge and 53% (15 of 28) within 1 week. A total of 17 (61%) subjects were readmitted to the hospital from the ED. Four subjects were found to have progression of AAS on imaging studies and underwent thoracic endovascular aortic repair during readmission. Comparing subjects who returned to the ED with those who did not, there were no significant differences in demographics, atherosclerotic risk factors except coronary artery disease, type of AAS, number of antihypertensive medications at admission or discharge, operative intervention, length of initial hospital stay, or discharge status. The chief complaints at the first ED visit were pain (n = 17), uncontrolled hypertension (n = 5), syncope (n = 3), and other (n = 3). CONCLUSIONS: These data show that one in three patients with AAS returned to the ED within 90 days of initial discharge. Although returning subjects had a higher number of readmissions, few had progression of AAS that required intervention. Because the vast majority were readmitted for medical therapy, early and frequent clinic follow-up may help decrease ED visits and readmissions after AAS.

Congenitally absent superior mesenteric artery in an asymptomatic adult.

Congenitally absent superior mesenteric artery is an extremely rare anatomic anomaly with only one other case reported in an adult. We have described an elderly patient who presented with complete absence of the superior mesenteric artery found incidentally on computed tomography imaging. The patient had no abdominal pain, nausea, or other gastrointestinal symptoms. An abnormally enlarged inferior mesenteric artery provided collateral circulation to the midgut. No intervention was performed at the time given the patient's adequate circulation and lack of symptoms. The present case highlights consideration of anatomic mesenteric vascular anomalies before procedures involving inferior mesenteric artery ligation or coverage.

Effects of the Affordable Care Act on Vascular Patient Amputation Rates in Arkansas.

BACKGROUND: The Patient Protection and Affordable Care Act was signed into law in 2010 and enacted in 2013 which improved insurance coverage across America due to increasing Medicaid eligibility as well as changes to individual insurance markets. In Arkansas, this was implemented by a Medicaid expansion waiver which allowed patients to purchase insurance with funds provided by the government to subsidize premiums through the marketplace. The goal of this study was to determine the effects of the Affordable Care Act (ACA) on Arkansas patients with peripheral arterial disease. METHODS: A pre-post research design using the Arkansas Hospital Discharge Dataset was used to study the impact of the ACA on limb amputation, distal bypass, discharge disposition, and total costs for patients diagnosed with peripheral arterial disease/atherosclerosis. The data were obtained for the years 2007 through 2009 (pre-ACA), 2011 through 2013 (post-ACA), and 2014 through 2015 (post-Arkansas expansion). Bivariate analysis, analysis of variance, and regression analyses were performed to analyze the data. RESULTS: A total of 10,923 patients were identified. Uninsured patients ("self-pay") decreased from 7% pre-ACA to 3.4% post-Arkansas expansion (P < 0.0001). There was a decrease in adjusted health-care costs after the Arkansas expansion (P < 0.0001). There was no change in mortality or transfer to rehabilitation facilities, but there was an increase in discharge to skilled nursing facilities along with a decrease in patients being discharged home (P < 0.0001). Regression analysis showed private insurance to be associated with a 49% reduction in the odds of an amputation (P < 0.0001). The Arkansas expansion was associated with a 26% reduction in the odds of an amputation when compared with that before the ACA implementation (P < 0.005). Having private insurance was associated with a 26% increase in the odds of having a bypass when compared with uninsured patients (P < 0.05). CONCLUSIONS: Patients with private insurance have a decreased chance of amputation and increased odds of having a bypass when compared with patients who were of the self-pay category. The increase in private insurance coverage in our patient population could improve the rate of amputation in the vascular population in Arkansas by increasing early interventions for peripheral vascular disease.

Contemporary Characteristics and Outcomes of Young Patients (Under 50 Years) Undergoing Open Carotid Artery Surgery.

BACKGROUND: Stroke is the second leading cause of death worldwide, with 10% of neurologic events occurring in adults aged 18-49 years. The incidence in this age group has risen over the last 2 decades (while falling in the aged), despite improved diagnostic capacity and greater ability to treat it medically and surgically. We are unaware of any modern data regarding the risk factors and outcomes after carotid artery surgery in this demographic. We sought to evaluate the contemporary characteristics and outcomes of young adults undergoing carotid surgery. METHODS: Retrospective analysis of patients aged 18-49 years who underwent carotid surgery from 2005 to 2015. We collected demographics, indications, and outcomes, comparing them to previously published series. RESULTS: Sixteen patients were with the mean age of 46 (41-49) years, and 44% were male. Most were Caucasian (88%) and smokers (94%), consuming 1.3 packs/day with a mean pack-year history of 32 years (10-100). Average body mass index was 29. The majority (81%) were symptomatic prior to surgery (69% of these were strokes). Complications after surgery were hyperperfusion (1) and one deep vein thrombosis. Compared to young patients treated from 1973 to 1990s, we found significantly more female patients (P < 0.001) and more strokes (P < 0.04) leading to the procedure, while smoking remained the most prevalent risk factor. CONCLUSIONS: Carotid artery surgery in young patients continues to be associated with symptomatic stenosis and smoking; however, compared to 2-4 decades ago it may be more common in young females, and following a stroke. This may be from an increased prevalence of female smoking and improved neuroimaging.