Extra-Anatomic Bypass and Excision is Superior to Graft Salvage Attempts with Antibiotic Beads to Treat Vascular Graft Infections in the Groin.

BACKGROUND: This study aimed to determine if conventional extra-anatomic bypass and graft removal versus aggressive attempts at graft preservation have better survival and limb salvage in patients with localized groin wound infections of vascular grafts. METHODS: We conducted a retrospective review of 53 consecutive patients with vascular graft infections presenting in the groin. Treatment groups consisted of group 1 (extra-anatomic bypass and graft excision, n = 22) and group 2 (initial graft preservation attempts with utilization of antibiotic beads, n = 31). In group 2, patients underwent serial debridement and placement of antibiotic beads until culture-negative wounds were achieved. Significantly more patients underwent muscle flap coverage in group 2 (27/31) compared with group 1 (7/22; P < 0.001). Data collected included demographics, comorbidities, intraoperative details, and outcomes, including patency, limb salvage, mortality, and number of procedures. Continuous variables were examined with Student's t-test, and dichotomous variables were examined with chi-squared test. Linear and logistic regressions were used to analyze factors associated with outcomes, in addition to Kaplan-Meier analysis with log rank for actuarial analysis. RESULTS: Both groups were similar with respect to demographics. The overall Kaplan-Meier 1- and 3-year survival rates were 66.2% and 34.1%, with no statistically significant difference between groups. The Kaplan-Meier 1- and 3-year limb salvage rates were 68.8% and 36.6% for group 1 vs. 58.5% and 38.7% for group 2 (P = not significant [NS]). The 1- and 3-year primary patency rates were 71% and 71% in traditional group 1 vs. 72% and 56% in group 2 (P = NS). One-year and 3-year secondary patency rates in traditional group 1 were 83% and 71% vs. 85% and 61% in group 2 (P = NS). Patients in group 1 underwent fewer total procedures when compared with group 2 (2.3 ± 0.2 vs. 5.1 ± 0.7, P = 0.03). The late reinfection rate was significantly less in group 1 (4.5%) compared with group 2 (26%; P = 0.04). Freedom from reinfection at 1 and 3 years were 94% and 94% in traditional group 1 vs. 74% and 62% in group 2 (P = 0.03). Multivariable analysis showed a higher incidence of amputation in patients who suffered reinfection (n = 13, P = 0.049). There was a higher mortality in patients with septic shock (n = 10, P = 0.007) and reinfection (n = 13, P = 0.036). Reinfection was associated with the highest mortality (P = 0.03). CONCLUSIONS: Conventional graft excision with extra-anatomic bypass resulted in similar mortality when compared with aggressive attempts at graft preservation and trended toward improved limb salvage and patency. However, attempts at graft preservation with antibiotic beads resulted in a significantly higher reinfection rate and greater number of procedures, and therefore, this approach should be used very selectively.

Factors associated with preference of choice of aortic aneurysm repair in the PReference for Open Versus Endovascular repair of AAA (PROVE-AAA) study.

OBJECTIVE: Patients can choose between open repair and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). However, the factors associated with patient preference for one repair type over another are not well-characterized. Here we assess the factors associated with preference of choice for open or endovascular AAA repair among veterans exposed to a decision aid to help with choosing surgical treatment. METHODS: Across 12 Veterans Affairs hospitals, veterans received a decision aid covering domains including patient information sources and understanding preference. Veterans were then given a series of surveys at different timepoints examining their preferences for open versus endovascular AAA repair. Questions from the preference survey were used in analyses of patient preference. Results were analyzed using χ2 tests. A logistic regression analysis was performed to assess factors associated with preference for open repair or preference for EVAR. RESULTS: A total of 126 veterans received a decision aid informing them of their treatment choices, after which 121 completed all preference survey questions; five veterans completed only part of the instruments. Overall, veterans who preferred open repair were typically younger (70 years vs 73 years; P = .02), with similar rates of common comorbidities (coronary disease 16% vs 28%; P = .21), and similar aneurysms compared with those who preferred EVAR (6.0 cm vs 5.7 cm; P = .50). Veterans in both preference categories (28% of veterans preferring EVAR, 48% of veterans preferring open repair) reported taking their doctor's advice as the top box response for the single most important factor influencing their decision. When comparing the tradeoff between less invasive surgery and higher risk of long-term complications, more than one-half of veterans preferring EVAR reported invasiveness as more important compared with approximately 1 in 10 of those preferring open repair (53% vs 12%; P < .001). Shorter recovery was an important factor for the EVAR group (74%) and not important in the open repair group (76%) (P = .5). In multivariable analyses, valuing a short hospital stay (odds ratio, 12.4; 95% confidence interval, 1.13-135.70) and valuing a shorter recovery (odds ratio, 15.72; 95% confidence interval, 1.03-240.20) were associated with a greater odds of preference for EVAR, whereas finding these characteristics not important was associated with a greater odds of preference for open repair. CONCLUSIONS: When faced with the decision of open repair versus EVAR, veterans who valued a shorter hospital stay and a shorter recovery were more likely to prefer EVAR, whereas those more concerned about long-term complications preferred an open repair. Veterans typically value the advice of their surgeon over their own beliefs and preferences. These findings need to be considered by surgeons as they guide their patients to a shared decision.

