Outcomes of prosthetic upper arm arteriovenous graft vs brachiobasilic fistula for hemodialysis access.

OBJECTIVE: Primary arteriovenous access such as radiocephalic and brachiocephalic fistulas are initial choices for creating vascular access in dialysis patients. When neither of these choices is an option, upper arm arteriovenous graft or brachiobasilic transposition is recommended. Although primary fistula is better than prosthetic graft for suitable patients, there is little data to guide the best treatment strategy in the absence of suitable vein for primary access creation. This study identifies factors that influence patency rates and compares outcomes of patients treated with brachiobasilic fistula vs upper arm graft in patients who have failed forearm access or are not candidates for primary access. METHODS: A prospectively maintained database of patients with dialysis-dependent renal failure from 2010 to 2022 was analyzed. Primary, primary assisted, and secondary patency rates were calculated. Incidence rates of complications and reinterventions were compared. RESULTS: There were 148 patients with brachiobasilic fistulas and 157 patients with upper arm grafts. The graft group was older (70.1 ± 14.7 vs 62.5 ± 14.6 years; P = .003) and had a higher incidence of pacemakers (11.9% vs 4.1%; P = .005). Brachiobasilic fistulas had higher 6-month (77.0% vs 64.3%; P = .02) and 1-year (68.2% vs 55.4%; P = .03) primary-assisted patency. Secondary patency rates were better for upper arm grafts at 1-year (82.2% vs 72.3%; P = .05). Access complications of non-maturation and aneurysm were higher in basilic vein transposition (21.6% vs 1.3%; P < .0001; 15.5% vs 6.4%; P = .017). Grafts had higher rates of occlusion (58.0% vs 25.7%; P < .0001). In terms of interventions, upper arm grafts had higher rates of thrombectomy (50.3% vs 18.9%; P < .0001), but there was no difference seen in angioplasty, stent, surgical revision, or steal procedures. Basilic vein transpositions had longer time to cannulation (104.6 ± 81.1 vs 32.5 ± 22.4 days; P < .0001), longer total catheter days (251.1 ± 181.7 vs 72.9 ± 56.3 days; P < .0001), and higher number of procedures to aid maturity (0.7 ± 0.7 vs 0.1 ± 0.3; P < .0001). CONCLUSIONS: In this retrospective analysis, when forearm access or primary arteriovenous access is not an option, basilic vein transposition and upper arm grafts have fairly equivalent primary patency. Primary assisted patency is slightly better in basilic vein fistulas, but secondary patency is better in upper arm grafts at 1 year. Basilic fistulas also had longer time to cannulation, longer total catheter days, and more procedures to aid maturity.

Multi-center experience with intravascular lithotripsy for treatment of severe calcification during transcarotid artery revascularization for high-risk patients.

OBJECTIVE: Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease. METHODS: All consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30 days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30 days, technical success, and <30% residual stenosis. RESULTS: Fifty-eight patients (62% male; mean age, 78 ± 6.6 years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87 ± 27 minutes and 25 ± 14 minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29 mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having <30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30 days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P = .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P = .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132 days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period. CONCLUSIONS: IVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30 days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.

Postoperative Outcomes and One-Year Mortality of Patients on Chronic Anticoagulation Medications Undergoing Infrainguinal Bypass.

