Gluteal and thigh compartment syndrome after open abdominal aortic aneurysm repair.

Although compartment syndrome (CS) can occur in any myofascial compartment, the thigh and buttock are among the least common. CS is characterized by an increase in pressure of a myofascial compartment that results in a reduction of capillary blood flow and myonecrosis. Although >75% of cases of CS occur after long bone fractures, acute CS can also occur from nontraumatic and vascular etiologies. We report a case of gluteal and thigh CS resulting from ischemia-reperfusion injury after abdominal aortic aneurysm repair and left common iliac artery bypass.

Extra-Anatomic Bypass and Excision is Superior to Graft Salvage Attempts with Antibiotic Beads to Treat Vascular Graft Infections in the Groin.

BACKGROUND: This study aimed to determine if conventional extra-anatomic bypass and graft removal versus aggressive attempts at graft preservation have better survival and limb salvage in patients with localized groin wound infections of vascular grafts. METHODS: We conducted a retrospective review of 53 consecutive patients with vascular graft infections presenting in the groin. Treatment groups consisted of group 1 (extra-anatomic bypass and graft excision, n = 22) and group 2 (initial graft preservation attempts with utilization of antibiotic beads, n = 31). In group 2, patients underwent serial debridement and placement of antibiotic beads until culture-negative wounds were achieved. Significantly more patients underwent muscle flap coverage in group 2 (27/31) compared with group 1 (7/22; P < 0.001). Data collected included demographics, comorbidities, intraoperative details, and outcomes, including patency, limb salvage, mortality, and number of procedures. Continuous variables were examined with Student's t-test, and dichotomous variables were examined with chi-squared test. Linear and logistic regressions were used to analyze factors associated with outcomes, in addition to Kaplan-Meier analysis with log rank for actuarial analysis. RESULTS: Both groups were similar with respect to demographics. The overall Kaplan-Meier 1- and 3-year survival rates were 66.2% and 34.1%, with no statistically significant difference between groups. The Kaplan-Meier 1- and 3-year limb salvage rates were 68.8% and 36.6% for group 1 vs. 58.5% and 38.7% for group 2 (P = not significant [NS]). The 1- and 3-year primary patency rates were 71% and 71% in traditional group 1 vs. 72% and 56% in group 2 (P = NS). One-year and 3-year secondary patency rates in traditional group 1 were 83% and 71% vs. 85% and 61% in group 2 (P = NS). Patients in group 1 underwent fewer total procedures when compared with group 2 (2.3 ± 0.2 vs. 5.1 ± 0.7, P = 0.03). The late reinfection rate was significantly less in group 1 (4.5%) compared with group 2 (26%; P = 0.04). Freedom from reinfection at 1 and 3 years were 94% and 94% in traditional group 1 vs. 74% and 62% in group 2 (P = 0.03). Multivariable analysis showed a higher incidence of amputation in patients who suffered reinfection (n = 13, P = 0.049). There was a higher mortality in patients with septic shock (n = 10, P = 0.007) and reinfection (n = 13, P = 0.036). Reinfection was associated with the highest mortality (P = 0.03). CONCLUSIONS: Conventional graft excision with extra-anatomic bypass resulted in similar mortality when compared with aggressive attempts at graft preservation and trended toward improved limb salvage and patency. However, attempts at graft preservation with antibiotic beads resulted in a significantly higher reinfection rate and greater number of procedures, and therefore, this approach should be used very selectively.

A prebifurcated axillobifemoral polytetrafluoroethylene graft simplifies carotid to carotid to subclavian bypass.

The use of thoracic endovascular aortic repair for thoracic aortic disease will necessitate cervical debranching in cases involving the proximal arch. We have presented the case of a 57-year-old athletic woman who had developed a type A dissection that extended to the bilateral iliac arteries. After hemiarch repair, she underwent staged cervical debranching with carotid-carotid-subclavian bypass using a prebifurcated axillobifemoral graft and subsequent thoracic endovascular aortic repair. We have detailed her successful clinical course and described the benefits of using a prebifurcated graft for cervical debranching in hybrid repairs of aortic arch pathology.

Factors associated with preference of choice of aortic aneurysm repair in the PReference for Open Versus Endovascular repair of AAA (PROVE-AAA) study.

