Outcomes of Endovascular Treatment for Critical Limb Threatening Ischemia.

BACKGROUND: Critical limb threatening ischemia (CLTI), particularly in patients with ischemic ulceration has been associated with significant morbidity and mortality. Typically, endovascular therapy has been first-line therapy for our patients, but this strategy has come into question based upon the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Threatening Ischemia (BEST-CLI) trial data. METHODS AND RESULTS: For comparative purposes, we evaluated outcomes from 150 CLTI patients with ischemic ulceration treated with endovascular-first therapy. The mean age was 72 years in this predominate male, Caucasian, ambulatory group. The major co-morbidities were smoking history in 49% and diabetes mellitus in 67%.` Anatomic scoring, using Society for Vascular Surgery criteria, revealed only 35.6% had favorable anatomy (Global Limb Anatomical Staging System stage of 0,1) for long-term patency compared to 64.4% of limbs with unfavorable anatomy for long-term patency (Global Limb Anatomical Staging System stage 2,3). Stents were used in 47% of cases. Reintervention occurred in 36% over 24 months follow-up. At 12 and 24 months, the Kaplan-Meier projections for survival was 0.80 (0.73, 0.87) and 0.69 (0.59, 0.79); amputation was 0.69 (0.61, 0.77) and 0.59 (0.46, 0.71); amputation-free survival (AFS) was 0.56 (0.48, 0.65) and 0.38 (0.27, 0.50), respectively. Amputation was more common in those with reinterventions (P = 0.033). Mortality was predicted with ankle brachial index ≤0.40 or ≥1.30 (P = 0.0019) and the presence of infection (P = 0.0047). AFS was predicted by the presence of any infection (P = 0.0001). CONCLUSIONS: Despite technically successful endovascular treatment, patients who present with CLTI maintain a high-risk for limb loss and mortality. Amputation prevention must vigilantly address infection risk. These data correlate with outcomes from BEST-CLI trial enhancing applicability to patient-centered care.

Comparison of Complications and Cost for Transfemoral Versus Transcarotid Stenting of Carotid Artery Stenosis.

BACKGROUND: Options for endovascular treatment of carotid artery disease have been developed to compliment with carotid endarterectomy, transfemoral carotid artery stenting (TFCAS) and a hybrid approach with transcarotid artery revascularization (TCAR). We sought to capture endpoints outside of stroke, myocardial infarction (MI), and death involved with each procedure at our institution as well as evaluate cost. METHODS: Carotid stent procedures performed from 2014 to 2020 at our institution underwent comparative analysis based upon access site and type of stent procedure performed, TFCAS versus TCAR. Procedural details and outcomes were captured prospectively and included in the National Cardiovascular Data Peripheral Vascular Intervention Registry (NCDR-PVI). Further retrospective review was performed to evaluate endpoints beyond stroke, MI, and death. Total in-hospital cost, including administrative, capital and utilities (fixed cost), and labor and supplies (variable cost) were also evaluated. RESULTS: One hundred thirty-seven patients were reviewed. Seventy-seven were treated with TFCAS and 60 with TCAR. The mean age was 74 years, predominantly male (68%) and Caucasian (90%). Patients undergoing TFCAS were more likely to be symptomatic compared to those receiving TCAR (81.8% vs. 50.0%, P = <0.001). There were no statistically significant differences in event rates, including mortality, recurrent cerebrovascular accident / transient ischemic attack, or bleeding. Complications not captured in the NCDR-PVI database were more frequent in the TCAR group (21.7% vs. 5.2%, P = 0.004) and included pneumothorax (n = 2), neck hematoma (n = 8), and common carotid artery stenosis or injury (n = 3). Rates of complications in the TFCAS group (n = 4) were lower and limited to groin hematoma (n = 2), central retinal artery occlusion causing vision loss and a case of postoperative dysphagia. Geographic miss of initial stent placement was identified in 15.0% of TCAR patients and 2.6% (P = 0.008) of TFCAS patients. Restenosis rates on duplex ultrasound were similar between the two groups (14.6% of patients) and were not associated with symptoms. The mean follow-up interval was similar for both groups of 31.8 months for TCAR and 30.7 months for TFCAS (P = 0.797). There was a statistically significant difference in total cost with TCAR being more expensive ($22,315 vs. $11,001) driven by direct costs that included devices, imaging, and extended length of stay in the TCAR group (P < 0.001). There was no significant difference between stroke free survival (91.1% vs. 88.6%, P = 0.69) and mortality (78.1% vs. 85.2%, P = 0.677) at 3 years follow-up between TCAR and TFCAS, respectively. CONCLUSIONS: Both TFCAS and TCAR provide similar 3-year stroke and mortality risk/benefit and are distinctly different procedures. Both should be evaluated independently with analysis of variables beyond stroke, death, and MI. TFCAS is more cost-effective than TCAR in this single institution study.

