Predicting wound complications following lower extremity revascularization.

OBJECTIVE: The aim of this study was to create a simple risk score to identify factors associated with wound complications after infrainguinal revascularization. METHODS: The Veterans Affairs Surgical Quality Improvement Program national data set was queried from 2005 to 2021 to identify 22,114 patients undergoing elective open revascularization for peripheral arterial disease (claudication, rest pain, tissue loss) or peripheral aneurysm. Emergency and trauma cases were excluded. The data set was divided into a two-thirds derivation set and one-third validation set to create a risk prediction model. The primary end point was wound complication (wound dehiscence, superficial/deep wound surgical site infection). Eight independent risk factors for wound complications resulted from the model and were assigned whole number integer risk scores. Summary risk scores were collapsed into categories and defined as low (0-3 points), moderate (4-7 points), high (8-11 points), and very high (>12 points). RESULTS: The wound complication rate in the derivation data set was 9.7% (n = 1428). Predictors of wound complication included age ≤73 (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.08-1.46), body mass index ≥35 kg/m2 (OR, 1.99; 95% CI, 1.68-2.36), non-Hispanic White (vs others: OR, 1.48; 95% CI, 1.30-1.69), diabetes (OR, 1.23; 95% CI, 1.10-1.37), white blood cell count >9900/mm3 (OR, 1.18; 95% CI, 1.03-1.35), absence of coronary artery disease (OR, 1.27; 95% CI, 1.03-1.35), operative time >6 hours (OR, 1.20; 95% CI, 1.05-1.37), and undergoing a femoral endarterectomy in conjunction with bypass (OR, 1.34; 95% CI, 1.14-1.57). In both the derivation and validation sets, wound complications correlated with risk category. Among the defined categories in the derivation set, wound complication rates were 4.5% for low-risk patients, 8.5% for moderate-risk patients, 13.8% for high-risk patients, and 23.8% for very high-risk patients, with similar results for the internal validation data set. Operative indication did not independently associate with wound complications. Patients with wound complications had higher rates of reoperation and graft failure. CONCLUSIONS: This risk prediction model uses easily obtainable clinical metrics that allow for informed discussion of wound complication risk for patients undergoing open infrainguinal revascularization.

Late type III endoleaks are common in early generation Endologix AFX stent grafts.

OBJECTIVE: Early generation Endologix AFX endovascular abdominal aortic aneurysm (AAA) stent graft devices are at risk of developing type IIIa (intercomponent/overlap-related) as well as type IIIb (fabric tear) endoleaks over time. Current follow-up studies are limited to short (<24 months) and midterm (24-48 months) reports. The purpose of this study was to identify the incidence of type III endoleaks associated with these endografts over a long-term follow-up (>4 years) period and discuss current management strategies. METHODS: A retrospective, single-institution cohort analysis of all Endologix AFX endografts implanted from October 2011 to October 2016 was performed. Patient characteristics, imaging, and follow-up were obtained via chart review. Type III endoleaks were characterized based on computed tomography angiogram/operative findings and confirmed by two surgeons. Statistical analysis was performed with SAS v9.4. RESULTS: Sixty-three patients underwent AFX stent graft implantation for aneurysmal disease. Forty-seven patients comprised the final cohort for analysis after exclusions were made for primary iliac aneurysms as well as off-label use of the device (eg, hypogastric snorkel) or primary occlusive indications. The average age was 73.3 years, with the longest follow-up being 8.7 years (median, 5.2 years). Most AAAs (89.2%) were fusiform, with initial median diameter 5.5 cm. Initial 30-day mortality was 0%. Of the initial cohort, 10 (21.3%) type III endoleaks were treated, of which six (60%) were type IIIa and four (40%) were type IIIb. By time-to-event analysis at latest follow-up, freedom from type III intervention was 48% at 8 years. The median time to type III endoleak discovery was 4.7 years (range, 1.1-7.2 years), an interval that was similar for type IIIa and type IIIb leak types (P = .73). Patients with type III endoleaks had average sac growth of 1.3 cm over the follow-up interval compared with a net decrease for patients without type III endoleaks (P < .0001). Of the 10 patients treated for type III leaks, seven (70%) underwent complete endovascular re-lining, one (10%) had partial re-lining, and two (20.0%) underwent open endograft explant with aortic graft reconstruction. Reintervention 30-day mortality was 0% for all approaches. CONCLUSIONS: Early generation Endologix AFX stent grafts have a high rate of type III endoleaks, with freedom from type III leak <50% at 8-year follow-up. Most of these are not detected until several years (>4.5 years) after initial implantation, beyond the range of the follow-up interval of most published reports. Long-term imaging surveillance is critical, and a low threshold for complete relining should be considered with any sign of sac enlargement, even if endoleak is not clearly demonstrated in patients with early generation Endologix AFX grafts.