OBJECTIVE: Patients can choose between open repair and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). However, the factors associated with patient preference for one repair type over another are not well-characterized. Here we assess the factors associated with preference of choice for open or endovascular AAA repair among veterans exposed to a decision aid to help with choosing surgical treatment. METHODS: Across 12 Veterans Affairs hospitals, veterans received a decision aid covering domains including patient information sources and understanding preference. Veterans were then given a series of surveys at different timepoints examining their preferences for open versus endovascular AAA repair. Questions from the preference survey were used in analyses of patient preference. Results were analyzed using χ2 tests. A logistic regression analysis was performed to assess factors associated with preference for open repair or preference for EVAR. RESULTS: A total of 126 veterans received a decision aid informing them of their treatment choices, after which 121 completed all preference survey questions; five veterans completed only part of the instruments. Overall, veterans who preferred open repair were typically younger (70 years vs 73 years; P = .02), with similar rates of common comorbidities (coronary disease 16% vs 28%; P = .21), and similar aneurysms compared with those who preferred EVAR (6.0 cm vs 5.7 cm; P = .50). Veterans in both preference categories (28% of veterans preferring EVAR, 48% of veterans preferring open repair) reported taking their doctor's advice as the top box response for the single most important factor influencing their decision. When comparing the tradeoff between less invasive surgery and higher risk of long-term complications, more than one-half of veterans preferring EVAR reported invasiveness as more important compared with approximately 1 in 10 of those preferring open repair (53% vs 12%; P < .001). Shorter recovery was an important factor for the EVAR group (74%) and not important in the open repair group (76%) (P = .5). In multivariable analyses, valuing a short hospital stay (odds ratio, 12.4; 95% confidence interval, 1.13-135.70) and valuing a shorter recovery (odds ratio, 15.72; 95% confidence interval, 1.03-240.20) were associated with a greater odds of preference for EVAR, whereas finding these characteristics not important was associated with a greater odds of preference for open repair. CONCLUSIONS: When faced with the decision of open repair versus EVAR, veterans who valued a shorter hospital stay and a shorter recovery were more likely to prefer EVAR, whereas those more concerned about long-term complications preferred an open repair. Veterans typically value the advice of their surgeon over their own beliefs and preferences. These findings need to be considered by surgeons as they guide their patients to a shared decision.

Mathematical model of atherosclerotic aneurysm.

Atherosclerosis is a major cause of abdominal aortic aneurysm (AAA) and up to 80% of AAA patients have atherosclerosis. Therefore it is critical to understand the relationship and interactions between atherosclerosis and AAA to treat atherosclerotic aneurysm patients more effectively. In this paper, we develop a mathematical model to mimic the progression of atherosclerotic aneurysms by including both the multi-layer structured arterial wall and the pathophysiology of atherosclerotic aneurysms. The model is given by a system of partial differential equations with free boundaries. Our results reveal a 2D biomarker, the cholesterol ratio and DDR1 level, assessing the risk of atherosclerotic aneurysms. The efficacy of different treatment plans is also explored via our model and suggests that the dosage of anti-cholesterol drugs is significant to slow down the progression of atherosclerotic aneurysms while the additional anti-DDR1 injection can further reduce the risk.

Patient Characteristics, Patterns, and Repair of Aneurysms in Human Immunodeficiency Virus-Positive Patients.

BACKGROUND: Human immunodeficiency virus (HIV) is a multisystem disease and is associated with vascular complications including aneurysm formation. HIV-associated aneurysms are well documented and may present in unusual locations with concerning features. However, the literature regarding aneurysms in HIV-positive patients is limited to case series with limited data regarding aneurysm patterns. Furthermore, several small series have documented poor outcomes with surgical repair. Thus, our aim was to investigate the characteristics, patterns, and repair of aneurysms in HIV-positive patients in a multicenter study. METHODS: All patients with a diagnosis of aneurysms and HIV were retrospectively identified from 2013 to 2018 across 2 institutions. Comorbidities, HIV-related characteristics, aneurysm characteristics, and repair were reviewed. RESULTS: There were a total of 104 HIV-positive patients with 129 aneurysms. The mean age at the time of diagnosis was 57.7 ± 10.3 years, 80.8% of patients were male, and 32.0% had a history of acquired immunodeficiency syndrome. The average time from HIV diagnosis to aneurysm diagnosis was 14.1 ± 10.1 years. There were 53 (41.1%) ascending aortic, 25 (19.4%) abdominal aortic, 14 (10.9%) cerebral artery aneurysms, 13 (10.1%) descending thoracic, 9 (7.0%) iliac, 6 (4.7%) femoropopliteal, 4 (3.1%) visceral, 3 (2.9%) axillosubclavian, 1 (0.8%) carotid, and 1 (0.8%) coronary artery aneurysms. There were 23 (22.1%) patients with aneurysms in multiple vascular beds, 10 (9.6%) saccular aneurysms, and 1 (0.8%) inflammatory aneurysm. There were 7 ruptures (cerebral, descending thoracic, and iliac), 3 type A dissections (ascending aorta), and 1 thrombosis (popliteal). There were 26 (25.0%) patients who underwent surgical repair. This included 8 endovascular aneurysm repairs for abdominal aortic aneurysms, 6 endovascular coiling, clipping, and stent procedures for cerebral aneurysms, 4 open ascending aorta repairs, 2 bypasses for popliteal artery aneurysms, 2 endovascular stents for axillosubclavian artery aneurysms, 1 open descending aortic aneurysm repair, 1 endovascular aneurysm repair for an iliac aneurysm, 1 endovascular coiling for a renal artery aneurysm, and 1 open repair of a femoral artery aneurysm. Perioperative complications were common at 46.2%, although mortality was low at 3.8%. CONCLUSIONS: Although aneurysms were widespread, most HIV-positive patients had large vessel aneurysms in this study. There was a high prevalence of saccular and multiple aneurysms, and repair was associated with low rates of mortality despite high rates of complications. Additional studies are necessary to characterize this rare entity.