BACKGROUND: Patients requiring open infrainguinal bypass (IIB) frequently are taking chronic anticoagulation (AC) medications. Taking these medications in the preoperative setting may affect the outcomes of surgery. This study aims to evaluate postoperative outcomes and 1-year mortality of patients taking chronic AC medications that undergo IIB. METHODS: Using data obtained from the Vascular Quality Initiative from January 2011 to October 2021, patients on warfarin or any direct oral anticoagulants (DOAC) within 30 days of IIB were compared with patients not taking chronic AC medications. The primary outcomes were in-hospital, 30-day, and 1-year mortality. The secondary outcomes included total procedure time, need for perioperative packed red blood cell transfusion, prolonged length of hospital stay, postoperative myocardial infarction or stroke, and graft patency at discharge. A subgroup analysis was performed comparing patients taking warfarin with those taking DOACs. Univariate analyses and multivariate logistic regression, Kaplan Meier survival, and Cox regression analyses were used to analyze the data for postoperative and 1-year outcomes, respectively. RESULTS: A total of 55,076 patients underwent IIB during the study period, and 11,547 (20.97%) were on chronic AC prior to surgery. The 2 cohorts differed significantly in almost every demographic and clinical characteristic. Multivariate analyses adjusting for 45 potential confounders revealed that there was no significant difference in in-hospital, 30-day, and 1-year mortality. The total procedure time for the chronic AC cohort was on average 11.46 ± 2.16 min longer (P ≤ 0.001) and there was a greater risk of prolonged length of stay in the hospital (adjusted odds ratio [aOR]: 1.19, 95% confidence interval [CI]: 1.13-1.26, P < 0.001). These patients also returned to the operating room (OR) at a greater rate (aOR: 1.12, 95% CI: 1.05-1.19; P = 0.016) and demonstrated a significantly lower rate of graft patency at discharge (aOR: 0.73, 95% CI: 0.62-0.86, P = 0.001). On subgroup analysis, multivariate analysis demonstrated lower 30-day mortality for the DOAC group in comparison to the warfarin group (aOR: 0.74, 95% CI: 0.57-0.94, P = 0.015), but no significant differences in in-hospital and 1-year mortality. CONCLUSIONS: Patients taking AC medications within 30 days prior to IIBs may require more perioperative red blood cell transfusions, longer hospitalizations, and return to the OR at a greater rate. They are also at an increased risk for loss of graft patency at discharge. However, these patients are not at increased risk of in-hospital, 30-day, or 1-year mortality. IIB can, therefore, be performed safely in patients taking chronic AC medications.

Perioperative and long-term outcomes after open conversion of endovascular aneurysm repair versus primary open aortic repair.

BACKGROUND: The use of endovascular abdominal aortic aneurysm repair (EVAR) has superseded that of open aneurysm repair (OAR) as the procedure of choice for abdominal aortic aneurysm repair. However, significant rates of late reintervention and aneurysm rupture have been reported after EVAR, resulting in the need for conversion to OAR (C-OAR). To assess the relative effects of C-OAR on patients, we compared the outcomes of these patients to those of patients who had undergone P-OAR. METHODS: The data from all patients who had undergone C-OAR and P-OAR in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018 were queried. Multivariable logistic regression and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to assess the perioperative long-term outcomes. RESULTS: A total of 4763 patients were included (91.4%, P-OAR; 8.6%, C-OAR). C-OAR was associated with a significant increase in the odds of perioperative mortality (odds ratio, 1.7; 95% confidence interval [CI], 1.1-2.7; P = .027) and renal complications (odds ratio, 1.5; 95% CI, 1.1-2; P = .004) vs P-OAR. At 5 years, conversion was associated with a higher risk of mortality (hazard ratio [HR], 1.5; 95% CI, 1.3-1.9; P < .001), aneurysmal rupture (HR, 1.9; 95% CI, 1.2-3.1; P = .007), and reintervention (HR, 1.4; 95% CI, 1.05-1.97; P = .022) compared with P-OAR. These results also persisted at 10 years, with conversion associated with a higher risk of mortality (HR, 1.5; 95% CI, 1.2-1.8; P < .001), rupture (HR, 1.8; 95% CI, 1.1-2.8; P = .018), and reintervention (HR, 1.5; 95% CI, 1.1-2.1; P = .010). CONCLUSIONS: The results from the present study have demonstrated that C-OAR is associated with a significantly higher risk of perioperative morbidity and mortality compared with P-OAR. We found a significant increase in mortality, aneurysm rupture, and reintervention at 5 and 10 years of follow-up.

Preoperative thrombolysis is associated with improved vein patency and functional outcomes after first rib resection in acute Paget-Schroetter syndrome.