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.

Peri-Procedural Management of Hemodynamic Instability in Patients Undergoing Carotid Revascularization.

Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) is common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.

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.

Sulodexide Improves Contraction and Decreases Matrix Metalloproteinase-2 and -9 in Veins Under Prolonged Stretch.

High pressure in the lower-limb veins is often associated with chronic venous insufficiency and varicose veins (VVs), making it important to search for the mechanisms and agents that control venous function. We have shown that protracted increases in venous stretch/wall tension reduce vein contraction and augment matrix metalloproteinase (MMP)-2 and -9. Also, MMP-2 and MMP-9 promote venodilation, a hallmark of VVs. Sulodexide (SDX) is a blend of glycosaminoglycans with efficient profibrinolysis and antithrombosis activities, but its actions on vein function and the mechanisms involved are unclear. We tested the hypothesis that SDX enhances venous contractile response by decreasing MMP expression/activity in veins subjected to protracted stretch. Rat inferior vena cava (IVC) rings were treated with SDX (0.001-1 mg/mL) or vehicle, equilibrated under control 0.5-g resting tension or protracted 2-g stretch for 18 hours, and the contractile response to 96-mM KCl and phenylephrine (Phe) in SDX-treated and nontreated veins was recorded. In IVC rings under control 0.5-g resting tension, SDX caused dose-dependent contraction, 96-mM KCl caused marked contraction (176-mg/mg tissue), and Phe caused dose-dependent contraction with a maximum (56-mg/mg tissue) at 10 M. In IVC subjected to protracted 2-g stretch, 96-mM KCl-induced contraction was reduced to 112 mg/mg and maximal Phe-induced contraction was decreased to 23 mg/mg. In IVC subjected to protracted 2-g stretch plus SDX, 96-mM KCl-induced contraction was restored to 228 mg/mg and maximal Phe-induced contraction was improved to 115 mg/mg. Gelatin zymography and Western blots revealed increases in MMP-2 and MMP-9 levels/gelatinolytic activity in veins subjected to protracted 2-g stretch and reversal to control levels in veins subjected to 2-g stretch plus SDX. Thus, SDX improves vein function and augments the contractile response in veins subjected to protracted stretch. The SDX-induced improvement of contraction and restoration of vein function appear to involve decreases in MMP-2 and MMP-9 and may contribute to the benefits of SDX in chronic venous insufficiency and VVs.

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.

Risk prediction of 30-day mortality after lower extremity major amputation.

OBJECTIVE: Universal risk calculators may underestimate mortality risk, whereas purely observational administrative data may lack appropriate granularity to individualize risk. The purpose of this study was to create a simple risk prediction model to identify the factors associated with 30-day morality after lower extremity major amputation for ischemic vascular disease. METHODS: The Veterans Affairs Surgical Quality Improvement Program national data set was queried from 2005 to 2015 to identify 14,890 patients undergoing elective above-knee or below-knee amputation for rest pain, tissue loss, or gangrene. The data set was divided into a two-thirds derivation set and one-third validation set for the purpose of creating a risk prediction model. The primary end point was 30-day mortality. Eight independent risk factors for mortality resulted from the model and were assigned whole number integer risk scores. Summary risk scores were collapsed into categories and defined as low (0-3 points), moderate (4-7 points), high (8-10), and very high (>10). RESULTS: Mortality in the derivation data set was 4.6% (n = 453). By multivariable backward elimination, predictors of 30-day mortality (odds ratio [95% confidence limits]) included preoperative do not resuscitate order (3.1 [2.3-4.0]), congestive heart failure (2.8 [2.1-3.6]), age >80 years (1.8 [1.4-2.2]), chronic renal insufficiency (2.1 [1.7-2.5]), above-knee amputation (1.8 [1.4-2.2]), dependent functional status (2.0 [1.6-2.5]), coronary artery disease (1.3 [1.1-1.6]), and chronic obstructive pulmonary disease (1.3 [1.0-1.6]); the final model held a C statistic of 0.74. In both the derivation and validation sets, 30-day mortality correlated with risk category. Among the defined categories in the derivation set, 30-day mortality rates were 2.3% for low-risk patients, 4.3% for moderate-risk patients, 7.5% for high-risk patients, and 17.5% for very-high-risk patients, with similar results for the validation data set. CONCLUSIONS: This risk prediction model uses eight easily obtainable clinical metrics that allow early assessment of 30-day mortality risk of patients undergoing major lower extremity amputation for ischemic indications. The internal validation of the risk score demonstrates the increased mortality with increasing risk category. Reliable expected mortality prediction is critically important for surgeons to make recommendations in accordance with a patient's or family's goals of care. These data may also be used to set realistic expectations for hospital-based quality initiatives and to provide guidance in preoperative medical optimization.