Long-term outcomes of transposed femoral vein arteriovenous fistula for abandoned upper extremity dialysis access.

BACKGROUND: The number and longevity of patients with end-stage renal disease requiring dialysis access have continued to increase, leading to challenging situations, including exhausted upper extremity access and severe central venous stenosis. This has led to an increase in the use of alternative access sites, including the lower extremities. The transposed femoral vein arteriovenous fistula for dialysis access is a previously described alternative, although limited data are available on its long-term patency. METHODS: Patients treated with a transposed femoral vein fistula were retrospectively reviewed. A transposed femoral vein fistula was created by harvesting the femoral vein and transposing it to the distal superficial femoral artery at the level of the adductor canal. The demographic information, perioperative characteristics, complications, and long-term outcomes were recorded and analyzed. RESULTS: A total of 21 patients had undergone transposed femoral vein fistula for dialysis access after an average of 5.3 ± 2.8 failed dialysis access procedures and a duration of 6.1 ± 4.9 years from the initiation of dialysis. The average age at the procedure was 53.5 ± 12.8 years. Ten patients (47.6%) had a history of diabetes mellitus and nine (42.9%) had a history of coronary artery disease. Technical success was achieved in 100% of cases, and 16 patients (76.2%) were discharged with anticoagulation therapy. The primary patency at 1, 3, and 5 years was 93%, 74%, and 74%, respectively. The secondary patency at 1, 3, and 5 years was 100%, 89%, and 89%, respectively. Two patients had compartment syndrome requiring fasciotomy, and six patients experienced wound complications. CONCLUSIONS: Transposed femoral vein fistula for dialysis access is a viable alternative for patients with an exhausted upper extremity access, with good long-term patency.

Predictors of Underutilization of Medical Therapy in Patients Undergoing Endovascular Revascularization for Peripheral Artery Disease.

OBJECTIVES: The aim of this study was to explore discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agent, statin, and ACE inhibitor or angiotensin receptor blocker use after endovascular lower extremity (LE) peripheral vascular intervention. BACKGROUND: Little is known about contemporary GDMT prescription following LE PVI. METHODS: Sex, age, and comorbid conditions were related to discharge GDMT prescription among patients undergoing LE PVI for symptomatic peripheral artery disease in the 2014-2018 Vascular Study Group of New England Vascular Quality Initiative. Multivariate logistic regression was used to identify independent predictors of discharge GDMT prescription. RESULTS: Among 12,316 patients, only 47.4% (n = 5,844) were discharged on GDMT after LE PVI. Most patients were discharged on antiplatelet agents (95.2%), with statins (83.5%) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (55.8%) prescribed less often. A higher proportion of patients were on Class 1 guideline-recommended therapy with antiplatelet agents and statins (80.5%). In multivariate analysis, female sex, older age, end-stage renal disease, chronic limb-threatening ischemia, and congestive heart failure were negative predictors of discharge GDMT prescription, while hypertension, diabetes, coronary artery disease, and prior LE PVI or bypass were positive predictors. CONCLUSIONS: Fewer than one-half of patients undergoing LE PVI are discharged on appropriate GDMT. As expected, traditional atherosclerotic risk factors and measures of greater atherosclerotic disease burden were associated with a greater likelihood of GDMT prescription. However, women and patients with the highest risk for atherothrombosis and limb loss were least likely to be prescribed these agents. Provider- and patient-directed educational efforts are needed to close these treatment gaps.