INTRODUCTION: Most patients with acute Paget-Schroetter syndrome (PSS) present in one of two manners: (1) thrombosis managed initially with thrombolysis and anticoagulation and then referred for surgery, and (2) initial treatment with anticoagulation only and later referral for surgery. Definitive benefits of thrombolysis in the acute period (the first 2 weeks after thrombosis) over anticoagulation alone have not been well reported. Our goal was to compare patients managed with early thrombolysis and anticoagulation followed by first rib resection (FRR) and later postoperative venography with venoplasty (PTA) with those managed with anticoagulation alone followed by FRR and PTA using vein patency assessed with venography and standardized outcome measures. METHODS: We reviewed a prospectively collected database from 2000 to 2019. Two groups were compared: those managed with early thrombolysis at our institution (Lysis) and those managed with anticoagulation alone (NoLysis). All patients underwent FRR. Venography was routinely performed before and after FRR. Standardized outcome measures included Quick Disability of Arm, Shoulder, and Hand (QuickDASH) scores and Somatic Pain Scale. RESULTS: A total of 50 Lysis and 50 NoLysis patients were identified. Pre-FRR venography showed that thrombolysis resulted in patency of 98% of veins, whereas 78% of NoLysis veins were patent. After FRR, postoperative venography revealed that 46 (92%) patients in the Lysis group and 37 (74%) patients in the NoLysis group achieved vein patency. Thrombolysis was significantly associated with final vein patency (odds ratio: 17 [4-199]; P < .001). Lysis patients had a trend toward lower QuickDASH scores from pre-FRR to post-FRR compared with NoLysis patients with a mean difference of -16.4 (±19.7) vs -5.2 (±15.6) points (P = .13). The difference in reduction of Somatic Pain Scale scores was not statistically significant. CONCLUSIONS: Thrombolysis as initial management of PSS, combined with anticoagulation, followed by FFR and VenoPTA resulted in improved final vein patency and may lead to an improved functional outcome measured with QuickDASH scores. Therefore, clinical protocols using thrombolysis as initial management should be considered when planning the optimal treatment strategy for patients with acute PSS.

In-situ bypass is associated with superior infection-free survival compared with extra-anatomic bypass for the management of secondary aortic graft infections without enteric involvement.

OBJECTIVE: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02). CONCLUSIONS: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective.

Embolic Protection Devices are Not Associated with Improved Outcomes of Atherectomy for Lower Extremity Revascularization.

BACKGROUND: Atherectomy is associated with a risk of distal embolization, but the role of embolic protection devices (EPDs) during atherectomy is not well-defined. This study examines the utilization and impact of EPD on the outcomes of atherectomy during peripheral vascular interventions (PVIs). METHODS: The annual trend in utilization of EPD during atherectomy in the Vascular Quality Initiative PVI files (2010-2018) was derived. Patients with concomitant open surgery, acute limb ischemia, emergent-status, concomitant thrombolysis, missing indication, missing EPD use, and missing long-term follow-up data were excluded. The characteristics of patients undergoing atherectomy with and without EPD were compared. Propensity matching based on age, gender, race, chronic obstructive pulmonary disease, coronary artery disease, end-stage renal disease, prior PVI, indication, urgent-status, TransAtlantic interSociety Consensus classification, and anatomical location of lesion was performed. The perioperative and 1-year outcomes of the matched groups were compared. RESULTS: EPD was used in 23.3% of atherectomy procedures (n = 5,013/21,500). The utilization of EPD with atherectomy increased from 8.8% to 22.7% (P = 0.003) during the study period. Patients undergoing atherectomy without EPD were more likely to have ESRD (7.8% vs. 5.2%; P < 0.001), tissue loss (31% vs. 23.1; P < 0.001), tibial intervention (39.6% vs. 23.3%; P < 0.001), higher number of arteries treated (1.78 ± 0.92 vs. 1.68 ± 0.93; P = 0.001), and longer length of lesion (21.15 ± 21.14 vs. 19 ± 20.27 cm; P = 0.004). Conversely, patients undergoing atherectomy with EPD were more likely to be White (81.1% vs. 74%; P < 0.001), have a history of smoking (80.6% vs. 74.5%; P < 0.001), chronic obstructive pulmonary disease (24.8% vs. 21.6%; P < 0.037), coronary artery disease (38.5% vs. 33.2%; P = 0.002), prior percutaneous coronary intervention (24.3% vs. 19.9%, P = 0.005), prior coronary artery bypass grafting (32.3% vs. 24.9%; P < 0.001), and prior PVI (49.2% vs. 45.1%; P = 0.023). After propensity matching, there were 1,007 patients in each group with no significant difference in baseline characteristics. There was no significant difference in short-term outcomes including the rate of distal embolization, technical success, dissection, perforation, discharge to home, and 30-day mortality. The use of EPD was, however, associated with longer fluoroscopy time. At 1-year, there was also no difference in primary patency, ipsilateral minor or major amputation, ankle brachial index improvement, reintervention, or mortality rate between patients who underwent atherectomy with and without EPD. CONCLUSIONS: EPD has been increasingly used in conjunction with atherectomy especially in patients with claudication and femoropopliteal disease. However, the use of EPD during atherectomy does not seem to impact the outcomes. Further research is needed to justify the additional cost and fluoroscopy time associated with the use of EPD during atherectomy.