Current Outcomes of Blunt Vertebral Artery Injuries.

BACKGROUND: There is no consensus on the treatment of blunt vertebral artery injuries, and studies are limited to small case series. We assessed the natural history and current management of these injuries. METHODS: We performed a retrospective study of a prospectively collected registry at a level I trauma center over a 5-year period. Additional information was gathered from patient charts and imaging review from electronic medical records. We analyzed demographics, mechanism of injury, Glasgow Coma Score, mortality, length of stay, associated injuries, Denver grading scale, neurological findings, level and laterality of injury, delay in diagnosis, treatment, and follow-up imaging. RESULTS: There were 13,080 trauma admissions during this time period yielding 141 patients with blunt vertebral artery injuries from 2013 to 2018 (1.1% incidence). Mean injury severity score (ISS) was 22 with a 30-day mortality of 14 (9.9%). An ISS of greater than 15 is associated with polytrauma and increased mortality. There were 112 (79.4%) associated cervical fractures. C6 and C7 were both equally the most common locations. There was one symptomatic injury manifesting as a cerebellar ischemic infarct. The degree of arterial injury was classified by the Denver grading scale. There were 61 (43.3%) instances of Denver grade I injuries, followed by grade IV at 36 (25.5%), grade II at 34 (24.1%), grade III at 8 (5.7%), and grade V at 1 (0.7%). The level of injury was recorded as follows: V2 = 67 (47.5%), V3 = 56 (39.7%), V1 = 48 (34%), V4 = 14 (9.9%). Medical therapy included aspirin in 93 patients (66%), 31 patients (22%) received systemic anticoagulation with heparin drip, and 2 patients (1%) were administered therapeutic Lovenox. A total of 15 patients (11%) received no medical treatment. There was one intervention in our series. Our only grade V injury was coil embolized. A total of 118 patients (84%) had follow-up imaging. Seventy-eight patients (96%) with grade I and grade II injuries did not worsen, and complete radiographic resolution was found in 50 patients (62%). Grade IV injuries persisted in 22 patients (75.9%). Median time to resolution for grade I and grade II injuries was 7 and 8 days, respectively. Most follow-up scans for grade I and II injuries occurred within 50 days. CONCLUSIONS: Posterior circulation stroke due to blunt vertebral artery injury is rare. In our experience, the natural course of blunt vertebral artery injury was benign and neither delay in medical treatment nor choice of antithrombotic had a significant impact on outcomes. In our series, only 3 (3.7%) grade I and II injuries worsened and were without any clinical sequelae. We suggest that routine serial imaging in grade I and II blunt vertebral injuries is not warranted.

The inside-out technique for tunneled dialysis catheter placement with central venous occlusion.

The "inside-out" technique eliminates the need for subclavian or femoral catheter placement by placing a supraclavicular catheter via a percutaneous femoral vein access. Few reports of its use in vascular surgery exist. The purpose of this article is to describe our version of the technique and report results. Between 2016 and 2017, the inside-out technique was performed on eight patients. All patients had more than four prior access sites and bilateral internal jugular vein occlusion. The technical success rates were 100% with no periprocedural complications and success in achieving dialysis access. One patient required catheter replacement within 48 hours, one catheter was used as a bridge to Hemodialysis Reliable Outflow (Hemosphere, a Cryolife Inc Company, Eden Prairie, Minn) graft placement, and one patient died of sepsis unrelated to their catheter. Our data show the inside-out technique to be safe and effective, removes the need for subclavian or femoral catheter placement, and should be a component of treatment algorithms for complex dialysis patients, which is consistent with National Kidney Foundation's Kidney Disease Outcomes Quality Initiative recommendations.

Current issues and future directions for vascular surgery training from the results of the 2016-2017 and 2017-2018 Association of Program Directors in Vascular Surgery annual training survey.

