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Studies have previously identified increased morbidity and mortality with celiac artery coverage during thoracic aortic endografting (TEVAR) for aneurysmal disease. This study aimed to delineate the risks associated with celiac artery coverage in all patients undergoing TEVAR for dissection, trauma, or aneurysmal disease.Utilizing the Vascular Quality Initiative database, we identified all patients undergoing TEVAR from 2012-2020 and categorized them based on the underlying pathology (aneurysm, dissection or acute/trauma). Patients were excluded if their endograft was deployed distal to aortic zone 6 or if they had any pre-operative/operative celiac revascularization procedure. Univariate, regression, and Kaplan Meier analysis were performed for all three groups, focusing on post-operative complications and survival.There were 8,265 patients who underwent TEVAR over the 8-year study period with 142 (1.7%) having celiac artery coverage during their index procedure. Of those patients, the celiac artery was covered during TEVAR in 1.2% of patients with dissection, 1.3% with aneurysm, and 0.7% with trauma. On unadjusted analysis, celiac artery coverage in TEVAR for aneurysmal disease was associated with increased in-hospital mortality (16% vs. 5%, p.001), 30-day mortality (33% vs. 23%, p=.029), any postoperative complication (excluding death) (42% vs. 25%, p.001), and post-operative bowel complication (3% vs. 0.7%, p.003). There were no differences in outcomes for patients treated with celiac coverage versus those without celiac coverage during TEVAR for dissection or trauma on univariate analysis. After risk adjustment, celiac artery coverage remained predictive of worse postoperative outcomes in patients with aneurysmal disease: in-hospital mortality (OR=3.6, CI 1.8-6.9), 30-day death (OR=1.6, CI 1.0-2.4), any postoperative complication (OR 2.2, CI 1.4-3.5), and bowel-specific postoperative complication (3.3, CI 1.0-10.8). There were no differences in patient outcomes for those treated with celiac coverage versus those without celiac coverage during TEVAR for dissection or trauma on multivariate analysis. Kaplan Meier curves (Figure 1) show a significant difference in overall survival based on pathology-specifically lower survival rates for patients with celiac coverage treated for aneurysmal disease. Cox regression analysis showed that celiac artery coverage for aneurysmal disease was associated with significantly increased hazard ratio affecting overall survival (HR=2.6, p.001), but there was no impact on survival in patients who underwent TEVAR with celiac coverage for dissection or trauma.Celiac artery coverage for patients with aneurysmal disease was correlated with a significant increase in post-operative morbidity, mortality, and lowers overall survival. However, for patients with dissection or acute/traumatic aortic pathology, celiac artery coverage does not portend worse outcomes.

Clinical outcomes in women with peripheral artery disease (PAD) after revascularization procedures are worse compared to men, yet there is little in the existing literature as why this may be the case. Platelet Mapping is an emerging point-of-care viscoelastic technology that measures the comprehensive properties of a blood clot, including fibrin-platelet interactions. This prospective observational study aimed to characterize the clinical and Platelet Mapping profiles of female and male patients undergoing lower extremity revascularization, and to correlate Platelet Mapping distribution to thrombotic potential.All patients with a diagnosis of PAD undergoing named vessel open or endovascular revascularization to re-establish inflow, outflow, or both, during December 2020 and January 2022 were prospectively included. Patients were followed clinically for thrombosis for up to 1 year. Platelet Mapping assays were performed in 3 clinical phases: preoperative, postoperative inpatient, and postoperative outpatient. Inferential analysis between female and male patient was performed. The quartile distribution of Platelet Mapping metrics associated with thrombosis was used to infer to thrombotic potential.One hundred seven patients were enrolled, of which 37 (34.6%) were female. Female patients had significantly lower rates of uncontrolled diabetes (2.7% vs. 18.6%), hypertension requiring combination therapy (37.8% vs. 58.6%), chronic kidney disease (27.0% vs. 51.4%), coronary artery disease (29.7% vs. 57.1%), and myocardial infarction (16.2% vs. 35.7%) (all P 0.05). Platelet reactivity was significantly higher in female patients with greater platelet aggregation (75.9 ± 23.3 vs. 63.5 ± 28.8) and lower platelet inhibition (23.8 ± 23.4 vs. 36.8 ± 28.9) (all P 0.01). This trend was consistent over time when stratified by the postoperative inpatient and postoperative outpatient clinical phases. There was no statistically discernible difference in the use of antiplatelet therapy between groups, yet female patients continued to exhibit greater platelet reactivity when analyzed by the type of pharmacologic regimen (platelet aggregation on mono-antiplatelet therapy: 80.6 ± 21.0 in women versus 69.4 ± 25.0 in men; platelet aggregation on dual antiplatelet therapy: 67.9 ± 23.8 in women versus 44.8 ± 31.8 in men) (all P 0.01). Twenty-one patients experienced postoperative graft/stent thrombosis within the study period. In relation to the overall study population, patients with thrombosis had Platelet Mapping metrics above the 50th percentile of overall platelet aggregation distribution.There is a growing appreciation for the differences in etiology, disease progression, and outcomes of cardiovascular conditions as they relate to sex. In this cohort, traditional cardiovascular risk factors were in lower prevalence in female patients. Platelet reactivity was found to be higher across clinical phases and antiplatelet regimens. High platelet reactivity was also associated with an increased incidence of thrombosis after lower extremity revascularization. These hypothesis-generating findings provide the basis for further exploration of sex-specific coagulation profiling in PAD patients.