Chronic venous disease - Part II: Proteolytic biomarkers in wound healing.

Venous leg ulcers (VLU) are characterized by sustained proteolytic microenvironment impairing the healing process. Wound fluid (WF) reflect the biomolecular activities occurring within the wound area; however, it is unclear if WF from different healing phases have different proteolytic profiles and how VLU microenvironment affects the wound healing mechanisms. We investigated the proteolytic network of WF from distinct VLU phases, and in WF- and LPS-stimulated THP-1 monocytes treated with glycosaminoglycan sulodexide, a well known therapeutic approach for VLU healing. WF were collected from patients with VLU during inflammatory (Infl) and granulating (Gran) phases. WF and THP-1 supernatants were analyzed for nine matrix metalloproteinases (MMP) and four tissue inhibitors of metalloproteinases (TIMP) by multiplex immunoassays. Our results demonstrated that: 1) WF from Infl VLU contained significantly increased concentrations of MMP-2, MMP-9, MMP-12, TIMP-1, and TIMP-2 compared to Gran WF; 2) WF from Gran VLU showed significantly increased levels of MMP-1, MMP-7, MMP-13, and TIMP-4 compared to Infl WF; 3) LPS- and WF-stimulation of THP-1 cells significantly increased the expression of several MMP compared to untreated cells; 4) Sulodexide treatment of both LPS- and WF-stimulated THP-1 significantly down-regulated the release of several MMPs. Our study provides evidence-based medicine during treatment of patients with VLU. WF from Infl and Gran VLU have different MMP and TIMP signatures, consistent with their clinical state. The modulation of proteolytic pathways in wound microenvironment by glycosaminoglycan sulodexide, provide insights for translating research into clinical practice during VLU therapy.

Chronic venous disease - Part I: Inflammatory biomarkers in wound healing.

Venous leg ulcers (VLUs) produce wound fluid (WF), as a result of inflammatory processes within the wound. It is unclear if WF from different healing phases of VLU has a peculiar biochemical profile and how VLU microenvironment affects the wound healing mechanisms. This study was conducted to evaluate the cytokine/chemokine profiles in WF from distinct VLU phases, in WF- and LPS-stimulated monocytes and treated with glycosaminoglycan Sulodexide, a therapeutic option for VLU healing. WF and plasma were collected from patients with VLU during active inflammatory (Infl) and granulating (Gran) phases. Demographics, clinical characteristics and pain measurements were evaluated. WF, plasma, and THP-1 supernatants were analyzed for 27 inflammatory mediators by multiplex immunoassay. Our results demonstrated that: 1) pain was significantly increased in patients with Infl compared to Gran VLU; 2) cytokine profile of Infl WF was found to be statistically different from that Gran WF, as well significantly increased respect to plasma; 3) LPS- and WF-stimulation of THP-1 cells significantly increased the expression of several cytokines compared to untreated cells; 4) Sulodexide treatment of both LPS- and WF-stimulated THP-1 monocytes was able to significantly down-regulate the release of peculiar inflammatory mediators. Our study highlighted the importance to understand biomolecular processes underlying CVI when providing treatment for chronic VLU. Identification of inflammatory biomarkers in leg ulcer microenvironment, may provide useful tools for predicting healing outcome and developing targeted therapies.

Rupture of a True Profunda Femoris Artery Aneurysm: Two Case Reports and Review of the English Language Literature.

Profunda femoris artery aneurysms (PFAAs) are very rare and easily overlooked because they are located deeply within thigh muscle. PFAAs have a high rate of rupture in comparison with other peripheral arterial aneurysms, resulting in emergency surgical procedures with significant morbidity. PFAA is diagnosed with color arterial Doppler ultrasound, although computed tomography angiography remains the best imaging method to precisely define the exact site and length of arterial involvement. PFAAs should be treated surgically once diagnosed, even if they are asymptomatic due to the high incidence of complications. Currently, around 28 patients with PFAA rupture, including the 2 cases from this report, have been described in the English language literature. In this report, we describe the diagnosis and treatment of 2 true ruptured aneurysms of the profunda femoris artery with 2 different approaches, and will review the relevant literature.