BACKGROUND: Surgical training is constantly adapting to better prepare trainees for an evolving landscape of surgical practice. Training in vascular surgery additionally underwent a paradigm shift with the introduction of the integrated training pathway now more than a decade ago. With this study, we sought to characterize the needs and goals of our current vascular surgery trainee population. METHODS: The Association of Program Directors in Vascular Surgery Issues Committee compiled a survey to assess demographics, current needs, and goals of trainees and to evaluate trainee distress using a validated seven-item Physician Well-Being Index. The survey was distributed electronically to all current vascular surgery trainees and recent graduates in the academic years 2016-2017 and 2017-2018, and responses were recorded anonymously. RESULTS: During the 2 years of the survey, the response rate was 30% (n = 367/1196). The respondents were 55% (n = 202) integrated vascular residents and 45% (n = 165) vascular surgery fellows. In each year of the survey, 60% (n = 102/170) and 58% (n = 86/148) of trainees expressed a desire to pursue academics in their careers, whereas 37% (n = 63/174) and 35% (n = 53/152) indicated their program had structured academic development time (2016-2017 and 2017-2018, respectively). Fifty-five percent (n = 96/174) and 52% (n = 79/152) stated that the overall impact of collaborative learners was positive. More than 60% of respondents in both years of the survey indicated experiencing one or more symptoms of distress on a weekly basis. The frequency of distress was associated with older age and with the presence of an advanced degree in both years of the survey. Sex, level of training, presence of collaborative learners, and having protected research time were not associated with frequency of distress in either year of the survey. CONCLUSIONS: These results highlight an opportunity for programs to further evaluate the needs of their trainees for academic development during vascular surgery training to better accommodate trainees' career goals. Further investigation to identify modifiable risk factors for distress among vascular surgery trainees is warranted.

Ligation of Common Iliac Artery Mycotic Aneurysm in a Neonate and Review of the Literature.

BACKGROUND: Mycotic aortoiliac aneurysms in neonates are rare. Surgical treatment has traditionally been the standard of care, but recent case reports have suggested that endovascular management of mycotic iliac aneurysms may also be safe and effective. In this case, we describe successful management of a mycotic aortoiliac aneurysm in a neonate with exploratory laparotomy and ligation of the left common iliac artery. METHODS: A full-term infant boy of uncomplicated delivery was transferred to our institution on day 2 of life after a barium enema concerning for small left colon syndrome. An umbilical artery catheter had been placed for monitoring but was removed before transfer. During his hospital course, he developed left leg edema and fever. He was found to have a mycotic aneurysm of the left common and internal iliac arteries, causing common iliac venous compression. A repeat ultrasound revealed the aneurysm measured a maximum of 12 mm in diameter and 26 mm in length. RESULTS: Treatment was delayed until the patient was clinically stable. He was monitored with serial ultrasounds, which showed no significant increase in aneurysmal size. A review of the literature supported the perception the aneurysm posed an impending risk to the patient. On day 16 of life, the neonate underwent ligation and excision of the left common iliac artery aneurysm. CONCLUSION: Our experience found ligation of the common iliac artery to be safe and effective, establishing that surgical reconstruction is not required.

Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure.

OBJECTIVE: The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. METHODS: The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. RESULTS: Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. CONCLUSIONS: The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.

Characterization of fracture behavior of human atherosclerotic fibrous caps using a miniature single edge notched tensile test.

UNLABELLED: One well-established cause of ischemic stroke is atherosclerotic plaque rupture in the carotid artery. Rupture occurs when a tear in the fibrous cap exposes highly thrombogenic material in the lipid core. Though some fibrous cap material properties have been measured, such as ultimate tensile strength and stress-strain responses, there has been very little, if any, data published regarding the fracture behavior of atherosclerotic fibrous caps. This study aims to characterize the qualitative and quantitative fracture behavior of human atherosclerotic plaque tissue obtained from carotid endarterectomy samples using two different metrics. Uniaxial tensile experiments along with miniature single edge notched tensile (MSENT) experiments were performed on strips of isolated fibrous cap. Crack tip opening displacement (CTOD) and stress in the un-cracked segment (UCS) were measured at failure in fibrous cap MSENT specimens subjected to uniaxial tensile loading. Both CTOD and the degree of crack blunting, measured as the radius of curvature of the crack tip, increased as tearing propagated through the tissue. Higher initial stress in the UCS is significantly correlated with higher collagen content and lower macrophage content in the fibrous cap (ρ=0.77, P=0.009; ρ=-0.64, P=0.047; respectively). Trends in the data show that higher CTOD is inversely related to collagen content, though the sample size in this study is insufficient to statistically substantiate this relationship. To the authors' knowledge, this is the pioneering study examining the fracture behavior of fibrous caps and the first use of the CTOD metric in vascular tissue. STATEMENT OF SIGNIFICANCE: A tear in the fibrous cap of atherosclerotic plaque can lead to ischemic stroke or myocardial infarction. While there is some information in the literature regarding quantitative measures of fibrous cap failure, there is little information regarding the behavior of the tissue during failure. This study examines the failure behavior of fibrous caps both qualitatively, by examining how and where the tissue fails, and quantitatively, by measuring (a) crack tip opening displacement (CTOD) in vascular tissue for the first time and (b) uniaxial stress in the un-cracked segment (UCS). This study shows that both metrics should be evaluated when assessing plaque vulnerability.

