ACR Appropriateness Criteria® Sudden Onset of Cold, Painful Leg: 2023 Update.

Acute onset of a cold, painful leg, also known as acute limb ischemia, describes the sudden loss of perfusion to the lower extremity and carries significant risk of morbidity and mortality. Acute limb ischemia requires rapid identification and the management of suspected vascular compromise and is inherently driven by clinical considerations. The objectives of initial imaging include confirmation of diagnosis, identifying the location and extent of vascular occlusion, and preprocedural/presurgical planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Proper technique of lower extremity pulse examination: a lost art.

A properly performed pulse examination can provide an accurate assessment of the arterial circulation to the lower extremity. However, increasing availability of non-invasive vascular laboratory testing, CT-angiography, magnetic resonance angiography, and catheter-based arteriography has deemphasized the use and teaching to student and resident physicians of classic techniques to examine lower extremity pulses. Clinical evaluation and accurate pulse examination may eliminate the need for these often unnecessary and expensive tests to evaluate arterial insufficiency. In this report, we describe our technique for precise lower extremity pulse examination to teach younger physicians and remind more experienced ones of the value and necessity of this critical aspect of a physical examination.

A minimally invasive approach to the infected aorta with novel endovascular use of biocomposite antibiotic material.

We have presented the case of a symptomatic, primarily infected aortic pseudoaneurysm treated with endovascular stent graft exclusion and adjunctive use of a long-acting biocomposite antibiotic material injected directly into the pseudoaneurysm sac. We have described preparation of the biocomposite antibiotic material and the catheter-directed delivery technique in detail. Although the use of long-acting antibiotic materials such as antibiotic beads has been well described when performing open surgery in an infected field, the application of these materials in endovascular procedures has been less certain. The techniques we have described have the potential to promote field sterilization in a minimally invasive manner for patients with aortic infections who could be poor candidates for open surgery.

Attitudes Regarding Pregnancy Among Vascular Surgery Trainees and Program Directors Based on a Survey of Vascular Residents, Vascular Fellows, and the Association of Program Directors in Vascular Surgery.

Introduction: We conducted a survey of vascular surgery (VS) trainees and program directors (PDs) to examine differing attitudes regarding pregnancy, starting a family, and work-life balance. Methods: A 20 question survey was e-mailed to VS residents (0+5), fellows (5+2) and PDs using Survey Monkey Inc. (San Mateo, California). Results: The survey was sent to 781 participants (608 VS trainees, 173 PDs) with a similar response rate among residents [39% (133/343)), fellows [37% (98/265)], and PDs [38% (65/173)]. Of the 296 total respondents, most were male [61% (181)] and ≤40 years old [81% (240)]. VS trainees and PDs believed their work load or scheduling-coverage issues significantly increased when a trainee or peer was pregnant [PDs = 73% (38/52); fellows = 66% (59/89); residents = 54% (38/71), 13 PDs, 7 fellows and 59 residents had never worked with a pregnant peer or trainee]. Male respondents overall were significantly more likely than females to opine that a pregnant vascular trainee or attending was less capable of performing her job while pregnant [28% (50/179) vs.16% (18/110); P = .024). Women overall reported each of the following factors more commonly than men as reasons for delaying childbearing: impairing professional advancement [42% (42/99) vs 14% (23/165); P < .001], limited time to devote to children [60% (59/99) vs 39% (64/165); P = .001], not wanting to burden peers or associates [36% (36/99) vs 13% (22/165); P < .001), extra stress [67% (66/99) vs 30% (50/165); P < .001], perceived negative view of peers and program directors towards pregnancy [29% (29/99) vs 1% (2/165); P < .001], and encouragement not to have children from peers or attending [15% (15/99) vs 2% (3/165); P < .001). More females than males overall regret their career choice in VS as it relates to starting a family [22% (24/107) vs. 12%; 21/170); P = .028]. When asked about the major barriers for female vascular surgeons who wanted to become pregnant, PDs cited an unsupportive home environment more than trainees [37% (24/65) vs 22% (51/231); P = .015], whereas trainees cited safety concerns affecting the pregnancy, such as radiation, more than PDs [71% (164/231) vs 43% (28/65); P < .001] Conclusions: There are significant differences in views toward pregnancy among males and females and among trainees and PDs overall. Contrasting gender-based perceptions of the impact of pregnancy on vascular training need to be addressed before adequate solutions to the challenge of work-life balance can be achieved. Significant opportunities exist for trainees and PDs to address these knowledge gaps.