Trends and perioperative outcomes of patients with human immunodeficiency virus (HIV) undergoing lower extremity revascularization.

The development of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients with human immunodeficiency virus (HIV), but has led to the rise of chronic conditions including peripheral artery disease (PAD). However, trends and outcomes among patients with HIV undergoing lower extremity revascularization are poorly characterized. The aim of this study was to investigate the trends and perioperative outcomes of lower extremity revascularization among patients with HIV and PAD in a national database. The National Inpatient Sample (NIS) was reviewed between 2003 and 2014. All hospital admissions with a diagnosis of PAD undergoing lower extremity revascularization were stratified based on HIV status. Outcomes were assessed using propensity score matching and multivariable regression. Among all patients undergoing lower extremity revascularization for PAD, there was a significant increase in the proportion of patients with HIV from 0.21% in 2003 to 0.52% in 2014 (p < 0.01). Patients with HIV were more likely to be younger, male, and have fewer comorbidities, including coronary artery disease and diabetes, at the time of intervention compared to patients without HIV. With propensity score matching and multivariable regression, HIV status was associated with increased total hospital costs, but not length of stay, major amputation, or mortality. Patients with HIV with PAD who undergo revascularization are younger with fewer comorbidities, but have increased hospital costs compared to those without HIV. Lower extremity revascularization for PAD is safe for patients with HIV without increased risk of in-hospital major amputation or mortality, and continues to increase each year.

Endovascular Balloon Occlusion: An Adjunct to Hemostasis for Above-Knee Amputation After Recalcitrant Chronic Prosthetic Joint Infection of Knee in a Morbidly Obese Patient: A Case Report.

CASE: A 72-year-old morbidly obese nonambulatory woman with bilateral chronically infected revision knee prostheses and incompetent extensor mechanisms who uses a wheelchair had limited functionality and presented with recalcitrant chronic infection with multiple hospitalizations. The patient underwent staged bilateral above-knee amputations. The first procedure caused extensive morbidity secondary to poor vascular control. For the second surgery, collaboration with vascular surgery was used to achieve endovascular control of the external iliac artery with improved postoperative course. CONCLUSIONS: Endovascular balloon occlusion may be an effective adjunct to customary hemostasis modalities during above-knee amputations in morbidly obese patients.

Impact of Temporal Artery Biopsy on Clinical Management of Suspected Giant Cell Arteritis.

BACKGROUND: Temporal arteritis (TA) is a systemic inflammatory vasculitis of unclear etiology that affects medium-sized vessels. The gold standard for diagnosis has traditionally been histological, by temporal artery biopsy. Improved imaging modalities have been increasingly used to aid diagnosis and are recommended in the newest 2018 European (EULAR) guidelines.1 We hypothesize that a negative TA biopsy result does not change management in patients for whom TA is strongly suspected and that duplex ultrasound can be successfully used as a screening tool. METHODS: This is a retrospective review of patients who underwent TA biopsy between May 1, 2012 and June 1, 2017. We reviewed patient's demographics, comorbidities, symptoms, histology, and treatment. We also present a small series of patients for whom ultrasound of the bilateral temporal arteries was performed. Radiology and pathology reports on these 7 patients were reviewed. RESULTS: A total of 264 patients underwent temporal artery biopsies over the study period. Histology was positive in 21 (8.0%) and negative in 243 (92%) patients. In 74 (41%) patients with negative biopsies on steroids preoperatively, steroids were continued despite negative biopsy result. In prospective series, 7 patients underwent duplex ultrasound evaluation before scheduling for biopsy. Biopsy followed ultrasound in 4 cases, and in all 4 cases, histology was congruent with ultrasound findings. CONCLUSIONS: The yield of temporal artery biopsy is low, and a negative biopsy alone often does not lead to termination of steroid therapy. Ultrasound may present a viable diagnostic tool to reduce the number of unnecessary temporal artery biopsies performed.

Design of the PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) Trial.