Nonoperative management of grade III blunt thoracic aortic injuries.

OBJECTIVE: Blunt thoracic aortic injuries (BTAIs) have historically been treated with open surgery; thoracic endovascular aortic repair (TEVAR), however, is rapidly becoming the standard of care for all grades of injury. Previous studies have shown successful, conservative management of low-grade (I and II) BTAI, but limited literature exists regarding nonoperative management (NOM) for high-grade BTAI. The purpose of this study was to evaluate NOM for grade III BTAI compared with TEVAR. METHODS: There were 75 patients diagnosed with BTAI between January 2004 and June 2015. Of these, 40 were excluded for different grades of BTAI (17), death before any treatment (6), and need for urgent open repair (17). The remaining 35 patients were divided into two groups by treatment approach: NOM (n = 18) and TEVAR (n = 17). Primary end points were complications and mortality. The secondary end point was difference in pseudoaneurysm and aortic diameter measurements between groups. RESULTS: The groups of patients were similar in age, gender, Injury Severity Score, length of stay, in-hospital mortality, and hospital-associated complications. There were four TEVAR-related complications: graft involutions (2), type I endoleak (1), and distal embolization (1). All TEVAR-related complications required either an adjunctive procedure at the time of the primary procedure or an additional procedure. No patients from the NOM group required operative intervention. There were seven in-hospital mortalities: two in the TEVAR group (11.8%) and five in the NOM group (27.8%; P = .402). One death in the NOM group was related to aortic disease. Follow-up computed tomography imaging revealed similar aortic-related outcomes between groups, with a high proportion showing resolved or improved aortic injury (NOM, 87.5%; TEVAR, 92.9%; P = .674). Initial computed tomography imaging showed similar aortic diameters between groups. The average diameter of the aorta distal to the subclavian artery was 22.6 mm in the NOM group vs 22.8 mm in the TEVAR group (P = .85). The average maximum diameter of the pseudoaneurysm was 30.1 mm in the TEVAR group and 29.9 mm in the NOM group (P = .90). The average ratio of diameter of the pseudoaneurysm to diameter of the aorta distal to the subclavian artery was 1.32 for the TEVAR group and 1.33 for the NOM group (P = .85). CONCLUSIONS: The natural history of grade III BTAIs is not well described. This study suggests that observation and NOM of grade III BTAI may be a reasonable therapeutic option in selected patients. It also speaks to the need for further delineation of the natural history of this injury. Serial imaging and long-term follow-up are necessary to monitor the progression of the pseudoaneurysm.

Heparin-Induced Thrombocytopenia Associated with a Heparin-Bonded Stent Graft.

We describe a case of heparin-induced thrombocytopenia (HIT) in association with heparin-bonded stent grafts. A 61-year-old man with claudication secondary to a left superficial femoral artery (SFA) occlusion was treated with 2 heparin-bonded polytetrafluorethylene (hep-PTFE) grafts. Despite the use of antiplatelet medication, he presented with thrombosed hep-PTFE grafts 1 week after initial treatment. An additional hep-PTFE graft was placed at the SFA origin because of migration of the first graft. He was discharged on anticoagulation; however, he presented again 2 weeks later with recurrent SFA thrombosis and a platelet count of 60,000, raising suspicion for HIT. All exogenous forms of heparin were discontinued, and he was started on an alternative anticoagulant. The patient returned again 5 days after being discharged with recurrent symptoms of acute limb ischemia. He underwent a left femoropopliteal artery bypass with autogenous conduit and removal of the grafts. He has since had an uneventful recovery. We believe HIT should be considered as a potential cause of hep-PTFE graft thrombosis. Diagnosis and management of these patients is complex and may require explantation of the graft.