Chronic Venous Insufficiency: Transforming Growth Factor-ß Isoforms and Soluble Endoglin Concentration in Different States of Wound Healing.

Venous leg ulcer (VLU) is a huge healthcare problem with poorly understood pathophysiology. Transforming growth factor-ß (TGF-ß) and endoglin (Eng), are inflammatory and wound healing mediators. Eng, co-receptor for TGF-ß type-II receptors, may be cleaved forming soluble Eng (sEng), antagonizing TGF-ß signaling, a crucial process in vascular pathologies. We evaluated the accumulation in wound fluid (WF) of TGF-ß isoforms and sEng in healing stages, showing the effects of sulodexide treatments, a glycosaminoglycan with clinical efficacy in VLU healing. Patients with inflammatory (Infl) and granulating (Gran) VLU were recruited. WFs and THP-1 monocytes exposed to Infl and Gran WF (treated/untreated with sulodexide) were analyzed for TGF-ß isoforms and sEng by multiplex immunoassay. In both Infl and Gran WF, TGF-ß1 and ß2 were similar; TGF-ß3 was significantly increased in Infl compared to Gran WFs (p = 0.033). sEng was significantly elevated in Gran compared to Infl WFs (p = 0.002). In THP-1 monocytes there was a significant increase in sEng after co-treatment of WF and sulodexide. The increase in TGF-ß3 found in Infl WF highlights its negative effect on wound healing, while the increased levels of sEng in Gran WF affects the leukocyte adhesion/transmigration through the endothelium, reducing the inflammatory response and favoring the wound healing. Glycosaminoglycan sulodexide potentiates the effects of sEng release from monocyte, representing an important therapeutic option for wound healing.

Contemporary comparison of aortofemoral bypass to alternative inflow procedures in the Veteran population.

OBJECTIVE: Multiple vascular inflow reconstruction options exist for claudication, including aortofemoral bypass (AFB) and alternative inflow procedures (AIPs) such as femoral reconstruction with iliac stents, and femoral-femoral, iliofemoral, and axillofemoral bypass. Contemporary multi-institution comparison of these techniques is lacking. METHODS: The Veterans Affairs Surgical Quality Improvement Project (VASQIP) national database (2005-2013) was used to compare AFB vs AIP in a propensity-matched analysis. Primary outcome was mortality at 30 and 90 days. Secondary outcomes included rates of postoperative complications. Multivariable regression assessed the adjusted effect of inflow procedure type on mortality. RESULTS: A matched cohort of 748 claudicant patients (373 AFB, 375 AIP) was identified. The AFB and AIP groups had similar mean age (59.9 vs 60.8 years; P = .30), gender (P = .51), race (P = .52), recent smoking (79.1% vs 76.5%; P = .43), history of coronary artery disease (14.8% vs 14.7%; P > .99), chronic obstructive pulmonary disease (18.8% vs 18.4%; P = .92), renal insufficiency (5.9% vs 6.1%; P > .99), and diabetes (22% vs 20%; P = .53), and American Society of Anesthesiologists Physical Status Classification (P = .41). The AFB group had longer mean operative time (4.9 vs 3.5 hours; P < .0001), more senior resident assistants (72.4% vs 61.1%; P < .0001), and greater mean red blood cell transfusion (1.1 vs 0.12 units; P < .0001). AFB and AIP had similar rates of outflow bypass (1.9% vs 1.3%; P = .58) and outflow endovascular interventions (0.54% vs 1.6%; P = .29). AFB trended toward a higher rate of mortality at 30 days postoperatively (2.7% vs 0.8%; P = .06), but by 90 days, the crude mortality rates were similar for the two (2.9% vs 2.1%; P = .5). AFB had higher rates of pneumonia (5.9% vs 0.8%; P < .001), deep vein thrombosis/pulmonary embolism (1.3% vs 0%; P = .03), postoperative transfusion (2.7% vs 0.53%; P = .02), and urinary tract infection (3.5% vs 0.8%; P = .01), but similar rates of myocardial infarction (1.6% vs 0.8%; P = .34), stroke (0.8% vs 0%; P = .12), wound complications (13.1% vs 12.8%; P = .91), renal failure (1.1% vs 0.3%; P = .22), graft failure (1.3% vs 1.1%; P = .75), and return to the operating room (12.9% vs 9.6%; P = .17). Multivariable analysis showed AFB was not independently associated with mortality (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.1-3.0). Significant factors included age (OR, 1.2; 95% CI, 1.1-1.4), postoperative renal insufficiency (OR, 2.5; 95% CI, 1.6-4.0), and unplanned reintubation (OR, 35.5; 95% CI, 3.1-399). CONCLUSIONS: For claudicant patients with inflow disease, AFB has higher rates of 30-day complications and a trend toward higher mortality; however by 90 days postoperatively, the two procedure types have similar rates of mortality.

