Serration Angioplasty Is Associated With Less Recoil in Infrapopliteal Arteries Compared With Plain Balloon Angioplasty.

PURPOSE: Recoil following balloon angioplasty of tibial arteries is a known mechanism of lumen loss and widely considered to be a contributing factor in early failure or later restenosis. The Serranator balloon has been designed to provide a controlled lumen gain while minimizing vessel injury. The objective of this study was to assess the ability to define and measure postangioplasty recoil in infrapopliteal arteries and to compare recoil after serration angioplasty and plain balloon angioplasty (POBA). METHODS: This multi-center, sequential comparative study included patients with de novo or restenotic lesions of infrapopliteal arteries up to 22 cm in length. Patients were enrolled sequentially and underwent alternating POBA or serration angioplasty with Serranator. The study captured angiographic imaging at pre, immediately post, and 15-minute after angioplasty. Vessel recoil, final diameter stenosis, and dissection were compared using core laboratory analysis. RESULTS: This study enrolled 36 patients who underwent treatment of 39 infrapopliteal lesions. There was no significant difference between Serranator (n=20) and POBA (n=19) with respect to baseline demographics and lesion characteristics. Arterial recoil (>10%) occurred in 25% of Serranator-treated lesions versus 64% in POBA-treated lesions (p=0.02. Clinically relevant recoil (>30%) was present after serration angioplasty in 10% of patients and after POBA in 53% (p=0.01). There was no significant difference in technical success (100% for both), dissection rate between Serranator (5%) and POBA (5.2%). CONCLUSIONS: Arterial recoil occurs after infrapopliteal angioplasty. Serration angioplasty produces substantially less arterial recoil compared with POBA. Additional studies are needed to assess whether reduced arterial recoil translates into superior long-term clinical outcomes. CLINICAL IMPACT: Prior studies have demonstrated over 90% recoil in patients after balloon angioplasty (POBA) of the infrapopliteal vessels, which significantly impacts the durability and impact of endovascular interventions in this clinical space. This study compared recoil after infrapopliteal angioplasty with serration angioplasty and POBA. Serration angioplasty produces substantially less arterial recoil compared with POBA. Additional studies are needed to assess whether reduced arterial recoil translates into superior long-term clinical outcomes.

Individual and Program-Related Predictors of Academic Vascular Surgery Practice.

BACKGROUND: Several studies have explored factors affecting academic employment in surgical subspecialties; however, vascular surgery has not yet been investigated. We examined which elements of surgical training predict future academic productivity and studied characteristics of NIH-funded vascular surgery attendings. METHODS: With approval from the Association of Program Directors in Vascular Surgery (APDVS), the database of recent vascular surgery fellowship (VSF) and integrated vascular surgery residency (IVSR) graduates was obtained, and public resources (Doximity, Scopus, PubMed, NIH, etc.) were queried for research output during and after training, completion of dedicated research years, individual and program NIH funding, current practice setting, and academic rank. Adjusted multivariate regression analyses were conducted for postgraduate academic productivity. RESULTS: From 2013 to 2017, there were 734 graduates. Six hundred three completed VSF and 131 IVSR; 220 (29%) were female. Academic employment was predicted by MD degree, advanced degree, training at a top NIH-funded program, number publications by end of training, and H-index. Dedicated research time before or during vascular training, advanced degree, or graduating from a top NIH-funded program were predictors of publishing >1 paper/year. Number of publications by end of training and years in practice were predictive of H-index ≥5. VSF versus IVSR pathway did not have an impact on future academic employment, annual publication rate as an attending, or H-index. Characterization of NIH-funded attendings showed that they often completed dedicated research time (72%) and trained at a top NIH-funded program (79%). Mean publications by graduation among this group was 15.82 ± 11.3, and they averaged 4.31 ± 4.2 publications/year as attendings. CONCLUSIONS: Research output during training, advanced degrees, and training at a top NIH-funded program predict an academic vascular surgery career. VSF and IVSR constitute equally valid paths to productive academic careers.

Neurogenic Thoracic Outlet Syndrome in Division 1 Collegiate Athletes: Presentation, Diagnosis, and Treatment.