Long-term outcomes of transposed femoral vein arteriovenous fistula for abandoned upper extremity dialysis access.

BACKGROUND: The number and longevity of patients with end-stage renal disease requiring dialysis access have continued to increase, leading to challenging situations, including exhausted upper extremity access and severe central venous stenosis. This has led to an increase in the use of alternative access sites, including the lower extremities. The transposed femoral vein arteriovenous fistula for dialysis access is a previously described alternative, although limited data are available on its long-term patency. METHODS: Patients treated with a transposed femoral vein fistula were retrospectively reviewed. A transposed femoral vein fistula was created by harvesting the femoral vein and transposing it to the distal superficial femoral artery at the level of the adductor canal. The demographic information, perioperative characteristics, complications, and long-term outcomes were recorded and analyzed. RESULTS: A total of 21 patients had undergone transposed femoral vein fistula for dialysis access after an average of 5.3 ± 2.8 failed dialysis access procedures and a duration of 6.1 ± 4.9 years from the initiation of dialysis. The average age at the procedure was 53.5 ± 12.8 years. Ten patients (47.6%) had a history of diabetes mellitus and nine (42.9%) had a history of coronary artery disease. Technical success was achieved in 100% of cases, and 16 patients (76.2%) were discharged with anticoagulation therapy. The primary patency at 1, 3, and 5 years was 93%, 74%, and 74%, respectively. The secondary patency at 1, 3, and 5 years was 100%, 89%, and 89%, respectively. Two patients had compartment syndrome requiring fasciotomy, and six patients experienced wound complications. CONCLUSIONS: Transposed femoral vein fistula for dialysis access is a viable alternative for patients with an exhausted upper extremity access, with good long-term patency.

Patient Characteristics, Patterns, and Repair of Aneurysms in Human Immunodeficiency Virus-Positive Patients.

BACKGROUND: Human immunodeficiency virus (HIV) is a multisystem disease and is associated with vascular complications including aneurysm formation. HIV-associated aneurysms are well documented and may present in unusual locations with concerning features. However, the literature regarding aneurysms in HIV-positive patients is limited to case series with limited data regarding aneurysm patterns. Furthermore, several small series have documented poor outcomes with surgical repair. Thus, our aim was to investigate the characteristics, patterns, and repair of aneurysms in HIV-positive patients in a multicenter study. METHODS: All patients with a diagnosis of aneurysms and HIV were retrospectively identified from 2013 to 2018 across 2 institutions. Comorbidities, HIV-related characteristics, aneurysm characteristics, and repair were reviewed. RESULTS: There were a total of 104 HIV-positive patients with 129 aneurysms. The mean age at the time of diagnosis was 57.7 ± 10.3 years, 80.8% of patients were male, and 32.0% had a history of acquired immunodeficiency syndrome. The average time from HIV diagnosis to aneurysm diagnosis was 14.1 ± 10.1 years. There were 53 (41.1%) ascending aortic, 25 (19.4%) abdominal aortic, 14 (10.9%) cerebral artery aneurysms, 13 (10.1%) descending thoracic, 9 (7.0%) iliac, 6 (4.7%) femoropopliteal, 4 (3.1%) visceral, 3 (2.9%) axillosubclavian, 1 (0.8%) carotid, and 1 (0.8%) coronary artery aneurysms. There were 23 (22.1%) patients with aneurysms in multiple vascular beds, 10 (9.6%) saccular aneurysms, and 1 (0.8%) inflammatory aneurysm. There were 7 ruptures (cerebral, descending thoracic, and iliac), 3 type A dissections (ascending aorta), and 1 thrombosis (popliteal). There were 26 (25.0%) patients who underwent surgical repair. This included 8 endovascular aneurysm repairs for abdominal aortic aneurysms, 6 endovascular coiling, clipping, and stent procedures for cerebral aneurysms, 4 open ascending aorta repairs, 2 bypasses for popliteal artery aneurysms, 2 endovascular stents for axillosubclavian artery aneurysms, 1 open descending aortic aneurysm repair, 1 endovascular aneurysm repair for an iliac aneurysm, 1 endovascular coiling for a renal artery aneurysm, and 1 open repair of a femoral artery aneurysm. Perioperative complications were common at 46.2%, although mortality was low at 3.8%. CONCLUSIONS: Although aneurysms were widespread, most HIV-positive patients had large vessel aneurysms in this study. There was a high prevalence of saccular and multiple aneurysms, and repair was associated with low rates of mortality despite high rates of complications. Additional studies are necessary to characterize this rare entity.

Patient information sources when facing repair of abdominal aortic aneurysm.