For patients with abdominal aortic aneurysm (AAA), randomized trials have found endovascular AAA repair (EVAR) is associated with lower perioperative morbidity and mortality than open surgical repair (OSR). However, OSR has fewer long-term aneurysm-related complications, such as endoleak or late rupture. Patients treated with EVAR and OSR have similar survival rates within two years after surgery, and OSR does not require intensive surveillance. Few have examined if patient preferences are aligned with the type of treatment they receive for their AAA. Although many assume that patients may universally prefer the less-invasive nature of EVAR, our preliminary work suggests that patients who value the lower risk of late complications may prefer OSR. In this study, called The PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) trial, we describe a cluster-randomized trial to test if a decision aid can better align patients' preferences and their treatment type for AAA. Patients enrolled in the study are candidates for either endovascular or open repair and are followed up at VA hospitals by vascular surgery teams who regularly perform both types of repair. In Aim 1, we will determine patients' preferences for endovascular or open repair and identify domains associated with each repair type. In Aim 2, we will assess alignment between patients' preferences and the repair type elected and then compare the impact of a decision aid on this alignment between the intervention and control groups. This study will help us to accomplish two goals. First, we will better understand the factors that affect patient preference when choosing between EVAR and OSR. Second, we will better understand if a decision aid can help patients be more likely to receive the treatment strategy they prefer for their AAA. Study enrollment began on June 1, 2017. Between June 1, 2017 and November 1, 2018, we have enrolled 178 of a total goal of 240 veterans from 20 VA medical centers and their vascular surgery teams across the country. We anticipate completing enrollment in PROVE-AAA in June 2019, and study analyses will be performed thereafter.

Patient information sources when facing repair of abdominal aortic aneurysm.

OBJECTIVE: Shared medical decision making is most important when there are competing options for repair such as in treatment of abdominal aortic aneurysm (AAA). We sought to understand the sources of patients' pre-existing knowledge about AAA to better inform treating physicians about patients' needs for preoperative counseling. METHODS: We performed a multicenter survey of patients facing AAA repair at 20 Veterans Affairs hospitals across the United States as part of the Preferences for Open Versus Endovascular Repair of AAA study. A validated survey instrument was administered to examine the sources of information available and commonly used by patients to learn about their repair options. The survey was administered by study personnel before the patient had any interaction with the vascular surgeon because survey data were collected before the vascular clinic visit. RESULTS: Preliminary analysis of data from 99 patients showed that our cohort was primarily male (99%) and elderly (mean age 73 years). Patients commonly had a history of hypertension (86%), prior myocardial infarction (32%), diabetes (32%), and were overweight (58%). Patients arrived at their surgeon's office appointment with limited information. A majority of patients (52%) reported that they had not talked to their primary care physician at all about their options for AAA repair, and one-half (50%) reported that their view of the different surgical options had not been influenced by anyone. Slightly less than one-half of patients reported that they did not receive any information about open surgical aneurysm repair and endovascular aortic aneurysm repair (41% and 37%, respectively). Few patients indicated using the internet as their main source of information about open surgical aneurysm repair and endovascular aortic aneurysm repair (10% and 11%, respectively). CONCLUSIONS: Patients are commonly referred for AAA repair having little to no information regarding AAA pathology or repair options. Fewer than one in five patients searched the internet or had accessed other sources of information on their own. Most vascular surgeons should assume that patients will present to their first vascular surgery appointment with minimal understanding of the treatment options available to them.

Practice patterns of dual antiplatelet therapy after lower extremity endovascular interventions.

Antiplatelet therapy is commonly prescribed following endovascular interventions. However, there is limited data regarding the regimen and duration of antiplatelet therapy following lower extremity endovascular interventions. The aim of this study was to investigate the practice patterns of dual antiplatelet therapy (DAPT) after lower extremity endovascular interventions. We identified all patients who received an endovascular intervention in the Vascular Study Group of New England (VSGNE) registry from 2010 through 2018. The antiplatelet regimen was examined at the time of discharge and follow-up. Variables predicting discharge antiplatelet therapy and duration of antiplatelet therapy were investigated. There were 13,510 (57.69%) patients discharged on DAPT, 8618 (36.80%) patients discharged on single antiplatelet therapy, and 1292 (5.51%) patients discharged without antiplatelet therapy. Patients with coronary artery disease (CAD), prior vascular bypass and endovascular intervention, preoperative statin use, stent placement compared with angioplasty, and femoropopliteal and tibial treatment were associated with higher odds of being discharged with DAPT compared with no antiplatelet therapy and single antiplatelet therapy. Of the patients discharged on DAPT who were followed up at 9-12 months and 21-24 months, 56.49% and 49.63% remained on DAPT, respectively. Only a narrow margin of the patient majority undergoing endovascular interventions was discharged with DAPT, suggesting that only a small proportion of patients undergoing endovascular intervention remain on DAPT long-term. As the number of peripheral vascular interventions continues to grow, further studies are crucial to identify the optimal duration of DAPT.