OBJECTIVE: Athletes who engage in repetitive upper-extremity exercise are susceptible to neurogenic thoracic outlet syndrome (nTOS). We sought to identify typical presenting symptoms and common findings on diagnostic workup, in addition to evaluating rates of return to play following various treatment interventions. DESIGN: Retrospective chart review. SETTING: Single institution. PARTICIPANTS: Medical records of Division 1 athletes containing the diagnosis of nTOS between the years 2000 and 2020 were identified. Athletes with arterial or venous thoracic outlet syndrome were excluded. INDEPENDENT VARIABLES: Demographics, sport, participation status, clinical presentation, physical examination findings, diagnostic workup, and treatments provided. MAIN OUTCOME MEASURES: Rate of return to play (RTP) to collegiate athletics. RESULTS: Twenty-three female and 13 male athletes were diagnosed and treated for nTOS. Digit plethysmography showed diminished or obliterated waveforms with provocative maneuvers in 23 of 25 athletes. Forty-two percent were able to continue competing despite symptoms. Of the athletes who were initially unable to compete, 12% returned to full competition after physical therapy alone, 42% of those remaining were able to RTP after botulinum toxin injection, and an additional 42% of the remaining athletes RTP after thoracic outlet decompression surgery. CONCLUSIONS: Many athletes diagnosed with nTOS will be able to continue competing despite symptoms. Digit plethysmography is a sensitive diagnostic tool for nTOS to document anatomical compression at the thoracic inlet. Botulinum toxin injection had a significant positive effect on symptoms and a high rate of RTP (42%), allowing numerous athletes to avoid surgery and its prolonged recovery and associated risks. CLINICAL RELEVANCE: This study demonstrates that botulinum toxin injection had a high rate of return to full competition in elite athletes without the risks and recovery needed for surgical intervention, suggesting that this may be a good intervention especially among elite athletes who only experience symptoms with sport-related activities.

Impact of Scalene Muscle Botulinum Toxin Injection With and Without Surgery in Neurogenic Thoracic Outlet Syndrome.

OBJECTIVE: Scalene blocks are part of both the diagnostic and treatment algorithm for patients presenting with symptoms of neurogenic thoracic outlet syndrome (nTOS). However, there is a paucity of data on the utility of scalene botulinum toxin injection (BTI) before surgical decompression. We sought to determine the impact of BTI with and without surgery at a multidisciplinary referral center. DESIGN: Retrospective cohort study. SETTING: Single institution tertiary academic center, 2011 to 2020. PATIENTS: Seventy-seven consecutive patients. INTERVENTIONS: Scalene muscle BTI for nTOS with or without surgical decompression. MAIN OUTCOME MEASURES: Pain relief and Quick Disability of the Arm, Shoulder and Hand (QDASH) score. RESULTS: Seventy-seven patients, with a mean age of 31.4 years, had BTI for symptoms of nTOS. All patients underwent pretreatment physical therapy through the Edgelow protocol for a mean duration of 3.4 months. However, 72.7% had dynamic vascular compression on duplex ultrasound with provocative maneuvers and 85.7% had a positive physical examination finding. After BTI, 77.9% reported subjective relief, confirmed by an improved QDASH disability score. Thirty-one patients (40.3%) then went on to have further persistent symptoms and proceeded with first rib resection. After BTI + Surgery, 96.8% reported symptomatic relief and had a median QDASH score improvement of 21 (range: 10-40), with all reaching minimal clinically important differences in the QDASH score after combination therapy. CONCLUSIONS: In this reported series of chemodenervation in patients with nTOS, BTI is helpful in alleviating symptoms before definitive surgical decompression. BTI followed by first rib resection provides additional symptom improvement over BTI alone.

Interview experience, post-interview communication, and gender-based differences in the integrated vascular surgery residency match.

OBJECTIVE: Integrated vascular surgery residency (IVSR) applicant perspective about the match process has been rarely studied, yet this has important implications on trainee recruitment. We sought to better understand the nature of the interview process and post-interview communication and its impact on students' ranking choices. METHODS: A voluntary and anonymous survey was sent to students who matched to IVSR in 2020, inquiring about interviews, post-interview communications, and factors influencing students' rank lists. RESULTS: Seventy of the 73 matched students completed the survey (96% response rate; 23 female and 47 male respondents). Applicants reported they were asked questions about other programs of interest (81.4%), top choice programs (65.7%), marital status (32.9%), family planning (7.1%), and religion (1.4%) during interviews. Female applicants were more frequently asked questions about family planning (17.4% vs 2.1%; P < .01) and marital status (52.5% vs 23.4%; P < .01) compared with male applicants. After interviews, 92.9% of applicants notified their top choice program of their ranking preference. Of applicants, 61.4% received post-interview communication with regards to ranking from at least one program, initiated by program directors in 81.3% of instances. Among these applicants, 58.1% reported that the post-interview communication had an impact on their rank list, and 46.5% matched at a program by which they were contacted. Of applicants, 5.7% were asked by a program to reveal their ranking of the program, and 11.4% were promised by a program to be ranked first if the applicant reciprocally ranked them first. Female and male applicants weighed program culture, operative volume, mentorship, and prestige equally in making their rank list. Male applicants weighed the sub-internship experience more significantly; however, female applicants weighed the sub-internship experience, personal relationships in certain cities, dedicated professional development years, and large female representation in the program more heavily (P < .02). CONCLUSIONS: This study provides insight into the interview experience and impactful factors for the vascular surgery match. Both female and male applicants were asked a high number of questions about personal matters unrelated to medical school performance. Female applicants, however, experienced a higher proportion of these instances, particularly regarding family planning. These findings demonstrate the factors that are important to applicants in the match process and raises awareness of potential challenges in the interview and recruitment process.