OBJECTIVE: Shared medical decision making is most important when there are competing options for repair such as in treatment of abdominal aortic aneurysm (AAA). We sought to understand the sources of patients' pre-existing knowledge about AAA to better inform treating physicians about patients' needs for preoperative counseling. METHODS: We performed a multicenter survey of patients facing AAA repair at 20 Veterans Affairs hospitals across the United States as part of the Preferences for Open Versus Endovascular Repair of AAA study. A validated survey instrument was administered to examine the sources of information available and commonly used by patients to learn about their repair options. The survey was administered by study personnel before the patient had any interaction with the vascular surgeon because survey data were collected before the vascular clinic visit. RESULTS: Preliminary analysis of data from 99 patients showed that our cohort was primarily male (99%) and elderly (mean age 73 years). Patients commonly had a history of hypertension (86%), prior myocardial infarction (32%), diabetes (32%), and were overweight (58%). Patients arrived at their surgeon's office appointment with limited information. A majority of patients (52%) reported that they had not talked to their primary care physician at all about their options for AAA repair, and one-half (50%) reported that their view of the different surgical options had not been influenced by anyone. Slightly less than one-half of patients reported that they did not receive any information about open surgical aneurysm repair and endovascular aortic aneurysm repair (41% and 37%, respectively). Few patients indicated using the internet as their main source of information about open surgical aneurysm repair and endovascular aortic aneurysm repair (10% and 11%, respectively). CONCLUSIONS: Patients are commonly referred for AAA repair having little to no information regarding AAA pathology or repair options. Fewer than one in five patients searched the internet or had accessed other sources of information on their own. Most vascular surgeons should assume that patients will present to their first vascular surgery appointment with minimal understanding of the treatment options available to them.

Trends and perioperative outcomes of patients with human immunodeficiency virus (HIV) undergoing lower extremity revascularization.

The development of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients with human immunodeficiency virus (HIV), but has led to the rise of chronic conditions including peripheral artery disease (PAD). However, trends and outcomes among patients with HIV undergoing lower extremity revascularization are poorly characterized. The aim of this study was to investigate the trends and perioperative outcomes of lower extremity revascularization among patients with HIV and PAD in a national database. The National Inpatient Sample (NIS) was reviewed between 2003 and 2014. All hospital admissions with a diagnosis of PAD undergoing lower extremity revascularization were stratified based on HIV status. Outcomes were assessed using propensity score matching and multivariable regression. Among all patients undergoing lower extremity revascularization for PAD, there was a significant increase in the proportion of patients with HIV from 0.21% in 2003 to 0.52% in 2014 (p < 0.01). Patients with HIV were more likely to be younger, male, and have fewer comorbidities, including coronary artery disease and diabetes, at the time of intervention compared to patients without HIV. With propensity score matching and multivariable regression, HIV status was associated with increased total hospital costs, but not length of stay, major amputation, or mortality. Patients with HIV with PAD who undergo revascularization are younger with fewer comorbidities, but have increased hospital costs compared to those without HIV. Lower extremity revascularization for PAD is safe for patients with HIV without increased risk of in-hospital major amputation or mortality, and continues to increase each year.

Impact of Temporal Artery Biopsy on Clinical Management of Suspected Giant Cell Arteritis.

BACKGROUND: Temporal arteritis (TA) is a systemic inflammatory vasculitis of unclear etiology that affects medium-sized vessels. The gold standard for diagnosis has traditionally been histological, by temporal artery biopsy. Improved imaging modalities have been increasingly used to aid diagnosis and are recommended in the newest 2018 European (EULAR) guidelines.1 We hypothesize that a negative TA biopsy result does not change management in patients for whom TA is strongly suspected and that duplex ultrasound can be successfully used as a screening tool. METHODS: This is a retrospective review of patients who underwent TA biopsy between May 1, 2012 and June 1, 2017. We reviewed patient's demographics, comorbidities, symptoms, histology, and treatment. We also present a small series of patients for whom ultrasound of the bilateral temporal arteries was performed. Radiology and pathology reports on these 7 patients were reviewed. RESULTS: A total of 264 patients underwent temporal artery biopsies over the study period. Histology was positive in 21 (8.0%) and negative in 243 (92%) patients. In 74 (41%) patients with negative biopsies on steroids preoperatively, steroids were continued despite negative biopsy result. In prospective series, 7 patients underwent duplex ultrasound evaluation before scheduling for biopsy. Biopsy followed ultrasound in 4 cases, and in all 4 cases, histology was congruent with ultrasound findings. CONCLUSIONS: The yield of temporal artery biopsy is low, and a negative biopsy alone often does not lead to termination of steroid therapy. Ultrasound may present a viable diagnostic tool to reduce the number of unnecessary temporal artery biopsies performed.

Design of the PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) Trial.

For patients with abdominal aortic aneurysm (AAA), randomized trials have found endovascular AAA repair (EVAR) is associated with lower perioperative morbidity and mortality than open surgical repair (OSR). However, OSR has fewer long-term aneurysm-related complications, such as endoleak or late rupture. Patients treated with EVAR and OSR have similar survival rates within two years after surgery, and OSR does not require intensive surveillance. Few have examined if patient preferences are aligned with the type of treatment they receive for their AAA. Although many assume that patients may universally prefer the less-invasive nature of EVAR, our preliminary work suggests that patients who value the lower risk of late complications may prefer OSR. In this study, called The PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) trial, we describe a cluster-randomized trial to test if a decision aid can better align patients' preferences and their treatment type for AAA. Patients enrolled in the study are candidates for either endovascular or open repair and are followed up at VA hospitals by vascular surgery teams who regularly perform both types of repair. In Aim 1, we will determine patients' preferences for endovascular or open repair and identify domains associated with each repair type. In Aim 2, we will assess alignment between patients' preferences and the repair type elected and then compare the impact of a decision aid on this alignment between the intervention and control groups. This study will help us to accomplish two goals. First, we will better understand the factors that affect patient preference when choosing between EVAR and OSR. Second, we will better understand if a decision aid can help patients be more likely to receive the treatment strategy they prefer for their AAA. Study enrollment began on June 1, 2017. Between June 1, 2017 and November 1, 2018, we have enrolled 178 of a total goal of 240 veterans from 20 VA medical centers and their vascular surgery teams across the country. We anticipate completing enrollment in PROVE-AAA in June 2019, and study analyses will be performed thereafter.