Safety and efficacy of venous ablation in octogenarians.

OBJECTIVE: Venous ablation (VA) is the recommended treatment of superficial venous insufficiency affecting the lower extremities. The safety and efficacy of the procedure in octogenarians have not been well studied. We postulate that VA in octogenarians is as safe and effective as in younger age groups. METHODS: A retrospective single-center review of consecutive patients undergoing VA using radiofrequency in an outpatient office was performed. Patients, imaging, and procedural characteristics were reviewed from the medical records. A telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment was conducted. Patients were divided into three groups based on age: <65 years, 65 to 79 years, and ≥80 years. Clinical success was defined by patients' reporting improvement or resolution of symptoms and was reported per leg. Technical success was defined by vein closure on duplex ultrasound and was reported per vein. Patients and outcomes were compared between the three groups using χ2 or analysis of variance test in SAS software (SAS Institute, Cary, NC). RESULTS: There were 362 patients who underwent 627 VAs in 512 legs. Octogenarians constituted 9.4% of the patient population and were more likely to have cardiovascular comorbidities. Octogenarians were significantly more likely to have advanced venous disease as determined by the Clinical, Etiology, Anatomy, and Pathophysiology classification compared with younger patients (P = .005). On ultrasound, younger patients had significantly larger vein diameters (P = .04) and longer reflux times (P < .001). There was no significant difference in the types of veins (P = .08) or the mean number of veins (P = .37) treated in the three groups; however, there was a trend toward younger patients' requiring more adjunctive procedures (P = .1). The clinical success (P = .86), technical success (P = .19), and complications (P = .36) were not different between octogenarians and younger patients. The survey results demonstrated similar findings with no difference in pain improvement (P = .27) or recurrence (P = .36). CONCLUSIONS: Octogenarians treated with VA present at a more advanced clinical stage compared with younger patients but have less severe ultrasound findings. VA is safe and effective in all age groups. Age should not be used to deny patients VA.

Intravascular Ultrasound in Venous Thoracic Outlet Syndrome.

BACKGROUND: Venous thoracic outlet syndrome (vTOS) is a rare disease with no defined guidelines regarding treatment. Patients with first rib resection with anterior scalenectomy (FRRS) often have residual subclavian vein stenosis. The aim of this study was to evaluate the use of intravascular ultrasound (IVUS) in the treatment of vTOS patients who have been surgically decompressed with FRRS. METHODS: Patients treated with venography after FRRS for vTOS during 2015-2017 were retrospectively reviewed. Patients were included if they received a venogram with IVUS after FRRS. The axillosubclavian vein at the site of the thoracic outlet was imaged using single-plane venography and IVUS. A greater than 50% diameter stenosis on venography or 50% cross-sectional area reduction on IVUS was considered significant and treated with balloon venoplasty. RESULTS: During the 2-year period, 14 patients underwent 24 upper extremity venograms performed after surgical decompression for vTOS, 18 of which included IVUS. Of the 18 cases with IVUS, 5 (27.8%) stenoses >50% were detected by IVUS, which were not apparent on venography, leading to intervention. IVUS detected a greater degree of stenosis than venography. Seven patients required repeat venograms. Overall, IVUS detected significant venous stenosis in 94.4% of patients compared with 66.7% of patients with venography after FRRS for vTOS. CONCLUSIONS: These results suggest that IVUS detected greater levels of stenosis than venography, leading to more interventions. Just as IVUS being ideal for identifying occult iliac venous lesions, it may have a similar role in identifying venous lesions not evident on single-plane venography for postsurgical decompression in vTOS patients. Further studies may show this technique to increase the number of stenoses identified and improve long-term symptom relief.

The effect of increasing catheter distance from the deep junction on the outcomes of radiofrequency vein ablation.