Trends in Utilization and Outcomes of Orbital, Laser, and Excisional Atherectomy for Lower Extremity Revascularization.

PURPOSE: The aim of this study is to analyze the utilization pattern of atherectomy modalities and compare their outcomes. MATERIALS AND METHODS: All patients undergoing atherectomy in the 2010-2016 Vascular Quality Initiative Database were identified. Utilization of orbital, laser, or excisional atherectomy was obtained. Characteristics and outcomes of patients treated for isolated femoropopliteal and isolated tibial disease by different modalities were compared. RESULTS: Atherectomy use increased from 10.3% to 18.3% of all peripheral interventions (n = 122 938). Orbital atherectomy was most commonly used and increased from 59.4% in 2010 to 63.2% of all atherectomies in 2016, while laser atherectomy decreased from 19.2% to 13.1%. Atherectomy was mostly used for treatment of isolated femoropopliteal disease (51.1%), followed by combined femoropopliteal and tibial disease (25.8%) and isolated tibial disease (11.7%). In isolated femoropopliteal revascularization, excisional atherectomy was associated with higher rate of perforation (1.2%) compared with laser (0.4%) and orbital atherectomy (0.5%). The technical success of orbital atherectomy (96.7%) was lower compared with excisional atherectomy (98.7%). Concomitant stenting was significantly higher with laser atherectomy (43.0%) compared with orbital (27.2%) and excisional (26.1%) atherectomy. Nevertheless, there was no difference in 1-year primary patency, reintervention, major amputation, improvement in ambulatory status, or mortality. Multivariable analysis also demonstrated no difference in 1-year primary patency and major ipsilateral amputation among the modalities. In isolated tibial revascularization, there were no differences in perioperative outcomes among the modalities. Excisional atherectomy was associated with the highest 1-year primary patency (88.1%). After adjusting for confounders, excisional atherectomy remained associated with superior 1-year primary patency compared with orbital atherectomy (odds ratio [OR] = 2.59, 95% confidence interval [CI] = [1.18-5.68]), and excisional atherectomy remained associated with a lower rate of 1-year major ipsilateral amputation compared with laser atherectomy (OR = 0.29, 95% CI = [0.09-0.95]). CONCLUSION: Atherectomy use has increased, driven primarily by orbital atherectomy. Despite significant variation in perioperative outcomes, there were no differences in 1-year outcomes among the different modalities when used for treating isolated femoropopliteal disease. In isolated tibial disease treatment, excisional atherectomy was associated with higher 1-year primary patency compared with orbital atherectomy and decreased major ipsilateral amputation rates compared with laser atherectomy. These differences warrant further investigation into the comparative effectiveness of atherectomy modalities in various vascular beds.

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.

Anatomic Factors Contributing to External Iliac Artery Endofibrosis in High-Performance Athletes.

BACKGROUND: External iliac artery endofibrosis (EIAE) classically presents in cyclists with intimal thickening of the affected arteries. We investigated possible anatomical predisposing factors including psoas muscle hypertrophy, arterial tortuosity, inguinal ligament compression, and arterial kinking via a case-control comparison of symptomatic and contralateral limbs. METHODS: All patients with unilateral EIAE treated surgically at our institution were reviewed. Each patient's symptomatic side was compared with their contralateral side using paired t-tests. Psoas hypertrophy was quantified by the transverse cross-sectional area (CSA) at L4, L5, and S1 vertebral levels, and inguinal ligament compression was measured as the anterior-posterior distance between the inguinal ligament and underlying bone. Tortuosity index for diseased segments and arterial kinking were measured on TeraRecon. RESULTS: Of 33 patients operated on for EIAE from 2004 to 2021, 27 with available imaging presented with unilateral disease, more commonly left-sided (63%). Most (96%) had external iliac involvement and 26% had ≥2 segments affected: 19% common iliac artery, 15% common femoral artery. The symptomatic limb had greater mean L5 psoas CSA (1,450 mm2 vs. 1,396 mm2, mean difference 54 mm2, P = 0.039). There were no significant differences in L4 or S1 psoas hypertrophy, tortuosity, inguinal ligament compression, or arterial kinking. 63% underwent patch angioplasty, and 85% underwent additional inguinal ligament release. 84% reported postoperative satisfaction, which was associated with a greater difference in psoas hypertrophy at L4 (P = 0.022). CONCLUSIONS: Psoas muscle hypertrophy is most pronounced at L5 and is associated with symptomatic EIAE. Preferential hypertrophy of the affected side correlates with improved outcomes, suggesting psoas muscle hypertrophy as a marker of disease severity.

Multidisciplinary Extremity Preservation Program Improves Quality of Life for Patients with Advanced Limb Threat.