Postoperative infection and wound dehiscence rates are higher than expected in peripheral artery disease and contribute significantly to limb loss and mortality. Microvascular pathology characterized by microthrombi and increased platelet aggregation have been cited as contributing factors to poor wound healing and infection. The emergence of viscoelastic assays, such as thromboelastography with platelet mapping (TEG-PM), have been utilized to identify prothrombotic states and may provide insight into a patient's microvascular coagulation profile. This prospective, observational study aimed to determine if TEG-PM could predict poor wound healing or infection following lower extremity revascularization.All patients undergoing revascularization between December 2020 and January 2022 were prospectively included and followed for wound complications or non-surgical site infections of the index limb. TEG-PM metrics at the first postoperative follow-up in the nonevent group was compared to the TEG-PM sample preceding the diagnosis of infection/dehiscence in the event group. Cox proportional hazards (PH) regression was used to model the predictive value of viscoelastic parameters. Cut-point analysis to determine high-risk groups was determined by performing receiver operating characteristic curve analysis.Of the 102 patients, 18.6% experienced infection/dehiscence. The TEG-PM sample analyzed in the event group was, on average, 19.5 days prior to the diagnosis of an event. The event group had significantly higher maximum clot amplitude (MA) (47.3 mm ± 16.0 vs. 30.6 mm ± 15.3, P0.01), higher platelet aggregation (71.3% ± 27.7 vs. 31.2% ± 24.0, P0.01), and lower platelet inhibition (28.7% ± 27.7 vs. 68.7% ± 24.1, P0.01). Cox PH analysis identified platelet aggregation as an independent and consistent predictor of infection (hazard ratio = 1.04, 95% confidence interval 1.03-1.06, P0.01). An optimal cut-point of33.2 mm MA,46.6% platelet aggregation, or55.8% platelet inhibition identifies those with infection/dehiscence with 79.0-89.5% sensitivity.These are the first data to provide a quantitative link between prothrombotic viscoelastic coagulation profiles with the development of infection/dehiscence. Based on the cut-points of33.2 mm MA,46.6% platelet aggregation, or55.8% platelet inhibition, we recommend consideration of an enhanced antimicrobial or antithrombotic approach for these high risk groups.

Evolution of aortic intramural hematoma (IMH) over time may range from resolution to degeneration and is difficult to predict. We sought to measure differences in contrast attenuation between arterial and delayed phase computed tomography angiography (CTA) images within the IMH as a surrogate of hematoma blood flow to predict resolution versus aortic growth and/or adverse outcomes.IMH institutional data were gathered from 2005-2020. Hounsfield unit ratio (HUR) was measured as hematoma Hounsfield unit (HU), on delayed phase images divided by HU on arterial phase images on CTA. Aortic growth and effect of HUR was determined using a linear mixed effects model. Freedom from adverse aortic event, defined as the composite of intervention, recurrence of symptoms, radiographic progression, and rupture, was determined using Kaplan-Meier analysis.IMH occurred in 73 patients, of which 27 met the inclusion criteria. HUR ranged from 0.38-1.92 (mean: 0.98). Baseline aortic diameter growth independent of HUR measurement was 0.49 mm/year (95% confidence interval CI: -1.23 to 2.2). With the HUR was introduced into the model, the beta coefficient for time was -5.83 mm/year (95% CI: -10.4 to -1.28 mm/year) and the beta coefficient for the HUR was 5.05 mm/year per one-unit HUR (95% CI: 0.56 to 9.56 mm/year). Thus, an HUR1.15 would correspond to aortic growth while an HUR1.15 would correspond to reduction in aortic diameter, consistent with IMH resolution. Aortic adverse events occurred in 13 (48%) patients, 7 (26%) patients had recurrence of symptoms, 8 (30%) required intervention, 5 (18%) progressed to dissection, and 1(4%) had aortic rupture. There was a trend towards an association between higher HUR and composite adverse aortic events (HR 3.2 per 1-unit HUR; 95% CI: 0.6-17.3; P = 0.18).Increased HUR is associated with increased aortic growth and a trend toward adverse aortic events. Diminished delayed phase enhancement may predict partial or complete IMH resolution. HUR can be used to guide IMH surveillance and treatment.