Midterm Results of the Supera Stent for the Treatment of Femoropopliteal Occlusive Disease.

BACKGROUND: The Supera (Abbott Vascular, Santa Clara, CA) stent is an interwoven nitinol, shape-memory stent with high strength and flexibility characteristics which are purported to increase resistance to kinking and compression. The purpose of this study was to review single-center outcomes of the use of this stent in the femoropopliteal segment. METHODS: We performed a single-center, retrospective analysis of patients who underwent Supera stent placement for femoropopliteal occlusive disease from 2016-2019. Data was collected on patient demographics and procedural details. Follow-up imaging data, including duplex imaging and ankle-brachial indices, and clinical data were abstracted from encounter notes. RESULTS: Sixty-two patients with 72 unique Supera stent placements were identified. Mean age was 76 and 69% were male. 56% of patients had severe calcification and 11% had moderate calcification. 48% of lesions were Trans-Atlantic Inter-Society Consensus Document C or D lesions. Primary patency rates at 12, 24, and 36 months were 85%, 82%, and 75%, respectively. Primary patency was not affected significantly by lesion length, degree of calcification, number of outflow vessels, concomitant interventions, or stent size. CONCLUSIONS: These results demonstrate sustained primary patency with the Supera stent over a 3-year interval in treatment of patients with femoropopliteal occlusive disease, including in the setting of severely calcified vessels.

Nationwide comparison of the medical complexity of patients by surgical specialty.

OBJECTIVE: Intuitively, the chronic disease burden of surgical patients varies considerably by surgical specialty, although sparse evidence in the literature supports this notion. We sought to characterize the medical complexity of surgical patients by surgical specialty and to quantify the association between medical complexity and outcomes. METHODS: The National Inpatient Sample, an all-payer inpatient database representative of 97% of all U.S. hospitalizations, was used to identify adults undergoing surgery between 2005 and 2014. The most commonly performed operations that constituted 80% of each surgical specialty's practice were abstracted. The previously validated Elixhauser Comorbidity Index (ECI) was calculated per year by surgical specialty as a measure of medical complexity. Outcomes and resource utilization were assessed by comparing mortality rate, length of stay, and cost. RESULTS: An estimated 53,232,144 patients underwent operations in one of nine surgical specialty categories. Surgical specialties were ranked by ECI, with cardiac surgery (3.56), vascular surgery (3.49), and thoracic surgery (2.86) having the highest mean ECI (all P values <.0001 compared with vascular surgery). Whereas the high ECI scores in cardiac surgery were driven by arrhythmias and hypertension, vascular patients had a more uniform distribution of comorbidities. The average ECI for all surgical patients increased during the study period from 2.03 in 2005 to 2.65 in 2014 (P < .001), with a similar trend for all specialties considered. Unlike the two specialties with the lowest burden of comorbidities (orthopedic surgery and endocrine surgery), cardiac surgery and vascular surgery exhibited significantly higher inpatient mortality, LOS, and costs. CONCLUSIONS: Although all surgical patients have exhibited an increase in comorbidities during the past decade, candidates for cardiac and vascular operations appear to carry the largest burden of chronic conditions. Despite caring for patients with the highest burden of comorbidities for emergent operations, vascular surgery did not have the highest mortality, inpatient costs, or length of stay compared with some of the other specialties. The intensity of care and assumed risk in treating medically complex vascular patients should be taken into consideration in deciding health policy, reimbursement, and hospital resource allocation.