BACKGROUND: The need for multidisciplinary care of patients with advanced limb threat is well established. We examined patient reported outcomes and health-related quality of life (HR-QoL) for those who completed a multidisciplinary extremity preservation program (EPP) at our institution. METHODS: Patients with advanced limb threat, who had previously failed standard management at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing specialists. HR-QoL was quantified before and after EPP participation with the RAND-36 questionnaire. The validated RAND-36 assesses physical function, role limitations caused by physical and emotional health problems, social functioning, emotional well-being, energy, pain and general health perceptions. RESULTS: From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary panel, 120 were accepted into the program, 63 of whom completed their course of care; 9 were one-time consultations. The median number of EPP in-person care visits was 23 (13-54) per participant; 87.3% of patients received one or more surgical procedure, including operative debridement (73%), revascularization (44%), soft-tissue reconstruction or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their course of treatment. 85.7% of patients achieved complete wound healing, 41.5% occurring within 6 months. Ultimately, 14.3% required a major amputation. Graduates noted improvement in all categories of the HR-QoL upon completion, including those undergoing major amputation. On adjusted multivariate regression analysis, patients with immunocompromised status were more likely to show greater improvement in their social function (OR: 10.1; P < 0.044) and emotional role limitation (OR: 8.1; P = 0.042), while, patients with larger wound volume at presentation were more likely to have greater improvement in their general health (OR: 1.1; P < 0.049). Conversely, patients with a smoking history had less improvement in energy level (OR: 0.4; P = 0.044) and patients with dialysis-dependence had less improvement in social function (OR: 0.2; P = 0.034). CONCLUSIONS: Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients with complex limb threat, including those who are immunocompromised with impaired social function and emotional role limitations. Furthermore, study is warranted to better characterize the generalizability of this approach, including considerations of cost-effectiveness, wound recidivism, and limiting the number of in-person visits required to achieve complete healing.

Factors influencing medical student choices in the integrated vascular surgery match: Implications for future post-pandemic residency matches.

OBJECTIVE: Integrated vascular surgery residency is among the most competitive specialties, but little is known about the applicant perspective. The coronavirus disease 2019 outbreak impacted the 2021 integrated vascular surgery residency match because of travel restrictions. We sought to better understand pre-pandemic applicant recruitment strategies, logistics of away rotations, and the residency interview process to identify areas for improvement in the application process. METHODS: An anonymous survey was sent to matched students in 2020, inquiring about motivations for pursuing vascular surgery (VS), logistic of away rotations and interviews, and factors influencing students' rank lists. RESULTS: Seventy of the 73 matched students completed the survey (95.9% response rate). The median age was 27 (range, 25-41); 32.9% were female, 91.4% were U.S. medical students, and 77.1% were from institutions with a VS training program. Factors most strongly influencing the decision to choose VS as a career were interest in open vascular procedures, endovascular procedures, perceived job satisfaction, emerging technologies, and influence of a mentor. The prospect of the job market, future salary, and competitiveness of the application process had the least impact. Of the matched students, 82.9% completed an away rotation (median, 2; range, 1-4), with 51.7% of students paying a total cost of more than $2500. Fifty percent of students matched either at their home institution or where they had performed an away rotation. Students reported application submissions to a median of 50 programs (range, 1-70) and interviewed at 17 (range, 1-28), with 40% of students paying a total of more than $4000 for interview costs. The most significant factors affecting students' rank lists included program culture, open aortic surgical volume, geography, and complex endovascular procedure volume. Tours of facilities, resident salary, and male/female distribution had the least importance. CONCLUSIONS: Successfully matched applicants in 2020 prioritized operative case volume and program collegiality when ranking programs. Despite their high cost, away rotations played an important role in the Match, suggesting that time spent at potential institutions allowed ideal assessment of factors for students. The high average number of away rotations and in-person interviews performed in 2019-2020 was limited for the 2021 Match due to coronavirus disease 2019 restrictions. Programs will have to continue developing creative alternatives or additions to away rotations and the application processes to assure continued success in future post-pandemic Match cycles.

Identifying enhancement-based staging markers on baseline MRI in patients with colorectal cancer liver metastases undergoing intra-arterial tumor therapy.