Prevention of abdominal aortic aneurysm progression by targeted inhibition of matrix metalloproteinase activity with batimastat-loaded nanoparticles.

RATIONALE: Matrix metalloproteinases (MMPs)-mediated extracellular matrix destruction is the major cause of development and progression of abdominal aortic aneurysms. Systemic treatments of MMP inhibitors have shown effectiveness in animal models, but it did not translate to clinical success either because of low doses used or systemic side effects of MMP inhibitors. We propose a targeted nanoparticle (NP)-based delivery of MMP inhibitor at low doses to the abdominal aortic aneurysms site. Such therapy will be an attractive option for preventing expansion of aneurysms in patients without systemic side effects. OBJECTIVE: Our previous study showed that poly(d,l-lactide) NPs conjugated with an antielastin antibody could be targeted to the site of an aneurysm in a rat model of abdominal aortic aneurysms. In the study reported here, we tested whether such targeted NPs could deliver the MMP inhibitor batimastat (BB-94) to the site of an aneurysm and prevent aneurysmal growth. METHODS AND RESULTS: Poly(d,l-lactide) NPs were loaded with BB-94 and conjugated with an elastin antibody. Intravenous injections of elastin antibody-conjugated BB-94-loaded NPs targeted the site of aneurysms and delivered BB-94 in a calcium chloride injury-induced abdominal aortic aneurysms in rats. Such targeted delivery inhibited MMP activity, elastin degradation, calcification, and aneurysmal development in the aorta (269% expansion in control versus 40% elastin antibody-conjugated BB-94-loaded NPs) at a low dose of BB-94. The systemic administration of BB-94 alone at the same dose was ineffective in producing MMP inhibition. CONCLUSIONS: Targeted delivery of MMP inhibitors using NPs may be an attractive strategy to inhibit aneurysmal progression.

Fistulas in octogenarians: are they beneficial?

BACKGROUND: The incidence of end-stage renal disease is increasing most rapidly in patients aged older than 75 years. Meanwhile, their 5-year survival rate remains the lowest of any dialysis cohort. The purpose of this study was to evaluate the benefit of arteriovenous fistula (AVF) construction in octogenarians, as the data regarding the effects of age on fistula success are conflicting. METHODS: Using our hemodialysis database, we performed a retrospective review of all AVFs placed between 1 November, 2007, and 17 July, 2013, in patients aged 80 years or older. Patient demographics, presence of catheters, time to first fistula use, fistula interventions, fistula patency, and time to patient death were all evaluated. RESULTS: We placed 32 fistulas in 31 patients. Our average patient was 82-year-old, men (75%) and Caucasian (71%). Three patients were excluded, as they never required dialysis. One patient required 2 fistulas; the second fistula was excluded from analysis. Of the remaining 28 patients, 22 (78%) were used for hemodialysis and 19 (68%) required catheter-based dialysis before fistula use. The mean length of catheter use was 166 days, and the median time to first fistula use was 109 days. Primary functional patency was 51% at year 1 and 38% at year 2, respectively. Secondary patency was 75% at year 1 and year 2. Of the 22 patients, 17 (77%) required intervention to achieve or maintain patency. The median time to death was 26 months. CONCLUSIONS: With substantial effort, successful fistula utilization can be achieved in an extremely elderly patient population. Our patients experienced significant catheter utilization and over 3 quarters required secondary interventions to achieve or maintain fistula utilization. Given this group's limited survival and the fact that 21% of their survival time was spent dialyzing with a catheter, the benefit of a functioning fistula to a patient older than 80 years can be questioned.

Platform technologies for decellularization, tunic-specific cell seeding, and in vitro conditioning of extended length, small diameter vascular grafts.