Impact of coexisting aneurysms on open revascularization for aortoiliac occlusive disease.

OBJECTIVE: National data evaluating outcomes for occlusive abdominal aortic reconstructions are well described. The relative effect of operative indication as well as the presence of concomitant abdominal aortic aneurysm (AAA) on in-hospital mortality is not well defined. METHODS: The Nationwide Inpatient Sample was queried to identify patients who underwent open aortic surgery (2003-2010). Indication for surgery was classified by International Classification of Diseases, Ninth Revision diagnostic codes to identify isolated occlusive indications as well as combined occlusive disease and AAA. Primary outcome was in-hospital mortality. Secondary outcomes were complications and discharge disposition. RESULTS: Overall, 56,374 underwent aortic reconstruction, 48,591 for occlusive disease (86.2%) and 7783 for combined occlusive disease with AAA (13.8%). Intermittent claudication was the most common indication for intervention (60.9%), whereas 39.7% underwent intervention for critical limb ischemia (22.2% rest pain, 17.6% gangrene). Patients with intermittent claudication had more concomitant AAAs (17.3%) than did patients with critical limb ischemia (8.4%). The baseline characteristics for those with occlusive disease and combined occlusive with AAA disease were similar in terms of obesity (4.8% vs 4.2%; P = .27) and congestive heart failure (6.6% vs 6.3%; P = .65) but differed by age (62.2 years vs 68.4 years; P < .0001) and hypertension (65.4% vs 69.1%; P = .005). Patients with combined occlusive and AAA disease had higher mortality than those with occlusive disease alone (3.9% vs 2.7%; P = .01). On multivariable regression, factors associated with in-hospital mortality included gangrene with AAA compared with gangrene alone (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6-4.7; P < .0002), age >65 years age (OR, 3.1; 95% CI, 2.4-4.1; P < .0001), renal failure (OR, 2.7; 95% CI, 1.9-3.8; P < .0001), and concurrent lower extremity revascularization (OR, 1.3; 95% CI, 1.1-1.7; P < .02). CONCLUSIONS: Intermittent claudication or critical limb ischemia with concomitant AAA carries a higher mortality than intermittent claudication or critical limb ischemia alone, especially in older patients with gangrene requiring revascularization and renal insufficiency. Preoperative risk stratification strategies should focus on the indication for surgery as well as the presence of concomitant AAA.

Venous leg ulceration pathophysiology and evidence based treatment.

Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.

Congenital Absence of Inferior Vena Cava in a Young Patient with Iliofemoral Deep Venous Thrombosis Treated with Ultrasound-accelerated Catheter-directed Thrombolysis: Case Report and Review of the Literature.

Absence of the inferior vena cava (AIVC) is a rare congenital anomaly and result from aberrant development during embryogenesis. Deep vein thrombosis (DVT) is a frequent finding in healthy young adults who are diagnosed with congenital AIVC. This condition is best diagnosed with color venous Doppler ultrasound and computed tomography angiography or magnetic resonance imaging, and managed using anticoagulation, mechanical catheter-directed thrombectomy, and thrombolysis. Catheter-directed thrombolysis (CDT) followed by systemic anticoagulation and use of compression stockings appears safe and effective in the treatment of patients who present with acute DVT and AIVC. We present a case report of DVT with underlying AIVC treated successfully with CDT and will review the relevant English literature.

Changes of the serum properties and its effect on the endothelial cells restoration in patients with chronic disease treated with sulodexide.