In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas.

OBJECTIVE: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. METHODS: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. RESULTS: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality. CONCLUSIONS: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.

Trainee Experience in Simulation-Based Education of Open Vascular Surgery.

BACKGROUND: Simulation continues to be an important adjunct to vascular surgery training, yet the optimal implementation of simulation to complement conventional surgical training continues to evolve. This study aims to find areas for improvement in current simulation-based training of open vascular skills by characterizing the experience of vascular trainees attending a national simulation-based course. METHOD: This was a survey study conducted at the simulation course of the Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What's New in Vascular and Endovascular Surgery, a national vascular surgery meeting. The survey consisted of 17 questions and was administered on paper or electronically via the Audience Response System, before the start of the course. The survey assessed the participants' experience in formal training, simulation training, and comfort with open surgical procedures. RESULTS: Between 2013 and 2018, the survey was completed by 150 participants of which 65% were vascular fellows. Only 48% of the participants had formal training in suturing and surgical instruments. Most participants had formal training in basic vascular techniques and advanced vascular operations. In 71%, simulation was incorporated into basic technique training and 60% in open surgical training. Simulation training was most commonly utilized in learning anastomotic techniques and open abdominal aortic aneurysm repair. Simulation skills were deemed translatable to the operating room by 59% of participants. Most participants were comfortable performing open vascular procedures. However, 68% of participants were uncomfortable performing an abdominal aortic aneurysm repair. CONCLUSIONS: There continues to be a significant portion of trainees who do not undergo a simulation-based education. Current simulation training is being targeted to meet trainee needs in open vascular surgery, specifically open aneurysm repair. Nonetheless, trainees continue to have doubts regarding applicability of simulation-based skills to the operating theater. Further studies investigating access to simulation education as well as its translatability are needed.

Contemporary Outcomes After Partial Resection of Infected Aortic Grafts.

INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.

Investigating uncommon vascular diseases using the Vascular Low Frequency Disease Consortium.

BACKGROUND: Standardized databases such as the Vascular Quality Initiative and National Surgical Quality Improvement Project assess the quality of care related to common vascular surgery procedures, but are not designed for uncommon vascular diseases. We describe a method of assessing uncommon vascular diseases using a multi-institutional collaboration, the Vascular Low Frequency Disease Consortium (VLFDC). METHODS: Uncommon vascular diseases are identified through a systematic literature review. A disease-specific database is developed and tested at a single institution, then refined and circulated to participating VLFDC investigators. Detailed inclusion and exclusion criteria and data point definitions are provided, allowing for standardized data collection across institutions. Each participating institution identifies all patients over a specific time period and enters the data into a VLFDC-provided database. The data are then de-identified and transmitted to our centralized data center for analysis. RESULTS: Since 2003, the VLFDC has conducted and published nine studies and enrolled 4532 patients, involving 232 institutions and 271 investigators. The studies include renal artery aneurysms, isolated femoral artery aneurysms, spontaneous mesenteric dissection, adventitial cystic disease, carotid body tumors, and vascular Ehlers-Danlos syndrome. Each published study reported on a minimum of 10 times the number of patients collected in previously published studies over the same time period, allowing stronger conclusions to be drawn from the larger sample size. Each study both confirmed previous management principles, which were based on small single-institution experiences, and challenged conventional management paradigms. CONCLUSIONS: When only small clinical series exist to provide guidance in managing uncommon vascular diseases, and/or where conflicting recommendations are made on the treatment of uncommon vascular diseases, a multi-institutional consortium can provide high-volume standardized data that either confirm or changes prior management principles.

Managing central venous access during a health care crisis.