OBJECTIVES: To determine if three-dimensional whole liver and baseline tumor enhancement features on MRI can serve as staging biomarkers and help predict survival of patients with colorectal cancer liver metastases (CRCLM) more accurately than one-dimensional and non-enhancement-based features. METHODS: This retrospective study included 88 patients with CRCLM, treated with transarterial chemoembolization or Y90 transarterial radioembolization between 2001 and 2014. Semi-automated segmentations of up to three dominant lesions were performed on pre-treatment MRI to calculate total tumor volume (TTV) and total liver volumes (TLV). Quantitative 3D analysis was performed to calculate enhancing tumor volume (ETV), enhancing tumor burden (ETB, calculated as ETV/TLV), enhancing liver volume (ELV), and enhancing liver burden (ELB, calculated as ELV/TLV). Overall and enhancing tumor diameters were also measured. A modified Kaplan-Meier method was used to determine appropriate cutoff values for each metric. The predictive value of each parameter was assessed by Kaplan-Meier survival curves and univariable and multivariable cox proportional hazard models. RESULTS: All methods except whole liver (ELB, ELV) and one-dimensional/non-enhancement-based methods were independent predictors of survival. Multivariable analysis showed a HR of 2.1 (95% CI 1.3-3.4, p = 0.004) for enhancing tumor diameter, HR 1.7 (95% CI 1.1-2.8, p = 0.04) for TTV, HR 2.3 (95% CI 1.4-3.9, p < 0.001) for ETV, and HR 2.4 (95% CI 1.4-4.0, p = 0.001) for ETB. CONCLUSIONS: Tumor enhancement of CRCLM on baseline MRI is strongly associated with patient survival after intra-arterial therapy, suggesting that enhancing tumor volume and enhancing tumor burden are better prognostic indicators than non-enhancement-based and one-dimensional-based markers. KEY POINTS: • Tumor enhancement of colorectal cancer liver metastases on MRI prior to treatment with intra-arterial therapies is strongly associated with patient survival. • Three-dimensional, enhancement-based imaging biomarkers such as enhancing tumor volume and enhancing tumor burden may serve as the basis of a novel prognostic staging system for patients with liver-dominant colorectal cancer metastases.

Use of neuraxial anesthesia for hybrid lower extremity revascularization is associated with reduced perioperative morbidity.

OBJECTIVE: Recent advances in endovascular technology have allowed complex peripheral arterial disease (PAD) to be treated with less invasive hybrid procedures under neuraxial anesthesia. This study investigates the perioperative outcomes of hybrid lower extremity revascularization (LER) performed under neuraxial anesthesia (NAA) vs general anesthesia (GA). We hypothesize that the use of NAA is associated with improved outcomes. METHODS: The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program dataset was used to identify patients who underwent hybrid LER for PAD. Based on the primary anesthetic technique, patients were divided into two groups: GA and NAA, which included spinal or epidural anesthesia. Baseline characteristics of the two groups were compared. A group of patients treated under GA were matched (2:1) to patients in the NAA group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease, wound infection, American Society of Anesthesiologists classification, emergent surgery, preoperative sepsis, indication, and type of hybrid procedure. Patient characteristics and 30-day outcomes were compared. RESULTS: Of 9430 patients who underwent hybrid LER, only 452 (4.8%) received NAA. Patients who received NAA were older (mean age, 68 ± 8.4 vs 72.3 ± 9.2; P = .004) and were more likely to be white (70.9% vs 85.6%; P < .0001), have dependent functional status (7.6% vs 13.1%; P < .0001), chronic obstructive pulmonary disease (24.3% vs 17.5%; P = .001), and a diagnosis of wound infection (15% vs 23.5%; P < .0001). After propensity matching, 904 patients in the GA group were compared with 452 patients in the NAA group with no difference in baseline characteristics. NAA was associated with reduced rate of more than 48 hours' ventilator requirement (2.4% vs 0.2%; P = .0014), bleeding requiring transfusion (17.5% vs 8%; P < .0001), and overall morbidity (29.3% vs 19%; P < .0001), as well as shorter length of hospital stay (6.8 ± 9.3 vs 5.3 ± 6.1 days; P = .0026) and total operating time (237.8 ± 109 vs 202.4 ± 113 minutes; P < .0001) compared with GA. CONCLUSIONS: NAA is an infrequently used anesthesia technique during hybrid LER and is primarily used for older patients with chronic obstructive pulmonary disease. NAA is associated with decreased perioperative morbidity and length of hospital stay compared with GA and may be considered in this sicker patient population.

A national post-Match webinar panel improves knowledge and preparedness of medical students interested in vascular surgery training.

BACKGROUND: The current shortage of vascular surgeons is projected to worsen. Compared with other surgical residency programs, integrated vascular surgery residency (IVSR) offers fewer training positions and attracts fewer applicants. As a result, only a few medical students from each school match into the specialty, and conventional resources like Match panels are not available to students interested in vascular surgery. We hypothesize that a national post-Match panel webinar will improve medical students' knowledge of the IVSR application process. METHODS: A panel of four recently matched medical students shared their experiences on their successful Match into an IVSR through a 65-minute-long national webinar. Data were collected from students who attended the webinar through anonymous online surveys before and after the panel discussion. The participants' self-reported understanding of the IVSR was assessed using a 5-point Likert scale for 11 questions. Objective knowledge of the IVSR Match process was assessed using five data-based questions. All prewebinar and postwebinar responses were paired and compared using bivariate analysis. RESULTS: A total of 76 participants completed both the prewebinar and postwebinar surveys. The majority of respondents were first-year medical students (51.3%) and attended medical school in the Northeast (38.2%). Among these respondents, 57.6% indicated that their home institution had an IVSR program, 44.7% had an active vascular surgery interest group (VSIG), 14.5% had previously attended a vascular surgery conference, and 28.9% were very likely to apply into an IVSR. After the webinar, more students correctly identified the number of currently existing IVSR training positions (76.3% vs 89.5%; P = .002), duration of IVSR (56.6% vs 85.5%; P < .001), and median Step 1 score (50% vs 84.2%; P < .001) and minimum number of applications (38.2% vs 65.8%; P < .001) recommended for a successful Match into IVSR. Students who had a VSIG at their home institution were found to have a better baseline knowledge of the IVSR based on their higher aggregate scores on the data-based questions (3.4 ± 1 vs 1.9 ± 1.2; P < .001) compared with those without one. CONCLUSIONS: A national webinar run by recently matched students can effectively improve medical students' understanding of the IVSR application process. Students with a VSIG at their institutions have a better baseline knowledge of IVSR. In addition to expanding the VSIG, instituting an annual national postmatch webinar may help students become better prepared applicants and improve the overall application pool.