Practice patterns of dual antiplatelet therapy after lower extremity endovascular interventions.

Antiplatelet therapy is commonly prescribed following endovascular interventions. However, there is limited data regarding the regimen and duration of antiplatelet therapy following lower extremity endovascular interventions. The aim of this study was to investigate the practice patterns of dual antiplatelet therapy (DAPT) after lower extremity endovascular interventions. We identified all patients who received an endovascular intervention in the Vascular Study Group of New England (VSGNE) registry from 2010 through 2018. The antiplatelet regimen was examined at the time of discharge and follow-up. Variables predicting discharge antiplatelet therapy and duration of antiplatelet therapy were investigated. There were 13,510 (57.69%) patients discharged on DAPT, 8618 (36.80%) patients discharged on single antiplatelet therapy, and 1292 (5.51%) patients discharged without antiplatelet therapy. Patients with coronary artery disease (CAD), prior vascular bypass and endovascular intervention, preoperative statin use, stent placement compared with angioplasty, and femoropopliteal and tibial treatment were associated with higher odds of being discharged with DAPT compared with no antiplatelet therapy and single antiplatelet therapy. Of the patients discharged on DAPT who were followed up at 9-12 months and 21-24 months, 56.49% and 49.63% remained on DAPT, respectively. Only a narrow margin of the patient majority undergoing endovascular interventions was discharged with DAPT, suggesting that only a small proportion of patients undergoing endovascular intervention remain on DAPT long-term. As the number of peripheral vascular interventions continues to grow, further studies are crucial to identify the optimal duration of DAPT.

Intravascular Ultrasound in Venous Thoracic Outlet Syndrome.

BACKGROUND: Venous thoracic outlet syndrome (vTOS) is a rare disease with no defined guidelines regarding treatment. Patients with first rib resection with anterior scalenectomy (FRRS) often have residual subclavian vein stenosis. The aim of this study was to evaluate the use of intravascular ultrasound (IVUS) in the treatment of vTOS patients who have been surgically decompressed with FRRS. METHODS: Patients treated with venography after FRRS for vTOS during 2015-2017 were retrospectively reviewed. Patients were included if they received a venogram with IVUS after FRRS. The axillosubclavian vein at the site of the thoracic outlet was imaged using single-plane venography and IVUS. A greater than 50% diameter stenosis on venography or 50% cross-sectional area reduction on IVUS was considered significant and treated with balloon venoplasty. RESULTS: During the 2-year period, 14 patients underwent 24 upper extremity venograms performed after surgical decompression for vTOS, 18 of which included IVUS. Of the 18 cases with IVUS, 5 (27.8%) stenoses >50% were detected by IVUS, which were not apparent on venography, leading to intervention. IVUS detected a greater degree of stenosis than venography. Seven patients required repeat venograms. Overall, IVUS detected significant venous stenosis in 94.4% of patients compared with 66.7% of patients with venography after FRRS for vTOS. CONCLUSIONS: These results suggest that IVUS detected greater levels of stenosis than venography, leading to more interventions. Just as IVUS being ideal for identifying occult iliac venous lesions, it may have a similar role in identifying venous lesions not evident on single-plane venography for postsurgical decompression in vTOS patients. Further studies may show this technique to increase the number of stenoses identified and improve long-term symptom relief.

Trends and outcomes in endovascular and open surgical treatment of visceral aneurysms.