OBJECTIVE: Thermal vein ablation (VA) is the recommended treatment modality for superficial venous reflux, with a recommended positioning of the catheter at 2 to 3 cm from the junction of the deep venous system. In contrast, novel sealing technology for saphenous VA involves treatment starting at 3 to 5 cm distal to the deep junction. This study examines the effect of increasing catheter distance from the junction on the outcomes of VA using radiofrequency. METHODS: A retrospective single-center review of patients treated with VA was performed. Demographics, symptoms, clinical class (Clinical, Etiology, Anatomy, and Pathophysiology classification), and ultrasound data were reviewed. The treatment groups were divided on the basis of the position of the catheter <3 cm (group A) or ≥3 cm (group B) from the deep junction. Clinical success, technical success, complications, and recurrence were compared between the two groups. Long-term follow-up was collected by telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment. A multivariable analysis was performed to identify predictors of recurrence. RESULTS: There were 362 patients with 529 veins treated. The mean age was 59.2 ± 14.4 years (63% women). There was a significantly higher proportion of patients with past medical history of hypertension (P = .02) and deep venous thrombosis (P = .02) in group B compared with group A. Group B also had significantly larger vein diameter on ultrasound (P = .04). The clinical success, technical success, and complication rates were 80%, 95.6%, and 11.5%. There were no significant differences between the two groups in outcomes. After a mean follow-up of 27.5 months, recurrence rate was 22.2%. There was a trend toward higher recurrence in group B that did not, however, reach statistical significance (P = .1). On multivariable analysis, there was no clinical or technical factor that could predict recurrence. CONCLUSIONS: The experience with radiofrequency ablation does not support difference in outcomes when treatment starts at ≥3 cm from the junction. However, there is a trend toward increased long-term recurrence that warrants further investigation with newer technology.

The effect of commercial insurance policies on outcomes of venous ablation.

OBJECTIVE: The use of venous ablation (VA) for treatment of chronic venous insufficiency has exponentially increased. To limit cost and overuse, insurance companies have adopted aleatory policies. The goal of this study was to compare the policies of five major local insurance carriers and to determine whether treatment within the criteria of a certain policy is associated with improved patient outcomes. METHODS: A retrospective single-center review of patients treated with VA was performed. Demographics, comorbidities, symptoms, and clinical class (Clinical, Etiology, Anatomy, and Pathophysiology classification) were recorded. Clinical success was defined on chart review by the patients' reporting of improvement or resolution of symptoms in the leg treated on follow-up, and technical success was defined by vein closure on ultrasound. Patients underwent a telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment of each leg as well as effects on quality of life (QOL). The policies of Aetna, Cigna, Anthem Blue Cross Blue Shield, UnitedHealthcare, and Connecticut Care were reviewed. The clinical and technical success rates were compared when veins were treated within the criteria of each policy. A subgroup analysis looking at patients who had clinical success only was performed to determine the potential rate of denial of coverage for each policy. A multivariable analysis was performed to determine independent predictors of clinical success. RESULTS: There were 253 patients with 341 legs treated. The mean age was 58.5 ± 15.2 years (68% women). The most common symptom was pain (89.7%), with 47.8% of patients having C3 disease. The clinical success, technical success, and complication rates were 84.2%, 95.1%, and 5.6%, respectively. On survey, there was improvement of the numeric rating scale score in 84.3% of legs treated after the procedure, and 76.7% continued to experience improvement after a mean follow-up of 26.8 months. There was improvement of QOL in 76.5% of patients. There was no significant difference in procedural success, technical success, complication rate, or improvement in QOL when patients were treated within any of the five insurance policies. On multivariable analysis, there was no single policy significantly associated with clinical success. However, subgroup analysis of procedures with clinical success (n = 287) showed a significant difference between the five policies on analysis of the potential denial of coverage, ranging from 5.6% for Connecticut Care to 64.1% for UnitedHealthcare (P < .0001). CONCLUSIONS: The different insurance policies have no correlation with outcomes of VA. Policies with more stringent criteria typically restrict treatment to larger veins and deny procedures to a significant number of patients with chronic venous insufficiency who can benefit from them.

The Impact of Functional Status on the Outcomes of Endovascular Lower Extremity Revascularization for Critical Limb Ischemia in the Elderly.