Rapid increase in hybrid surgery for the treatment of peripheral artery disease in the Vascular Quality Initiative database.

OBJECTIVE: Advances in technology have increased the use of endovascular therapy for lower extremity revascularization (LER), but the impact on hybrid surgery has not been studied. This study aims to (1) investigate the contemporary national trends in frequency of hybrid LER and (2) compare the outcomes of open bypass (BYP) and hybrid surgery for isolated femoropopliteal revascularization. METHODS: Using the national Vascular Quality Initiative database from 2010 to 2017, all patients receiving bypass or hybrid LER for PAD were identified. A trend of all hybrid LER compared with open LER was obtained. Next, only patients who underwent hybrid or open isolated femoropopliteal LER were identified. Patients treated with hybrid surgery underwent femoral endarterectomy and antegrade endovascular intervention of the femoropopliteal vessels (HYB), whereas patients treated with BYP underwent femoral endarterectomy and femoropopliteal bypass. These two groups of patients were matched based on age, gender, race, indication, ambulatory status, emergency status, diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, and hemodialysis. Patient characteristics and the perioperative and 1-year outcomes of the two groups were compared. RESULTS: The overall rate of hybrid LER procedures increased from 6.1% in 2010 to 32% in 2017 (P = .03). Hybrid LER was significantly more commonly used in patients with claudication (47%) and BYP surgery was used in patients with tissue loss (38.5%; P = .019). There were 456 HYB and 2665 BYP for isolated femoropopliteal revascularization. After propensity matching, the cohort comprised 425 patients in each group. HYB was associated with lower rate of myocardial infarction (1.9% vs 5.7%; P = .005) and renal complications (2.1% vs 6.7%; P = .003), length of stay (4.7 vs 6.1 days; P = .001), and higher rate of discharge to home (90.8% vs 81.4%; P < .001) compared with BYP. There was no significant difference in 30-day mortality (HYB 1.5% vs BYP, 2.5%; P = .44). The 1-year outcomes comparison suggested that patients in the BYP group had a higher likelihood of improvement in ambulatory status compared with patients in HYB group (16.7% vs 7.7%; P = .044). However, Kaplan-Meier analysis showed no difference in overall survival (P = .13) or amputation-free survival (P = .057) between the two groups. There was no statistical difference in graft patency, limb loss, or secondary interventions. CONCLUSIONS: Hybrid LER for PAD has been increasingly used and accounts for up to one-third of open LER in the Vascular Quality Initiative. Hybrid femoropopliteal revascularization improves perioperative outcomes compared with femoropopliteal bypass. However, the 1-year outcomes between the two procedures are comparable, suggesting that hybrid femoropopliteal revascularization should be favored in high-risk patients because of its perioperative advantages.

Reduced patency in left-sided arteriovenous grafts in a porcine model.

OBJECTIVE: The porcine arteriovenous graft model is commonly used to study hemodialysis vascular access failure, with most studies using a bilateral, paired-site approach in either the neck or femoral vessels. In humans, left- and right-sided central veins have different anatomy and diameters, and left-sided central vein catheters have worse outcomes. We assessed the effect of laterality on arteriovenous prosthetic graft patency and hypothesized that left-sided carotid-jugular arteriovenous prosthetic grafts have reduced patency in the porcine model. METHODS: Arteriovenous polytetrafluoroethylene grafts were placed ipsilaterally or bilaterally in 10 Yorkshire male pigs from the common carotid artery to the internal jugular vein. Ultrasound measurements of blood flow velocities and diameters were assessed before graft placement. Animals were sacrificed at 1 week, 2 weeks, or 3 weeks. Patency was determined clinically; grafts and perianastomotic vessels were excised and analyzed with histology and immunostaining. RESULTS: At baseline, left- and right-sided veins and arteries had similar blood flow velocities. Although internal jugular veins had similar diameters at baseline, left-sided carotid arteries had 11% smaller outer diameters (P = .0354). There were 10 left-sided and 8 right-sided polytetrafluoroethylene grafts placed; only 4 of 10 (40%) grafts were patent on the left compared with 7 of 8 (88%) grafts patent on the right (P = .04). Left-sided grafts had increased macrophages at the arterial anastomosis (P = .0007). Left-sided perianastomotic arteries had thicker walls (0.74 vs 0.60 mm; P = .0211) with increased intima-media area (1.14 vs 0.77 mm2; P = .0169) as well as a trend toward 38% smaller luminal diameter (1.6 vs 2.5 mm; P = .0668) and 20% smaller outer diameter (3.0 vs 3.7 mm; P = .0861). Left- and right-sided perianastomotic veins were similar histologically, but left-sided veins had decreased expression of phosphorylated endothelial nitric oxide synthase (P = .0032) and increased numbers of α-actin-positive smooth muscle cells (P = .0022). CONCLUSIONS: Left-sided arteriovenous grafts are associated with reduced short-term patency compared with right-sided grafts in the Yorkshire pig preclinical model of arteriovenous prosthetic grafts. Laterality must be considered in planning and interpreting surgical preclinical models.

Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization.

Purpose: To investigate the utilization of local anesthesia or peripheral nerve block with monitored anesthesia care (LPMAC) and its impact on the perioperative outcomes of hybrid lower extremity revascularization (LER) compared with general anesthesia (GA). Materials and Methods: A search of the ACS-NSQIP database between 2005 and 2017 identified 9430 patients who underwent hybrid LER for peripheral artery disease. Excluding 449 ineligible cases left 8981 hybrid LER patients for analysis. The patients were dichotomized based on the anesthetic technique: 8631 (96.1%) GA and 350 (3.9%) LPMAC. The GA patients were matched 3:1 based on propensity scores to patients in the LPMAC group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease (COPD), dialysis status, American Society of Anesthesiologists (ASA) class, emergent surgery, preoperative sepsis, indication, and type of open and endovascular procedure. Outcomes including complications, mortality, procedure time, and hospital length of stay were compared between the matched groups (801 GA vs 267 LPMAC). Results: Comparing the unmatched groups, those treated under LPMAC were older (72.7±9 vs 68±8.4 years, p<0.001) and had higher rates of COPD (24.3% vs 17%, p=0.001), dialysis dependence (8.1% vs 4.2%, p=0.002), preoperative sepsis (6.6% vs 4.2%, p=0.029), and ASA class ≥IV (29.1% vs 24.1%, p=0.036) than in the unmatched GA cohort. In the matched comparison, LPMAC was associated with lower overall morbidity (25.5% vs 32.3%, p=0.042) and shorter operating time (202.7±98 vs 217.7±102 minutes, p=0.034) compared with GA. The rate of myocardial infarction was lower (1.1% vs 2.4%) and ventilator use for >48 hours was less frequent (0.4% vs 2.6%) for LPMAC patients, though statistical significance was not reached. There was no difference in mortality or hospital length of stay. Conclusion: LPMAC is an infrequent anesthetic technique for hybrid LER and is primarily used for patients with a high burden of comorbidities. LPMAC is associated with reduced overall morbidity and operating time. Further studies are needed to identify which patients undergoing hybrid LER benefit most from LPMAC.

Using the epidemiology of critical limb ischemia to estimate the number of patients amenable to endovascular therapy.

Critical limb ischemia represents the advanced stage of peripheral artery disease, a health problem with increasing prevalence. Critical limb ischemia is associated with significant mortality, limb loss, pain, and diminished health-related quality of life. Public awareness and early diagnosis are necessary for an effective treatment with early risk factor modification, smoking cessation, and exercise therapy. Herein, we present an overview of the epidemiology as well as the clinical stages of the disease, and estimate that there are 6.5 million patients with critical limb ischemia in the US, Europe, and Japan based on global population-based studies. At least 75% of these patients, accounting for approximately 4.8 million patients, are amenable to endovascular therapy.

Endovascular Revascularization Incorporating Infrapopliteal Coronary Drug-Eluting Stents Improves Clinical Outcomes in Patients with Critical Limb Ischemia and Tissue Loss.

BACKGROUND: Critical limb ischemia (CLI) involving infrapopliteal arterial atherosclerosis and tissue loss remains a formidable clinical scenario with significant morbidity and mortality. Despite level IA evidence, tibial revascularization with coronary drug-eluting stents (DES) remains a seldom-used technique in the United States due, in part, to lack of a Food and Drug Administration-approved indication and dedicated stent technology for infrapopliteal application. Furthermore, follow-up data beyond 1 year remain scarce, and further evidence for improvement in clinical outcomes using this technique is needed. Herein, we present our multi-institutional experience with endovascular revascularization of patients with CLI and tissue loss using coronary DES for infrapopliteal lesions of appropriate dimensions and the Wound, Ischemia, and foot Infection (WIfI) score as supportive evidence for improvement in clinical outcomes. METHODS: In this retrospective study, 40 sequential tibial revascularization procedures performed in 32 patients with CLI were reviewed. Outcomes including changes in WIfI scores, patency rates, freedom from major amputation, target lesion recurrence, and all-cause mortality were analyzed. Average follow-up duration was 19.3 months (interquartile range: 7-27.1 months). RESULTS: Freedom from major amputation was 88.6%. One-year primary patency was 90.3%. Mean ankle-brachial indices increased after revascularization (0.57 ± 0.26 to 0.97 ± 0.26; P = 0.03). All components of the WIfI score significantly improved after revascularization (W: 1.9 to 1.1, P = 0.03; I: 2.0 to 0.6, P = 0.001; and fI: 1.5 to 0.8, P = 0.01). WIfI risk of major amputation score before revascularization was 3.58 ± 0.75 (high risk), which was reduced to 2.04 ± 1.31 (low risk; P < 0.001). One-year survival rate was 90.6%. CONCLUSIONS: Coronary DES continue to demonstrate promising primary patency and limb salvage rates in appropriately selected patients undergoing multilevel endovascular revascularization for CLI and tissue loss. In addition to its value as a predictor for major amputation and revascularization benefit, the WIfI score can also serve as a multicomponent tool for objective assessment of outcomes after revascularization.