OBJECTIVE: Inflammation and endothelial dysfunction are important venous changes in patients with chronic venous disease (CVD). The use of the venoactive drugs remains an important treatment modality for patients with CVD, reducing the severity of the CVD-related symptoms and swelling but also reducing inflammation and protecting endothelial cells. In this research, the effects of the serum obtained from patients with CVD before and after sulodexide treatment were evaluated for in vivo and in vitro inflammatory markers and endothelial cell function. METHODS: Inflammatory markers (IL-6, matrix metalloproteinase-9 [MMP-9], vascular cell adhesion molecule-1 [VCAM-1], and von Willebrand factor [vWF]) from the incompetent great saphenous veins (GSVs) and from the systemic venous circulation were studied in 10 patients with CVD (C2s) before and after 2 months of sulodexide (2 × 500 LSU/d) therapy. Serum from pretreatment and following sulodexide treated patients was evaluated for in vitro cultured human umbilical vein endothelial cell function. RESULTS: The serum collected from lower leg incompetent GSVs had significantly elevated levels of VCAM-1 (+29%, P < .001) compared with the serum from the systemic circulation. Endothelial cells exposed to the serum from the incompetent lower leg veins of the untreated CVD patients demonstrated higher stimulated synthesis of MMP-9 (+17%, P < .01), as well as increased markers of senescence (prolongation of population doubling time, ß-galactosidase activity, and expression of p21 and p53 genes). CVD serum-induced senescent endothelial cells had a higher expression of genes regulating IL-6, MMP-9, VCAM-1, and vWF synthesis. The overall proinflammatory effect on endothelial cells by the serum collected from the incompetent GSVs was stronger as compared with the serum from the systemic circulation. Serum collected from the veins after sulodexide treatment caused lower levels of endothelial cell inflammatory markers as well as respective gene expression than serum obtained at the beginning of the study (before sulodexide treatment). Sulodexide application also reduced the inflammatory secretory activity of the senescent endothelial cells. Sulodexide treatment resulted in the decrease of the majority of the studied inflammatory parameters in both lower limb incompetent vein and systemic blood. CONCLUSIONS: In patients with CVD, there are significant differences between circulating inflammatory markers analyzed from the lower leg incompetent GSV segments compared with the systemic circulation, indicating a higher inflammatory condition in CVD. Treatment with sulodexide reduces the proinflammatory and endothelial cell activation properties of the serum from patients with CVD. CLINICAL RELEVANCE: The study documented the significant proinflammatory human vascular endothelial cell activation when exposed to the serum collected from the varicose veins as compared with the serum from the systemic circulation in patients with chronic venous disease (CVD). The inflammatory marker expression, endothelial dysfunction, and endothelial cell senescence transformation can be successfully controlled and downregulated by patients' exposure to the glycosaminoglycan (sulodexide) treatment. Further studies are needed to confirm if glycosaminoglycan application can prevent further CVD clinical progression due to potential CVD-related pathological processes' modulation and their downregulation.

Venous compression syndromes in females: A descriptive review.

Venous compression syndromes have been described, yet the role of sex is poorly understood. Although iliac vein compression has been discussed more often with the advent of newer technologies, research has fallen short on defining epidemiology, best practices for evaluation and treatment, and differences in responses to treatment between men and females. The authors report on iliac vein compression, nonthrombotic renal vein compression, and other venous compression syndromes in females. Literature searches of PubMed were performed using the following keywords: females/females and May Thurner, venous stenting, venous outcomes, deep venous disease, deep venous compression, venous stenting, renal vein compression, renal vein surgery/stent, popliteal vein entrapment, venous thoracic vein entrapment, and popliteal vein entrapment. The articles prompted the authors to research further as the referenced articles were reviewed. Sex representation has not been addressed adequately in the research of venous compression syndromes, making the discussion of best treatment options and long-term outcomes difficult. More specific understanding of epidemiology and response to interventions will only come from research that addresses these issues directly, understanding that some of these syndromes occur rarely.

Fake-news-free evidence-based communication for proper vein-lymphatic disease management.

Published scientific evidence demonstrate the current spread of healthcare misinformation in the most popular social networks and unofficial communication channels. Up to 40% of the medical websites were identified reporting inappropriate information, moreover being shared more than 450,000 times in a 5-year-time frame. The phenomenon is particularly spread in infective diseases medicine, oncology and cardiovascular medicine. The present document is the result of a scientific and educational endeavor by a worldwide group of top experts who selected and analyzed the major issues and related evidence-based facts on vein and lymphatic management. A section of this work is entirely dedicated to the patients and therefore written in layman terms, with the aim of improving public vein-lymphatic awareness. The part dedicated to the medical professionals includes a revision of the current literature, summing up the statements that are fully evidence-based in venous and lymphatic disease management, and suggesting future lines of research to fulfill the still unmet needs. The document has been written following an intense digital interaction among dedicated working groups, leading to an institutional project presentation during the Universal Expo in Dubai, in the occasion of the v-WINter 2022 meeting.