OBJECTIVE: During the COVID-19 pandemic, central venous access line teams were implemented at many hospitals throughout the world to provide access for critically ill patients. The objective of this study was to describe the structure, practice patterns, and outcomes of these vascular access teams during the COVID-19 pandemic. METHODS: We conducted a cross-sectional, self-reported study of central venous access line teams in hospitals afflicted with the COVID-19 pandemic. To participate in the study, hospitals were required to meet one of the following criteria: development of a formal plan for a central venous access line team during the pandemic; implementation of a central venous access line team during the pandemic; placement of central venous access by a designated practice group during the pandemic as part of routine clinical practice; or management of an iatrogenic complication related to central venous access in a patient with COVID-19. RESULTS: Participants from 60 hospitals in 13 countries contributed data to the study. Central venous line teams were most commonly composed of vascular surgery and general surgery attending physicians and trainees. Twenty sites had 2657 lines placed by their central venous access line team or designated practice group. During that time, there were 11 (0.4%) iatrogenic complications associated with central venous access procedures performed by the line team or group at those 20 sites. Triple lumen catheters, Cordis (Santa Clara, Calif) catheters, and nontunneled hemodialysis catheters were the most common types of central venous lines placed by the teams. Eight (14%) sites reported experience in placing central venous lines in prone, ventilated patients with COVID-19. A dedicated line cart was used by 35 (59%) of the hospitals. Less than 50% (24 [41%]) of the participating sites reported managing thrombosed central lines in COVID-19 patients. Twenty-three of the sites managed 48 iatrogenic complications in patients with COVID-19 (including complications caused by providers outside of the line team or designated practice group). CONCLUSIONS: Implementation of a dedicated central venous access line team during a pandemic or other health care crisis is a way by which physicians trained in central venous access can contribute their expertise to a stressed health care system. A line team composed of physicians with vascular skill sets provides relief to resource-constrained intensive care unit, ward, and emergency medicine teams with a low rate of iatrogenic complications relative to historical reports. We recommend that a plan for central venous access line team implementation be in place for future health care crises.

Caval Reconstruction with Undersized Ringed Graft after Resection of Inferior Vena Cava Leiomyosarcoma.

BACKGROUND: The en bloc resection of inferior vena cava (IVC) leiomyosarcoma often necessitates IVC reconstruction. The objective of this study is to examine outcomes after IVC reconstruction and determine optimal graft sizing. METHODS: A retrospective review was conducted of all IVC reconstructions after IVC leiomyosarcoma resection at a single institution. Cross-sectional dimensions at the IVC resection margins were measured on preoperative imaging. The tumor location was based on the most superiorly involved region of the IVC and was classified as infrarenal, between hepatic and renal veins, or superior to the hepatic veins. Perioperative details and long-term outcomes including graft sizing, graft patency, morbidity, and mortality were recorded. RESULTS: Between 2007 and 2017, 12 patients (6 females, mean age: 64.5 years, age range: 46-80 years) underwent IVC leiomyosarcoma resection and reconstruction. All reconstructions were performed with ringed polytetrafluoroethylene (PTFE); graft sizes ranged from 12 mm to 16 mm. The tumor location was exclusively infrarenal in seven patients, between the renal and hepatic veins in two patients, and involved multiple segments in three patients. Larger graft sizes were utilized in reconstructing more superior segments of the IVC. Grafts were typically undersized and based on the diameter of the superior resection margin with 12 mm grafts approximately correlating to a 20 mm diameter, 14 mm to 25 mm, and 16 mm to 30 mm. The average undersizing ratio was 0.6. At a mean follow-up time of 43 ± 27 months, radiographic graft patency was 92%, overall survival was 83%, and disease-free survival was 25%. CONCLUSIONS: After en bloc resection of IVC leiomyosarcoma, caval reconstruction with an undersized ringed PTFE has acceptable patency. Grafts sizes should be based on the IVC diameter superior to the tumor and undersizing by approximately 40% appears to be associated with acceptable patency rates. Further multiinstitutional studies should be performed to best determine the optimal treatment of this rarely encountered tumor.

Comparison of one-stage and two-stage upper arm brachiobasilic arteriovenous fistula in the Vascular Quality Initiative.