OBJECTIVE: Visceral artery aneurysms (VAAs) are rare but often repaired because of dire consequences of rupture. This is a population-based evaluation of chronologic trends in management, risk factors, and outcomes of endovascular and open therapy. METHODS: The 2003 to 2013 Agency for Healthcare Research and Quality (AHRQ) National Inpatient Sample (NIS) database was reviewed. Cases with primary diagnosis of VAA and undergoing endovascular or open repair were identified. Patients with renal artery or abdominal or thoracoabdominal aortic disease were excluded. Case numbers of respective techniques were charted over time. Baseline characteristics and in-hospital outcomes were compared for endovascular and open groups using χ2 test, Fisher exact test, or t-test. Predictors of mortality and complications were evaluated with multivariate logistic regression. RESULTS: There were 9260 interventions for VAAs from 2003 to 2013, including 5166 endovascular and 4094 open. Endovascular repairs increased from 5.3 to 24.7 per 10 million U.S. population (P < .001), surpassing open repairs in 2008, which decreased from 14.3 to 9.2 per 10 million (P < .001). Endovascular patients were more likely to have been treated at urban teaching hospitals (77.1% vs 61.8%; P < .0001); to have higher proportions of renal failure (7.6% vs 4.9%; P = .02), liver disease (11.3% vs 6.6%; P < .001), alcohol abuse (13.1% vs 3.6%; P < .001), chronic blood loss anemia (4.5% vs 1.6%; P < .001), metastatic cancer (2.7% vs 0.8%; P = .003), solid tumor without metastases (3.6% vs 2.0%; P < .037), and weight loss (9.8% vs 5.2%; P < .001); and less likely to have had elective admission (28.9% vs 59.8%; P < .0001). In-hospital mortality (4.1% vs 4.5%; P = .618) and overall complication rates (37.8% vs 38.8%; P = .688) were similar between groups; however, pulmonary complications were decreased for endovascular patients (10.6% vs 19.7%; P < .001). Endovascular patients had shorter hospital stays (6.5 vs 8.7 days; P < .001). Multivariate adjustment for mortality predictors, including coagulopathy (odds ratio [OR], 4.34; confidence interval [CI], 2.56-7.35; P < .001), liver disease (OR, 2.25; CI, 1.25-4.07; P = .01), fluid and electrolyte disorders (OR, 2.84; CI, 1.73-4.66; P < .001), and solid tumor without metastases (OR, 2.81; CI, 1.10-7.18; P = .03), showed that open treatment was associated with increased mortality (OR, 1.70; CI, 1.03-2.81; P = .04). Analysis of overall complications revealed that open treatment was again associated with increased complications (OR, 1.78; CI, 1.43-2.21; P < .001). CONCLUSIONS: Endovascular VAA repairs are increasing. Despite patients' having worse comorbidities and more nonelective admissions, endovascular therapy appears to be associated with decreased mortality and complications and shorter hospital stays.

The Impact of Functional Status on the Outcomes of Endovascular Lower Extremity Revascularization for Critical Limb Ischemia in the Elderly.

BACKGROUND: Functional status is an important predictor of outcomes after infrainguinal bypass surgery. There are little data on the effect of functional status on the outcomes of endovascular lower extremity interventions, especially in the elderly frail population. METHODS: This is a retrospective analysis of the American College of Surgeons - National Surgical Quality Improvement Program files for the years 2011-2013 to assess the impact of functional status on outcome after endovascular intervention for critical limb ischemia (CLI). Elderly patients (age ≥70) undergoing revascularization for CLI were included. The patients were divided into 2 groups based on functional status prior to surgery: independent (IND) or dependent (DEP), which included partially dependent as well as totally dependent patients. The 2 groups were compared with respect to demographics, comorbidities, complications, length of stay, limb loss, and mortality. Statistical analysis was performed using Student's t-test for continuous variables and Fisher's exact test for categorical variables. RESULTS: There were 1,055 patients (DEP = 253, 24%). There was no difference in gender or race but DEP patients were older than IND (P = 0.008). DEP patients were significantly more likely to have history of congestive heart failure (P = 0.003), hypertension (P = 0.042), and diabetes (P <0.001). There was no difference in emergent surgeries between the 2 groups (P = 1.00). DEP patients had more tibial interventions compared with IND (P <0.001). DEP developed more pneumonia (P <0.001) and septic shock (P = 0.016) and had a trend toward more urinary tract infections (P = 0.051) after endovascular revascularization. There was no significant difference in operating time (P = 0.232) or major amputation (P = 0.092). DEP had significantly longer length of hospital stay (P = 0.0068). DEP had significantly higher mortality (5.98% vs. 2.01%, P = 0.002). On multivariate analysis, DEP status, emergency procedure, congestive heart failure, cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, sepsis, and septic shock were independently associated with 30 days of mortality. Irrespective of age, DEP functional status was the most significant preoperative predictor of mortality with an odd ratio of 5.16 [1.93-13.83], P = 0.001 (parsimonious model). CONCLUSIONS: Functional status should be carefully assessed when considering endovascular revascularization in the elderly as DEP has significantly higher morbidity and mortality.

Validation of a modified Frailty Index to predict mortality in vascular surgery patients.

BACKGROUND: Patient frailty has been implicated as a predictor of poor patient outcomes; however, there is no consensus on how to define or quantify frailty to assess perioperative risk. A previously described modified Frailty Index (mFI) has been shown to predict adverse outcomes after selected vascular surgical procedures, but no studies to date have compared its utility against other recognized risk indices in specific populations of vascular surgery patients. METHODS: National Surgical Quality Improvement Program data were reviewed for all patients undergoing carotid revascularization, abdominal aortic aneurysm (AAA) repair, and lower extremity revascularization for peripheral arterial disease (PAD) from 2006 to 2012. Patients were then further stratified into "open" and "endovascular" cohorts. The mFI was compared with the Lee Cardiac Risk Index (LCRI) and the American Society of Anesthesiologists (ASA) Physical Status Classification using a receiver operating characteristic area under curve (AUC). The primary end point was 30-day mortality, with a secondary end point of Clavien-Dindo class IV complications. RESULTS: A total of 72,106 patients were identified in the study period, with 40,931 (56.8%), 20,975 (29.1%), and 10,200 (14.1%) in the carotid, AAA, and PAD populations, respectively. For carotid endarterectomy, mFI demonstrated better discrimination regarding mortality than LCRI and ASA, with an AUC of 0.66 (95% confidence interval [CI], 0.63-0.70; P < .01 vs P = .65 and P = .60, respectively). The open AAA cohort had similar findings, with an AUC of 0.63 (95% CI, 0.59-0.67; P = .02 vs P = .58, and P = .58, respectively). In open PAD patients, mFI was comparable to ASA (AUC, 0.64 [95% CI 0.60-0.69] vs 0.65), with a trend toward better discrimination compared with the 0.60 AUC of LCRI (P = .08). The mFI was a better discriminator of class IV complications than LCRI and ASA after open AAA (AUC for mFI, 0.59 vs 0.56 and 0.55; 95% CI, 0.57-0.61; P < .01) and endovascular AAA repair (AUC for mFI, 0.60 vs 0.59 and 0.57; 95% CI, 0.58-0.62; P = .01). There were no significant differences in discrimination of class IV complications after open or endovascular PAD or carotid endarterectomy. CONCLUSIONS: The mFI was a better discriminator of mortality than other risk indices; however this was only significant for the open cohort. The mFI was also a better discriminator of class IV complications for the open and endovascular AAA repair groups. These data suggest that mFI should be used in place of previously recognized risk indices to define perioperative mortality after open vascular surgery and risk of major complications after aneurysm repair.