Systematic Review of the Influence of Anatomy and Aneurysm Type on Treatment Choice and Outcomes in Extracranial Carotid Artery Aneurysms.

BACKGROUND: Extracranial carotid artery aneurysms (ECAA) are rare. Open surgery has traditionally been the treatment of choice, and endovascular management has recently been increasingly described. However, operative guidelines have not been defined. METHODS: A systematic review following PRISMA guidelines was performed to identify articles related to the symptoms, treatments, and outcomes of ECAAs. Included studies were further evaluated to identify distribution of treatment strategy based on anatomical location by Attigah classification (Type I-V) and aneurysmal type (true versus pseudoaneurysm). RESULTS: Twenty-eight retrospective reviews were included. A total of 906 patients (63% male) with 959 ECAAS were identified. The most common presenting symptoms included neck mass (45%) and neurological deficits (26%), while 218 (23%) were asymptomatic. True aneurysms accounted for 52% and pseudoaneurysms for 45% of cases. Of the 959 ECAAs, 750 were treated with open surgery, 85 with an endovascular procedure, and 124 conservatively. Perioperative complications of open surgery included cranial nerve injuries (CNI) in 9% (68), strokes in 4% (27), and death in 2% (18) of cases. There were no CNI, perioperative stroke, or perioperative mortality associated with 85 endovascular procedures; however, there was 1 case of restenosis (1%). Of the 124 patients treated conservatively, 3% (4) died as a result of the aneurysm. Twenty-two of 28 studies (688 ECAAs) reported anatomical location according to Attigah classification. The distribution of ECAAs were Type I (296/688; 43%), Type II (19/688; 3%), Type III (195/688; 28%), Type IV (76/688: 11%), and Type V (102/688; 15%). Eleven of 28 studies (241 ECAAs) reported treatment choice according to Attigah classification and revealed that the majority of Type I (82%), Type II (81%), Type III (91%), and Type IV (100%) ECAAs were treated via open surgery, while Type V ECAAs were evenly treated by open surgery and endovascular surgery. Twenty-three of 28 studies (780 ECAAs) reported treatment choice stratified by aneurysmal type. Of 417 true ECAAs, 88% were treated open surgically, 4% were treated endovascularly, and 8% were treated conservatively. Of 357 pseudoaneurysms, 67% were treated open surgically, 14% were treated endovascularly, and 19% were treated conservatively. CONCLUSIONS: Most reported patients with ECAAs are symptomatic. Type I and III account for more than two-thirds of ECAAs, while true aneurysms account for roughly half. The vast majority of ECAAs have been treated surgically with results comparable to reoperative carotid endarterectomy. In selected patients, endovascular treatment has been very successful with no reported morbidity or mortality.

Completion Arteriogram Following Carotid Endarterectomy Yields Lower Perioperative Stroke Rate.