OBJECTIVE: An upper arm brachiobasilic arteriovenous fistula (BBAVF) is a reliable autogenous hemodialysis access created with a one-stage or two-stage technique. Although both techniques are variably used, the optimal approach is uncertain. In this study, we compared the outcomes of one-stage and two-stage BBAVF procedures. METHODS: We identified 2648 patients who had received BBAVFs within the Vascular Quality Initiative data set (2010-2016) and compared those created using the one-stage and two-stage technique. The primary outcome measures were primary and secondary patency rates at 12 months. Other outcomes assessed were wound infection, steal, and swelling at 3 months. The log-rank test was used to evaluate patency by Kaplan-Meier analysis. Cox proportional hazards models were used to examine the adjusted association between surgical technique and outcomes. RESULTS: There were 1234 (47%) one-stage and 1414 (53%) two-stage BBAVFs in the study cohort, including 1848 (70%) patients who were on dialysis at the time of surgery and 1795 (68%) patients with a history of previous access. Patients who underwent a one-stage BBAVF were more likely to be male (54% vs 45%; P < .001), to be white (60% vs 41%; P < .001), and to have a history of coronary artery disease (22% vs 17%; P = .001). Patients undergoing one-stage BBAVFs have larger vein diameters (4.1 vs 3.4 mm; P < .001) and have the procedure in an inpatient setting (21% vs 13%; P < .001) compared with patients undergoing a two-stage procedure. The 12-month primary patency rate was higher for the one-stage BBAVF (49.1% vs 40.4%; P = .005), although the secondary patency rate was comparable (80.0% vs 77.9%; P = .54). Postoperative bleeding (4% vs 1.5%; P < .001), wound infection (1.01% vs 0.4%; P = .047), and arm swelling (2.1 % vs 0.8%; P = .006) were higher for one-stage BBAVFs. In multivariable analysis, although loss of primary patency at 12 months (adjusted hazard ratio [aHR], 1.12; 95% confidence interval [CI], 0.97-1.30; P = .12) and 3-month wound infection (aHR, 0.42; 95% CI, 0.14-1.25, P = .12) were similar between the two approaches, the risk of 3-month arm swelling was significantly lower for two-stage BBAVFs (aHR, 0.35; 95% CI, 0.16-0.77; P = .009). CONCLUSIONS: Whereas surgeons were more likely to perform a two-stage BBAVF in patients with a history of previously failed access and smaller basilic vein, our data show no difference in primary or secondary patency of one-stage and two-stage BBAVFs at 12 months.

Atherectomy-Associated Complications in the Southern California Vascular Outcomes Improvement Collaborative.

BACKGROUND: Atherectomy has become an increasingly utilized modality for the endovascular treatment of peripheral arterial occlusive disease. The objective of this study was to determine the incidence and risk factors for atherectomy-associated complications. METHODS: A retrospective review was performed for all atherectomy procedures performed between January 2011 and December 2015 in the Southern California Vascular Outcomes Improvement Collaborative. Atherectomy was defined as laser, orbital, or excisional atherectomy. Complications were dissection, perforation, and distal embolization. RESULTS: Seven hundred twenty-nine atherectomy procedures were performed at 7 institutions by 27 practitioners. The mean age was 73 years with 415 (57%) males. Four hundred nineteen (57%) were diabetic, 673 (92%) hypertensive, 457 (63%) smokers, and 244 (34%) had coronary artery disease. Dissection occurred in 51 (7%) procedures, embolization in 23 (3.1%), and perforation in 12 (1.6%). The mean number of lesions treated per artery was the same at 1.6 in patients with any complication and no complication (P = 0.77). The total occluded length was 7.4 cm for complications versus 7.2 cm for no complication (P = 0.73). The total treated length was 12.9 cm for complications versus 11.3 cm for no complication (P = 0.03). The incidence of complications for Trans-Atlantic Inter-Society Consensus (TASC) C/D lesions were 13% compared to 10% for TASC A/B lesions (P = 0.05). The incidence of complications in superficial femoral/popliteal lesions was 12.9% vs. 10.4% in tibial lesions (P = 0.13). In multivariable analysis, treatment length was associated with a small increased risk of complication (odds ratio = 1.02, 95% confidence interval = 1.0-1.04). CONCLUSIONS: Increased treatment length is associated with an increased risk of atherectomy-associated complications. Demographic factors and comorbidities were not predictors of complications.

Risk stratification for the development of respiratory adverse events following vascular surgery using the Society of Vascular Surgery's Vascular Quality Initiative.