Risk of venous thromboembolic events following inferior vena cava resection and reconstruction.

OBJECTIVE: The perioperative risk of an acute venous thromboembolism (VTE) event after inferior vena cava (IVC) reconstruction is unknown. We sought to describe VTE outcomes of our 15-year IVC reconstruction experience. METHODS: We performed a retrospective institutional review of all patients who underwent IVC reconstruction (September 1999-October 2014) and describe perioperative VTE outcomes. RESULTS: Sixty-five patients (mean age 58 ± 2 years) underwent IVC reconstruction (primary repair, 25%; patch, 43%; graft, 32%), most commonly for renal cell carcinoma (51%) and retroperitoneal sarcoma (22%). The overall incidence of perioperative VTE was 22% (n = 14), including isolated deep vein thrombosis (DVT) in 9% (n = 6) and pulmonary embolism in 12% (n = 8; 4 with concomitant DVT). Median time to diagnosis was 6 days (range, 1-37 days). Most VTE patients were symptomatic (57%; 8 of 14), including lower extremity edema in 50%, acute desaturation in 43%, and hemodynamic compromise in 36%. No patient died as a result of his or her VTE. There was a trend for more overall VTE events in patients who underwent graft reconstruction (primary, 13%; patch, 18%; graft, 33%; P = .06). VTE was also significantly associated with larger tumor size, renal vein reimplantation, and blood transfusions (P ≤ .05). Late complications of VTE included lower extremity edema in two patients and graft thrombosis in one patient. CONCLUSIONS: IVC reconstruction can be performed safely with low VTE-associated morbidity. Routine anticoagulation might not be warranted in these patients, but early postoperative screening for DVT should be considered, especially in cases with large tumor burden or when graft reconstruction is performed.

Thirty-day readmission after lower extremity bypass in diabetic patients.

BACKGROUND: Lower extremity bypass (LEB) for peripheral vascular disease is a common procedure in diabetics and is associated with readmission. Thus, we hypothesized that diabetes might be a predictor of 30-d unplanned readmission after LEB. METHODS: Patients undergoing infrainguinal LEB in the 2011-12 American College of Surgeons National Surgery Quality Improvement Program database were divided into nondiabetics mellitus (NDM), non-insulin-dependent diabetics mellitus (NIDDM), and insulin-dependent diabetic mellitus (IDDM). Univariate and multivariate analyses were used to evaluate the influence of diabetes on 30-d readmission. RESULTS: A total of 9207 patients (5155 [56%] NDM, 1690 (18%) NIDDM, and 2362 (26%) IDDM) underwent LEB. Unplanned readmission was observed in 1448 patients (16%). IDDM had significantly higher crude postoperative complication (43% versus 30% NDM, 36% NIDDM; P < 0.001) and unplanned readmission rates (20% versus 14% NDM, 16% NIDDM; P < 0.001). Concomitant cardiac disease significantly modified the association between diabetes and unplanned readmission. On multivariable analysis, IDDM was an independent predictor of unplanned readmission in the absence of cardiac disease (odds ratio [OR] = 1.23; 95% confidence interval [CI], 1.03-1.47; P = 0.01). However, this association did not remain significant in the presence of cardiac disease (OR = 0.70; 95% CI, 0.48-1.01; P = 0.56). On subgroup analysis of those without cardiac disease, cardiac complications were a significant risk factor for readmission in IDDM (OR = 2.00; 95% CI, 1.12-3.57; P = 0.02) but not NDM (P = 0.31) or NIDDM (P = 0.10). CONCLUSIONS: Although post-LEB unplanned readmission was more common among diabetics, IDDM was independently associated with unplanned readmission only in those without cardiac disease. This was driven, in part, by increased cardiac complications. Therefore, a more stringent preoperative cardiac workup in this group should be considered before LEB.

Aortocaval Fistula: Is Endovascular Repair the Preferred Solution?