The aim of this study was to generate extended length, small diameter vascular scaffolds that could serve as potential grafts for treatment of acute ischemia. Biological tissues are considered excellent scaffolds, which exhibit adequate biological, mechanical, and handling properties; however, they tend to degenerate, dilate, and calcify after implantation. We hypothesized that chemically stabilized acellular arteries would be ideal scaffolds for development of vascular grafts for peripheral surgery applications. Based on promising historical data from our laboratory and others, we chose to decellularize bovine mammary and femoral arteries and test them as scaffolds for vascular grafting. Decellularization of such long structures required development of a novel "bioprocessing" system and a sequence of detergents and enzymes that generated completely acellular, galactose-(α1,3)-galactose (α-Gal) xenoantigen-free scaffolds with preserved collagen, elastin, and basement membrane components. Acellular arteries exhibited excellent mechanical properties, including burst pressure, suture holding strength, and elastic recoil. To reduce elastin degeneration, we treated the scaffolds with penta-galloyl glucose and then revitalized them in vitro using a tunic-specific cell approach. A novel atraumatic endothelialization protocol using an external stent was also developed for the long grafts and cell-seeded constructs were conditioned in a flow bioreactor. Both decellularization and revitalization are feasible but cell retention in vitro continues to pose challenges. These studies support further efforts toward clinical use of small diameter acellular arteries as vascular grafts.

Radiation safety education in vascular surgery training.

OBJECTIVE: Endovascular volume during vascular surgery training has increased profoundly over recent decades, providing heavy exposure to ionizing radiation. The study purpose was to examine the radiation safety training and practices of current vascular surgery trainees. METHODS: An anonymous survey was distributed to all current U.S. trainees. Responses were compared according to the presence of formal radiation safety training and also the trainees' perception of their attendings' adherence to As Low As Reasonably Achievable (ALARA) strategies. RESULTS: The response rate was 14%. Forty-five percent had no formal radiation safety training, 74% were unaware of the radiation safety policy for pregnant females, 48% did not know their radiation safety officer's contact information, and 43% were unaware of the yearly acceptable levels of radiation exposure. Trained residents knew more basic radiation safety information, and more likely wore their dosimeter badges (P < .05). Trained residents found their radiation safety officer helpful in developing safety habits; untrained residents relied on other residents (P < .05). Trainees who felt their attendings consistently practiced ALARA strategies more likely practiced ALARA themselves (P < .05). CONCLUSIONS: The lack of formal radiation safety training in respondents may reflect an inadequate state of radiation safety education and practices among U.S. vascular surgery residents.

The influence of a Vascular Surgery Hospitalist program on physician and patient satisfaction, resident education, and resource utilization.

A number of surgery practice models have been developed to address general and trauma surgeon workforce shortages and on-call issues and to improve surgeon satisfaction. These include the creation of acute or urgent care surgery services and "surgical hospitalist" programs. To date, no practice models corresponding to those developed for general and trauma surgeons have been proposed to address these same issues among vascular surgeons or other surgical subspecialists. In 2003, our practice established a Vascular Surgery Hospitalist program. Since its inception nearly a decade ago, it has undergone several modifications. We reviewed hospital administrative databases and surveys of faculty, residents, and patients to evaluate the program's impact. Benefits of the Vascular Surgery Hospitalist program include improved surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians and ancillary staff, and resident teaching/supervision. Elements of this program may be applicable to a variety of surgical subspecialty settings.

Comparison of arteriovenous fistulas and arteriovenous grafts in patients with favorable vascular anatomy and equivalent access to health care: is a reappraisal of the Fistula First Initiative indicated?

BACKGROUND: Initiatives to increase arteriovenous fistula (AVF) use are based on studies that show that AVFs require fewer interventions and have better patency than arteriovenous grafts (AVGs). Because patients who receive AVFs typically have more favorable vascular anatomy and are referred earlier for access placement than those who receive AVGs, the advantages of AVF might be overestimated. We compared outcomes for AVFs and AVGs in patients with equivalent vascular anatomy who were on dialysis via catheter at the time of vascular access placement. STUDY DESIGN: The study included patients who underwent placement of a first-time AVF or AVG between 2006 and 2009, who were on dialysis via catheter at the time of access placement, and who had favorable arterial and venous (>3 mm) anatomy. Outcomes for AVF and AVG were compared. RESULTS: Eighty-nine AVF and 59 AVG patients met study inclusion criteria. Similar secondary patency was achieved by AVG and AVF at 12 (72% vs 71%) and 24 months (57% vs 62%), respectively (p = 0.96). The number of interventions required to maintain patency for AVF (n = 1; range 0 to 10) and AVG (n = 1; range 0 to 11) were not different (p = 0.36). However, the number of catheter days to first access use was more than doubled in the AVF group (median 81 days) compared with the AVG group (median 38 days; p < 0.001). CONCLUSIONS: For patients who are receiving dialysis via catheter at the time of access placement, the maturation time, risk of nonmaturation, and interventions required to achieve a functional AVF can negate its benefits over AVG. A fistula first approach might not always apply to patients who are already on dialysis when referred for chronic access placement.