Introduction: Completion imaging following carotid endarterectomy (CEA) remains controversial. We present our experience performing routine completion arteriography (CA). Methods: A retrospective review of our prospectively maintained institutional database was performed for patients undergoing isolated CEA. Results: 1439 isolated CEAs with CA were performed on 1297 patients. CEA was for asymptomatic lesions in 70% (1003) of cases. There were no complications related to arteriography. An abnormal arteriogram documented significant abnormalities in the internal carotid artery (ICA) and prompted revision in 1.7% (24/1439) of cases: 20 unsatisfactory distal endpoints of the endarterectomy (12 residual stenoses, 7 intimal flaps, and 1 dissection), 3 kinks or stenoses within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3 cases. The other 4 cases were treated by patch angioplasty (3) or thrombectomy (1). None suffered a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 patients in our series was 1.5% (22), .5% (7), and 1.9% (27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11/1003) and for symptomatic lesions was 2.5% (11/436). Of the 22 strokes in the entire series (all with normal CA), 15 were non-hemorrhagic strokes ipsilateral to the CEA; 14 were confirmed to have widely patent endarterectomy sites by CT-A (13) or re-exploration and repeat arteriography (1). The occluded site was re-explored and underwent thrombectomy, but no technical problems were identified. The remaining strokes were hemorrhagic (4 reperfusion syndrome and 1 surgical site bleeding) or contralateral to the CEA (2). Conclusion: Although not all patients in this series who underwent intraoperative revision due to abnormal CA might have suffered a stroke, performing this simple and safe study may have halved our overall perioperative stroke rate from 3.2% to 1.5%.

Management of Pancreaticoduodenal Artery Aneurysms Based on a Single-Institution Experience.

OBJECTIVES: Pancreaticoduodenal artery aneurysms (PDAAs) are rare and have a high propensity for rupture. Historically, management of PDAAs included surgical reconstruction but has evolved with advances in endovascular therapy. We report our experience with management of PDAAs during the last 30 years. METHODS: We retrospectively reviewed our prospectively maintained registry between January 1, 1992 - March 30, 2020. RESULTS: We identified 8 patients with PDAAs: 4 with associated celiac artery occlusive disease and 4 without identifiable etiologies. Four patients were treated with surgical resection of the PDAAs: 2 intact aneurysms underwent concomitant revascularization (superior mesenteric artery-to-hepatic artery Dacron bypass; supra celiac aorta-to-hepatic artery Dacron bypass) and 2 (1 intact, 1 rupture) underwent ligation alone. Four patients were treated with coil embolization of the PDAA: 2 with concomitant stent-graft exclusion of the aneurysm (1 non-rupture, 1 rupture) and 2 without adjunctive measures (intact). There were no deaths nor any significant procedure-related morbidity. CONCLUSION: Our large single-center experience shows that PDAAs can be successfully treated by open or endovascular intervention with selective revascularization.

The Utility of Duplex Ultrasonography Surveillance in Identifying Failing Aortobifemoral Grafts.

OBJECTIVE: The Society for Vascular Surgery stated there are a lack of studies describing long-term surveillance for aortobifemoral (AoBF) bypasses. Our goal was to investigate the value of DU studies as a surveillance tool for AoBF bypasses. METHODS: We retrospectively identified patients in our prospectively maintained database who underwent AoBF bypasses between 1995-2018. Surveillance was performed routinely with DU post-operatively, every 6 months for 1 year, and then annually. We considered "abnormal" DU findings to include peri-graft fluid, pseudoaneurysm or, peak systolic velocities (PSVs) > 350 cm/sec or PSV ratio > 3.5 anywhere from the proximal aortic to distal femoral anastomosis. If abnormalities were identified patients underwent intervention or shorter surveillance intervals. RESULTS: Of 153 AoBF bypasses, 60 patients with 120 graft limbs fulfilled our post-operative surveillance protocol with a mean follow-up of 4.0 years (0.5-24 years). "Normal" DU surveillance studies were documented throughout follow-up in 112 (93%) limbs. Of these, 2 (1.7%) developed acute limb occlusion. Eight (6.7%) limbs had "abnormal" DU findings: 5 failing grafts with focal elevated PSVs, 2 with peri-graft fluid leading to a diagnosis of an infected graft, and 1 with a pseudoaneurysm (PSA). Contrast arteriography or CT-angiography confirmed > 75% diameter stenosis, fluid or PSA in all 8 limbs. Graft revision (5 endovascular, 2 surgical) was performed in 7 of the 8 limbs initially or after 2 successive "abnormal" DU studies within 6 weeks of each other; 1 patient refused intervention. Without surveillance, urgent or emergent treatment might have proved necessary in 7.5% (7 + 2 = 9/120) of cases instead of only 1.7% (2/120) of cases. CONCLUSION: Vascular surgeons should adopt DU as a useful surveillance tool to identify AoBF bypasses that are failing or have other problems not identified clinically. Persistence of "abnormal" DU findings should prompt operative or endovascular intervention.