Comparison of Atherectomy to Balloon Angioplasty and Stenting for Isolated Femoropopliteal Revascularization.

BACKGROUND: The use of atherectomy for lower extremity revascularization is increasing despite concerning reports about its long-term safety and effectiveness. This study compares the outcomes of atherectomy to percutaneous transluminal angioplasty (PTA) and stenting for treatment of isolated femoropopliteal disease. METHODS: All patients undergoing endovascular treatment of isolated femoropopliteal lesions in the Vascular Quality Initiative (2009-2018) were identified. Patients with concomitant open surgery, acute limb ischemia, or iliac or tibial intervention were excluded. Patients were divided into 3 treatment groups: atherectomy with or without PTA, PTA alone, and stenting alone. Propensity matching was performed based on age, gender, race, ambulatory status, diabetes, smoking, hypertension, coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, dialysis, prior inflow bypass and intervention, prior major ipsilateral amputation, indication, length of treated lesion, American Society of Anesthesiologists class, and Trans-Atlantic Society Consensus II classification. The perioperative and one-year outcomes of the matched groups were compared. RESULTS: A total of 10,007 cases of atherectomy, 22,000 cases of PTA, and 27,579 cases of stenting of isolated femoropopliteal disease were identified. After matching, there were 6,372 procedures in atherectomy and PTA groups, respectively. Atherectomy was associated with higher likelihood of technical success (98.3% vs. 97.5%; P < 0.001) and shorter length of stay (1.8 ± 8.2 days vs. 2.7 ± 15.7 days; P < 0.001), but had increased rate of distal embolization (2% vs. 1.1%; P < 0.001) compared with PTA. At one year, atherectomy was associated with improved primary patency (84.2% vs. 82%; P = 0.047) and survival rate (91.1% vs. 90%; P = 0.044), but was also associated with a higher reintervention rate (15.7% vs 13.6%; P = 0.033) compared with PTA. There was no difference in the rates of major amputation, ambulatory status improvement, or ankle brachial index (ABI) improvement. In the second analysis, after matching, there were 6,877 procedures in the atherectomy and stenting groups, respectively. Atherectomy was associated with lower rate of dissection (3.7% vs. 8.2% <0 .001), lower rate of perforation (0.6% vs. 1.2%; P < 0.001), and a shorter length of stay (1.9 ± 8.1 vs. 2.9 ± 9.8 days; P < 0.001) than stenting. However, patients treated with atherectomy had a lower rate of technical success (98.3% vs. 99.2%; P < 0.001) and a higher rate of distal embolization (2% vs. 1.2%; P < 0.001) than stenting. At one year, atherectomy was associated with a higher rate of major ipsilateral amputation (5.3% vs. 4.1%; P = 0.046) and less improvement in ABI (0.19 ± 0.42 vs. 0.25 ± 0.4; P < 0.001) than stenting. There was no difference in rates of primary patency, survival, reintervention, and ambulatory status improvement at one year. CONCLUSIONS: Atherectomy does not seem to confer any significant additional clinical benefit compared with balloon angioplasty or stenting. Further research is needed to justify its additional cost over other endovascular modalities.

Molecular changes associated with vascular malformations.

Vascular anomalies are typically classified into two major categories, vascular tumors and vascular malformations. Most vascular malformations are caused sporadically by somatic mosaic gene mutations, and genetic analyses have advanced our understanding of the biomolecular mechanisms involved in their pathogenesis. Culprit gene mutations typically involve two major signaling pathways; the RAS/MAPK/ERK pathway is typically involved in fast-flow arteriovenous malformations, whereas the PI3K/AKT/mTOR pathway is typically mutated in slow-flow venous and lymphatic malformations. These findings suggest new therapeutic approaches to vascular malformations, focusing on targeting the etiologic mutated pathways. This review summarizes the currently available literature reflecting the updated International Society for Study of Vascular Anomalies classification system with emphasis on potential therapeutic targets that will provide vascular surgeons with an updated perspective on the etiologic basis of vascular malformations, allowing improved multidisciplinary collaboration.