BACKGROUND: To compare outcomes of open and endovascular repair of aortocaval fistulas (ACFs) in the setting of abdominal aortic aneurysms (AAAs). METHODS: A literature review was undertaken on Pubmed from 1999 to 2014 to identify reported cases of both endovascular and open repair of ACF, including the index case, presented here. Primary outcomes for endovascular repair were: complications, presence of endoleak, and death. Primary outcomes for open repair were: complications and death. RESULTS: Forty articles were reviewed with a total of 67 patients, including the index case. Endovascular approach was used in 26 patients (39%). Endoleaks were present in 50%, whereas similarly 46% of patients had a reported complication. Five deaths (19%) occurred in the endovascular group. Open repair was performed in 41 cases (61%). The rate of complication and the death in open repair were 36% and 12%, respectively (P = 0.327 and P = 0.910, respectively) compared with endovascular. Mean follow-up was 7.7 months for the endovascular group and 8.5 months in the open group. CONCLUSIONS: Previous demonstrations of high morbidity and mortality with open repair of ACF in the setting of AAA have motivated endovascular approaches. However, endoleaks are a significant problem and were present in 50% of ACF cases. The continued presence of an endoleak in the setting of an ACF may result in persistence of the ACF, unlikely thrombosis of the endoleak, and continued sac enlargement. Endovascular repair presents theoretical benefit, yet is not associated with a reduced rate of complication or death versus open repair in this contemporary review.

Gender Predicts Rupture of Pancreaticoduodenal Artery Aneurysms.

BACKGROUND: There remains no consensus on indication or technique for repair of pancreaticoduodenal artery aneurysms (PDAA) due to the fact that they are exceedingly rare. We sought to evaluate risk factors for rupture, as well as compare the outcomes of open and endovascular surgery. METHODS: We performed a retrospective review of all PDAAs over a 15-year period. The primary outcome was technical success, defined as complete cessation of flow within the aneurysm sac on follow-up imaging. Secondary outcomes included complications greater than Clavien-Dindo Grade I. RESULTS: A total of 21 PDAAs was identified (mean size 20 mm, interquartile range 8-32). Eight patients (38%) were male with an average age at diagnosis of 54.3 ± 2.4 years. Aneurysm etiology included degenerative (90%), pancreatitis (14%), and connective tissue disorder (5%). Seven patients (33%) had additional aneurysms on imaging. Ten patients (48%) were asymptomatic, while 5 patients (24%) presented with rupture. Six patients (29%) had an open repair, including 4 aneurysm ligations and 2 emergent Whipple procedures. Eleven patients underwent an endovascular intervention including 10 (48%) embolizations and 1 stent-assisted coiling (9%). Technical success was 100% for the open group and 91% in the endovascular group. Clavien-Dindo grade >1 complications occurred in 67% of open patients and 0% of endovascular patients (P = 0.01). Death occurred in 2 ruptured patients who underwent open repair. On univariate analysis, male gender was statistically associated with rupture (P = 0.02); however, size of the aneurysm was not (P = 0.77). There was a trend toward an increased rupture rate in those with celiac stenosis (P = 0.10). CONCLUSIONS: In one of the largest series of PDAA to date, only male gender was associated with rupture. Furthermore, size of the aneurysm was not associated with rupture and should not be considered a criterion for repair. While technical success was greater in the open group, it was also associated with an increased incidence of clinically significant complications and death. Endovascular aneurysm embolization should be considered the treatment of choice.

Fenestrated endovascular repair of abdominal aortic aneurysms is associated with increased morbidity but comparable mortality with infrarenal endovascular aneurysm repair.

OBJECTIVE: A recent prospective study found that fenestrated endovascular abdominal aortic aneurysm (AAA) repair (FEVAR) was safe and effective in appropriately selected patients at experienced centers. As this new technology is disseminated to the community, it will be important to understand how this technology compares with standard endovascular AAA repair (EVAR). The goal of this study was to compare the outcomes of FEVAR vs EVAR of AAAs. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program database from 2005 to 2012 was queried for AAAs (International Classification of Diseases, Ninth Revision code 441.4). Patients were stratified according to procedure (FEVAR vs EVAR). A bivariate analysis was done to assess preoperative and intraoperative risk factors for postoperative outcomes. Thirty-day postoperative mortality and complication rates were described for each procedure type. Multivariable logistic regression was performed to assess the association between the type of procedure and the risk of postoperative complications. RESULTS: A total of 458 patients underwent FEVAR and 19,060 patients underwent EVAR for AAA. Patients undergoing FEVAR were older (P = .02) and less likely to have a bleeding disorder (P = .046). Otherwise, the incidence of comorbidities in both groups was similar. FEVAR was associated with increased median operative time (156 vs 137 minutes; P < .001), and average postoperative length of stay (3.3 vs 2.8 days; P = .03). There was a statistically significant increase in overall complications (23.6% vs 14.3%; P < .001) and postoperative transfusions (15.3% vs 6.1%, P < .001) and trends toward increased cardiac complications (2.2% vs 1.3%; P = .09) and the need for dialysis (1.5% vs 0.8%; P = .08) in the FEVAR group. Mortality (2.4% vs 1.5%; P = .12) was not statistically different. On multivariable analysis, FEVAR remained independently associated with the need for postoperative transfusions when operative time was <75th percentile (adjusted odds ratio, 1.72; 95% confidence interval, 1.09-2.72; P = .02) as well as when operative time was >75th percentile for respective procedures (adjusted odds ratio, 5.33; 95% confidence interval, 3.55-8.00; P < .001). CONCLUSIONS: Patients undergoing FEVAR are more likely than patients undergoing EVAR to receive blood transfusions postoperatively and are more likely to sustain postoperative complications. Although mortality was similar, trends toward increased cardiac and renal complications may suggest the need for judicious dissemination of this new technology. Future research with larger number of FEVAR cases will be necessary to determine if these associations remain.