BACKGROUND: Functional status is an important predictor of outcomes after infrainguinal bypass surgery. There are little data on the effect of functional status on the outcomes of endovascular lower extremity interventions, especially in the elderly frail population. METHODS: This is a retrospective analysis of the American College of Surgeons - National Surgical Quality Improvement Program files for the years 2011-2013 to assess the impact of functional status on outcome after endovascular intervention for critical limb ischemia (CLI). Elderly patients (age ≥70) undergoing revascularization for CLI were included. The patients were divided into 2 groups based on functional status prior to surgery: independent (IND) or dependent (DEP), which included partially dependent as well as totally dependent patients. The 2 groups were compared with respect to demographics, comorbidities, complications, length of stay, limb loss, and mortality. Statistical analysis was performed using Student's t-test for continuous variables and Fisher's exact test for categorical variables. RESULTS: There were 1,055 patients (DEP = 253, 24%). There was no difference in gender or race but DEP patients were older than IND (P = 0.008). DEP patients were significantly more likely to have history of congestive heart failure (P = 0.003), hypertension (P = 0.042), and diabetes (P <0.001). There was no difference in emergent surgeries between the 2 groups (P = 1.00). DEP patients had more tibial interventions compared with IND (P <0.001). DEP developed more pneumonia (P <0.001) and septic shock (P = 0.016) and had a trend toward more urinary tract infections (P = 0.051) after endovascular revascularization. There was no significant difference in operating time (P = 0.232) or major amputation (P = 0.092). DEP had significantly longer length of hospital stay (P = 0.0068). DEP had significantly higher mortality (5.98% vs. 2.01%, P = 0.002). On multivariate analysis, DEP status, emergency procedure, congestive heart failure, cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, sepsis, and septic shock were independently associated with 30 days of mortality. Irrespective of age, DEP functional status was the most significant preoperative predictor of mortality with an odd ratio of 5.16 [1.93-13.83], P = 0.001 (parsimonious model). CONCLUSIONS: Functional status should be carefully assessed when considering endovascular revascularization in the elderly as DEP has significantly higher morbidity and mortality.

Trends and outcomes in endovascular and open surgical treatment of visceral aneurysms.

OBJECTIVE: Visceral artery aneurysms (VAAs) are rare but often repaired because of dire consequences of rupture. This is a population-based evaluation of chronologic trends in management, risk factors, and outcomes of endovascular and open therapy. METHODS: The 2003 to 2013 Agency for Healthcare Research and Quality (AHRQ) National Inpatient Sample (NIS) database was reviewed. Cases with primary diagnosis of VAA and undergoing endovascular or open repair were identified. Patients with renal artery or abdominal or thoracoabdominal aortic disease were excluded. Case numbers of respective techniques were charted over time. Baseline characteristics and in-hospital outcomes were compared for endovascular and open groups using χ2 test, Fisher exact test, or t-test. Predictors of mortality and complications were evaluated with multivariate logistic regression. RESULTS: There were 9260 interventions for VAAs from 2003 to 2013, including 5166 endovascular and 4094 open. Endovascular repairs increased from 5.3 to 24.7 per 10 million U.S. population (P < .001), surpassing open repairs in 2008, which decreased from 14.3 to 9.2 per 10 million (P < .001). Endovascular patients were more likely to have been treated at urban teaching hospitals (77.1% vs 61.8%; P < .0001); to have higher proportions of renal failure (7.6% vs 4.9%; P = .02), liver disease (11.3% vs 6.6%; P < .001), alcohol abuse (13.1% vs 3.6%; P < .001), chronic blood loss anemia (4.5% vs 1.6%; P < .001), metastatic cancer (2.7% vs 0.8%; P = .003), solid tumor without metastases (3.6% vs 2.0%; P < .037), and weight loss (9.8% vs 5.2%; P < .001); and less likely to have had elective admission (28.9% vs 59.8%; P < .0001). In-hospital mortality (4.1% vs 4.5%; P = .618) and overall complication rates (37.8% vs 38.8%; P = .688) were similar between groups; however, pulmonary complications were decreased for endovascular patients (10.6% vs 19.7%; P < .001). Endovascular patients had shorter hospital stays (6.5 vs 8.7 days; P < .001). Multivariate adjustment for mortality predictors, including coagulopathy (odds ratio [OR], 4.34; confidence interval [CI], 2.56-7.35; P < .001), liver disease (OR, 2.25; CI, 1.25-4.07; P = .01), fluid and electrolyte disorders (OR, 2.84; CI, 1.73-4.66; P < .001), and solid tumor without metastases (OR, 2.81; CI, 1.10-7.18; P = .03), showed that open treatment was associated with increased mortality (OR, 1.70; CI, 1.03-2.81; P = .04). Analysis of overall complications revealed that open treatment was again associated with increased complications (OR, 1.78; CI, 1.43-2.21; P < .001). CONCLUSIONS: Endovascular VAA repairs are increasing. Despite patients' having worse comorbidities and more nonelective admissions, endovascular therapy appears to be associated with decreased mortality and complications and shorter hospital stays.