OBJECTIVE: Postoperative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however, little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication, and the overall impact of RAEs on patient outcomes. METHODS: The Vascular Quality Initiative was queried (2003-2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm repair, thoracic endovascular aortic repair, suprainguinal bypass, or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created, and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables, and other postoperative adverse events. RESULTS: The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (9.9%), chronic obstructive pulmonary disease requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open abdominal aortic aneurysm repairs (17.6%), in situ suprainguinal bypasses (9.68%), and thoracic endovascular aortic repairs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, congestive heart failure severity, chronic obstructive pulmonary disease severity, degree of renal insufficiency, ambulatory status, transfer status, urgency, and operative type. The predicted compared with the actual RAE incidence were highly correlated, with a correlation coefficient of 0.943 (P < .0001) and a c-statistic = 0.818. RAEs had a significantly higher rates of in-hospital mortality (25.4% vs 1.2%; P < .0001; adjusted odds ratio, 5.85; P < .0001), and discharge to a nursing facility (57.8% vs 19.0%; P < .0001; adjusted odds ratio, 3.14; P < .0001). CONCLUSIONS: RAEs are frequent and one of the strongest risk factors for in-hospital mortality and inability to be discharged home. Our risk prediction score accurately stratifies patients based on key demographics, comorbidities, presentation, and operative type that can be used to guide patient counseling, preoperative optimization, and postoperative management. Furthermore, it may be useful in developing quality benchmarks for RAE following major vascular surgery.

Comparative effectiveness of anticoagulation on midterm infrainguinal bypass graft patency.

OBJECTIVE: Therapeutic anticoagulation (AC) is used clinically for prolongation of infrainguinal bypass patency, but evidence for the efficacy of this practice is conflicting. The objective of our study was to determine the association of AC with bypass graft primary patency. METHODS: Clinical and comorbid data of patients undergoing infrainguinal bypass grafts to a below-knee target with at least 1 year of follow-up performed from 2003 to 2015 were obtained from the Society for Vascular Surgery Vascular Quality Initiative. Inverse propensity of treatment-weighted Cox regression was used to assess the effect of AC on patency in the total cohort while adjusting for clinical, operative, and comorbid differences between treatment groups. Subgroup analyses of distal targets and conduit type were performed. Perioperative complications were analyzed using propensity-weighted logistic regression. RESULTS: We identified 7612 bypass grafts with intact 1-year follow-up information from 2003 to 2015. The mean age was 67.5 ± 11.2 years; 30.5% (n = 2320) were female, and 28.6% (n = 2165) were discharged on therapeutic AC. The anticoagulated group had a higher rate of tibial, ankle, and pedal targets (52.1% [n = 1127] vs 47.6% [n = 2269]; P < .001), had a greater use of non-single-segment vein conduits (44.3% [n = 951] vs 26.5% [n = 1426]; P < .001), and was more likely to have had a previous ipsilateral bypass (27.2% [n = 589] vs 14.7% [n = 794]; P < .001) or stent (25.4% [n = 550] vs 20.9% [n = 1130]; P < .001). Estimated unadjusted primary patency was 70.8% ± 0.6% at 1 year and lower for anticoagulated bypasses (66.9% ± 1.2% vs 72.4% ± 0.7%; P < .001). Propensity-weighted analysis showed no significant association of AC with primary patency in the overall cohort (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.86-1.11; P = .8) but demonstrated a trend toward improvement of primary patency in those with a non-single-segment vein conduit to a below-knee popliteal target (HR, 0.85; 95% CI, 0.80-1.02; P = .09). AC was associated with significantly improved secondary patency in those with prosthetic bypass grafts (HR, 0.77; 95% CI, 0.62-0.96; P = .02) or prosthetic bypasses to an infrapopliteal target (HR, 0.72; 95% CI, 0.54-0.97; P = .02). Odds of postoperative wound complications were significantly higher in those receiving AC (odds ratio, 1.33; 95% CI, 1.11-1.61; P = .002). CONCLUSIONS: This study does not demonstrate a significant impact of therapeutic AC on primary patency for infrainguinal bypass grafts. Treatment with AC may benefit secondary patency in those with a prosthetic bypass, especially to an infrapopliteal target, but at an increased risk of postoperative wound complications.