Outcomes of nonelective weekend admissions for lower extremity ischemia.

OBJECTIVE: A "weekend effect" has been demonstrated for a number of diagnoses, including many cardiovascular pathologies. Whether patients with lower extremity ischemia admitted over the weekend have inferior outcomes compared with those admitted on a weekday is unknown. METHODS: Nonelective admissions for critical limb ischemia (CLI) and acute limb ischemia (ALI) from lower extremity thrombosis or embolism were identified in the 2005 to 2010 Nationwide Inpatient Sample, and outcomes were compared based on weekend vs weekday admission by using multiple logistic and linear regression. RESULTS: Of the 63,768 patients identified with lower extremity vascular emergencies, 15.4% were admitted during the weekend. Patients admitted on the weekend were less likely to have CLI than those admitted on a weekday (51.2% vs 65.4%; P < .001) and were more likely to have ALI than patients admitted during a weekday (48.8% vs 34.5%; P < .001). Weekend admission was independently associated with a lower likelihood of revascularization (adjusted odds ratio [aOR], 0.90; 95% confidence interval [CI], 0.85-0.95; P < .001), a longer time until revascularization (3.09 days vs 2.75 days; P < .001), an increased likelihood of major amputation (aOR, 1.35; 95% CI, 1.19-1.53; P < .001), in-hospital complications (aOR, 1.18; 95% CI, 1.11-1.25; P < .001), and discharge to a skilled nursing facility (aOR, 1.15; 95% CI, 1.06-1.25; P = .001), and a longer predicted length of stay (10.1 days vs 9.5 days; P < .001). There was no statistically significant association between weekend admission and in-hospital mortality (aOR, 1.15; 95% CI, 1.06-1.25; P = .10). CONCLUSIONS: Patients admitted on the weekend for lower extremity vascular emergencies are significantly more likely to experience adverse outcomes, including major amputation, than patients admitted on a weekday, independent of their presenting diagnosis with ALI or CLI. Further investigation into the etiologies of these differences is needed to address this disparity. These data raise questions about the proper staffing models to optimize urgent treatment of lower extremity vascular emergencies.

Readmissions after complex aneurysm repair are frequent, costly, and primarily at nonindex hospitals.

OBJECTIVE: Readmissions after complex vascular surgery are not well studied. We sought to determine the rate of readmission after thoracic and thoracoabdominal aortic aneurysm repair (TAA/TAAAR) at our institution and to identify risk factors for and costs of readmission. METHODS: Using a prospectively collected institutional database in conjunction with a Maryland statewide database, we reviewed index admissions and early readmissions for all patients who underwent TAA/TAAAR between 2002 and 2013 at the Johns Hopkins Hospital. Only Maryland residents were included to capture readmissions to any Maryland hospital. RESULTS: We identified 115 Maryland residents (58% men; mean age, 65 ± 1.2 years) undergoing TAA/TAAAR (57% open repair). Early readmissions were frequent and occurred in 29% of patients. Of the readmitted patients, 79% (P < .001) were not readmitted to the index hospital where their operation was performed. Readmitted patients were not significantly different from nonreadmitted patients in age, gender, race, aneurysm type, and index length of stay. They were not different in preoperative comorbidities (including coronary artery disease, diabetes mellitus, smoking, renal insufficiency, and pulmonary disease), postoperative neurologic, renal, and cardiovascular complications, or 30-day or 5-year mortality. Multivariable analysis showed that significant risk factors for readmission were open repair (odds ratio, 3.12; 95% confidence interval, 1.12-9.54; P = .03) and postoperative pneumonia (odds ratio, 4.31; 95% confidence interval, 1.28-15.4; P = .02). Readmitted patients had significantly lower average income compared with the nonreadmitted cohort (U.S. $62,000 ± $4000 vs $73,000 ± $3000; P = .04). Striking differences were seen between patients readmitted to the index hospital where the operation was performed, and those who were readmitted to a nonindex hospital: patients readmitted to the index hospital were readmitted mainly for aneurysm-related surgical issues, whereas patients readmitted to the nonindex hospital were readmitted for medical morbidities. An aneurysm-related intervention was required in 75% of patients readmitted to the index hospital vs in 9% of patients readmitted to the nonindex hospital. Readmissions to a nonindex hospital cost significantly less than to the index hospital (U.S. $20,000 ± $4400 vs $42,000 ± $8800; P = .03) and were not associated with increased overall mortality. CONCLUSIONS: Early readmissions after TAA/TAAA repair are frequent and often occur at hospitals other than the index institution. Risk factors for readmission include open repair and postoperative pneumonia but not pre-existing patient comorbidities. Readmissions to nonindex hospitals were related to medical morbidities that were associated with fewer interventions and lower costs compared with the index hospital. Focusing on preoperative risk factors in this group of patients may not lead to reduction in readmissions. Minimizing nonsurgical complications may reduce post-TAA/TAAAR readmissions and the high costs associated with repeat care.