Co-Operative Vascular Intervention Disease (COVID) Team of Greater Philadelphia.

We established the Co-Operative Vascular Intervention Disease (COVID) Team of Greater Philadelphia because national guidelines may not apply to different geographic areas of the United States owing to varying penetrance of the virus. On April 10, 2020, a 10-question survey regarding issues and strategies dealing with COVID-19 was e-mailed to 58 vascular surgeons (VSs) in the Greater Philadelphia area. Fifty-four VSs in 18 surgical groups covering 28 hospitals responded. All groups accepted transfers because of continued availability of intensive care unit beds. Thirteen groups were asked to "redeploy" if the need arose to function outside of the usual duties of a VS. None imposed age restrictions regarding older VSs continuing clinical hospital work. The majority restricted noninvasive vascular laboratory studies to those studies for which findings might mandate intervention within 2 or 3 weeks, restricted dialysis access operations to urgent revisions of arteriovenous fistulas or grafts that were failing or had ulcerations, converted from in-person to telemedicine clinic interactions, and experienced moderate-severe anxiety or fear about personal COVID-19 exposure in the hospital. The majority of VSs in the Philadelphia area dramatically adjusted their clinical practices before the COVID-19 crisis reached peak levels experienced in other metropolitan areas.

Site of service influence on stent use for hemodialysis access interventions.

OBJECTIVE: With rising health care spending in the United States, the Centers for Medicare and Medicaid Services (CMS) in recent years attempted to use reimbursement rates to influence use of less expensive care sites for covered patients, such as ambulatory surgery centers (ASCs) and office-based laboratories (OBLs), in lieu of hospital service sites. It has been suggested that cost savings have not been realized because of more procedures being performed by physicians with ownership interests in nonhospital facilities. CMS adopted massive reimbursement changes for 2019 OBL and ASC-based procedures, which reduced dialysis access angioplasty reimbursement in the ASC setting by 50%, whereas facility reimbursement for stenting increased by 33% above prior levels. The clinical utility of adjunctive stenting in treating dialysis access stenosis remains controversial and highly discretionary. As a vascular group performing such procedures in both a hospital and nonhospital facility in which we have equity interest, we reviewed our use of stents in dialysis access procedures both in the hospital and in the ASC/OBL to determine whether site of service affected stent use. METHODS: A retrospective review of a prospectively maintained database was performed from 2014 to 2018. All patients undergoing dialysis access angiography with angioplasty and adjunctive stent placement at our OBL (later ASC) and our primary hospital were included in the study. RESULTS: There were 961 angioplasty or stent procedures performed for dialysis accesses between the two sites, 564 (58.7%) in the hospital setting and 397 (41.3%) at the OBL/ASC. There was a significant difference in race and age between the two sites, with younger, minority patients more frequently being treated in the hospital and older, white patients more likely to be treated in the ambulatory setting; 153 (27.1%) underwent adjunctive stent placement in the hospital and 127 (32.0%) in the ambulatory setting (P = .09). CONCLUSIONS: Whereas financial incentives have not yet had an appreciable influence on stent use for dialysis access within previous reimbursement paradigms, the dramatic changes recently adopted by CMS may well alter this dynamic and could lead to substantially higher overall costs without proven clinical advantage. Interventionalists may be incentivized to add stents when performing balloon angioplasty in ASCs. With high failure and reintervention rates and increasingly expensive adjuncts (drug-coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific type of procedure or site of care are substantial, and unintended negative consequences are likely to occur.