The management of malfunctioning prosthetic arteriovenous accesses by interventional nephrologists and surgeons: a retrospective comparison of long-term outcomes.

PURPOSE: To compare the outcomes of arteriovenous grafts (AVG) managed by interventional nephrologists (IN) to those managed by vascular surgeons (VS). METHODS: Between January 2004 and February 2005, 106 forearm loop AVG were placed. Ten AVG did not meet inclusion criteria and thus were excluded from study. Forty-seven AVG were managed by IN using percutaneous interventional techniques. Vascular surgeons, using surgical techniques, cared for 49 AVG. High-risk AVG in the IN group were surveyed with fistulagrams, whereas AVG in the VS group were not. Outcomes of the IN and VS groups were retrospectively compared. RESULTS: The secondary patency rates at 6 and 18 months were 84% and 69% in the IN group and 79% and 68% in the VS group, respectively (P=.38). Twenty-five (53%) AVG in the IN required at least one surgical procedure to achieve a patency equivalent to that of the VS group. The mean number of AVG interventions to final failure was 4.8 in the IN group and 3.0 in the VS group (P=.03). Infection requiring AVG removal occurred in six patients in the IN group and one patient in the VS group (P=.07). CONCLUSIONS: Surveillance fistulagrams and percutaneous intervention for malfunctioning AVG by IN do not provide superior patency and may require more interventions over the "life" of the graft when compared to no surveillance and surgical intervention by VS. In order to achieve optimal vascular access outcomes, a collaborative relationship between nephrologist and surgeon is essential so as to ensure that the most appropriate intervention is selected and futile interventions are avoided.

Description and outcomes of a simple surgical technique to treat thrombosed autogenous accesses.

OBJECTIVE: Owing to the difficulty of removing acute and chronic thrombus from autogenous accesses (AA) by standard surgical and endovascular techniques, many surgeons consider efforts to salvage a thrombosed AA as being futile. We describe a simple technique to extract acute and chronic thrombus from a failed AA. This technique involves making an incision adjacent to the anastomosis, directly extracting the arterial plug, and manually milking thrombus from the access. This report details the outcomes of a series of thrombosed AAs treated by surgical thrombectomy/intervention using this technique for manual clot extraction. METHODS: A total of 146 surgical thrombectomies/interventions were performed in 102 patients to salvage a thrombosed AA. Mean follow-up was 15.6 months. Office, hospital, and dialysis unit records were reviewed to identify patient demographics, define procedure type, and determine functional patency rates. Kaplan-Meier survival analysis was used to estimate primary and secondary functional patency rates. RESULTS: Complete extraction of thrombus from the AA was achieved in 140 of 146 cases (95%). The studied procedure itself was technically successful in 127 cases (87%). Reasons for failure were the inability to completely extract thrombus from the AA in six, failed angioplasty due to long segment vein stenosis or sclerosis in seven or vein rupture in two, and central vein occlusion in one. Three failures occurred for unknown causes ≤ 3 days of successful thrombectomy. No single factor analyzed (age, sex, race, diabetes status, access type or location) was associated with technical failure. The estimated primary and secondary functional patency rates were 27% ± 5% and 61% ± 6% at 12 months. CONCLUSIONS: The manual clot extraction technique described in this report effectively removed acute and chronic thrombus from failed AAs. Its use, combined with an intervention to treat the underlying cause for AA failure, significantly extended access durability.

Lower extremity arteriovenous hemodialysis access: an important adjunct in select patients.

Given the current survival rates of patients receiving hemodialysis, it has become increasingly common for patients to exhaust their upper extremity access options. Likewise, overzealous catheter use can lead to central venous occlusion or stenosis, further limiting the upper extremity access options. In these patients, use of the lower extremities for access is often required. Fortunately, there are a number of options available that have acceptable durability and utility. The purpose of this article is to review the various techniques available for placement of hemodialysis access in the lower extremity and discuss their results.