There is a paucity of data regarding the conversion rate from dry gangrene to wet gangrene after lower extremity revascularization. This study aimed to determine the rate of conversion from dry to wet gangrene within 30 days post-procedure in patients who underwent endovascular or open revascularization for critical limb ischemia. Secondary aims included determining the time to conversion and associated risk factors with conversion.A multicenter, retrospective review was performed utilizing the MGH/Brigham Healthcare System's Research Patient Data Registry (RPDR). All adult patients who had lower extremity dry gangrene that underwent a revascularization procedure (endo, open, hybrid) from April 2002 to March 2020 were included. Patients who had no lower extremity gangrene, a concurrent amputation with the revascularization procedure, or wet gangrene on initial presentation were excluded. Univariate analysis was performed using the Fisher's exact test and Wilcoxon rank-sum test.There were 1,518 patients identified who underwent revascularization; 194 (12.8%) patients met inclusion criteria and served as our study cohort. There were 15 (7.7%) conversions from dry to wet gangrene within 30 days post-procedure. The mean time to conversion was 13.5 ± 8.6 days. Univariate analysis did not identify any associated risk factors for conversion.The rate of dry to wet gangrene conversion post revascularization is 7.7% within 30 days. The mean time of conversion is 13.5 ± 8.6 days.

The purpose of this study was to examine sex-based trends in incidence of elective abdominal aortic aneurysm (AAA), ruptured AAA, ruptured AAA repair and AAA-related mortality.A retrospective analysis of patients presenting with AAA from 2005-2015 was conducted. Rates of elective AAA repair, ruptured AAA, ruptured AAA repair, and mortality were obtained from linking provincial administrative data using medical services insurance billing number. The age-adjusted incidence of elective AAA repair, overall rate of ruptured AAA, ruptured AAA repair, and AAA-related mortality was calculated for each sex based on Canadian census estimates, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends in incidence over time.1986 elective AAA repairs were identified, of which 1098 were repaired open and 898 endovascular AAA repair (EVAR). 570 ruptured AAAs were identified, of which 295 (52%) were repaired: 259 open and 36 EVAR. The proportion of ruptured AAA that was repaired did not change over time (p=0.54). The proportion repairs performed using EVAR increased significantly in both elective (p0.001) and rupture repairs (p0.001). During the study period, 662 patients died of AAA-associated mortality. The average incidence of elective AAA repair in men was 29.3 (95% CI: 27.8 to 30.8) per 100,000 and decreased over time (p=0.04), whereas the average incidence in women was 9.2 [8.3 to 10.0] and stable (p=0.07). The incidence of open elective AAA repair was 10.5 [9.9-11.1] with a decreasing trend over time (p0.001) and EVAR was 9.0 (8.5-9.6) with an increasing trend over time (p0.001). A decreasing trend of overall ruptured AAA (5.4 [5.0-5.9], p0.001), ruptured AAA repair (2.9 [2.5-3.2], p=0.02), and of AAA-related mortality (6.2 [5.8-6.8], p0.001) was found, with consistent trends in both sexes. The incidence of open ruptured AAA repair decreased over time (p=0.001) whereas the incidence of ruptured EVAR remained stable (p=0.23).The incidence of elective AAA repair is decreasing in males but not females, whereas the incidence of rupture has decreased in both sexes. This has translated into reduced incidence of AAA-related mortality. Increased adoption of EVAR for ruptured AAA should continue these trends.

Background Short-term outcomes in patients with all forms of TOS have been widely reported in the literature and have established that rib resection can be beneficial in decompressing the thoracic outlet and relieving pressure on traversing structures. We sought to determine long-term functional outcomes using the Disability of the Arm, Shoulder, and Hand (QuickDASH) survey in patients with TOS who underwent rib resection. Methods Clinical records for patients who underwent rib resection for TOS at a single institution were retrospectively reviewed. All patients were contacted via telephone and long-term functional outcome was assessed at latest follow-up via the 11-item version of the QuickDASH questionnaire. Demographics, TOS type, preoperative QuickDASH score, and athletic status were recorded. Patients were asked if they returned to baseline activity since their surgery, would have the procedure again, and if they were subjectively better postoperatively. Results From 2000 to 2018, 261 patients underwent rib resection surgery. One hundred seventy patients (65.1%) were able to be contacted via telephone for long-term follow-up. A total of 188 surgeries (102 neurogenic thoracic outlet syndrome, 82 venous thoracic outlet syndrome, 4 arterial thoracic outlet syndrome) were performed in these 170 patients. The mean follow-up time for the cohort was 5.3 years (range 1–18). Overall, 167 (88.9%) patients returned to baseline activity postoperatively. Postop QuickDASH decreased to 12 from 44 preoperatively for the cohort. Conclusions First rib resection and thoracic outlet decompression for all forms of TOS is a durable surgical treatment which results in excellent long-term functional outcomes as determined by both the QuickDASH score and subjective patient reporting.

This study evaluates 30-day mortality after endovascular aneurysm repair (EVAR) versus open repair for ruptured complex abdominal aortic aneurysms (cAAAs), including juxtarenal, pararenal, suprarenal, and extent IV thoracoabdominal aortic aneurysms (TAAA) in a real-world setting.The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing repair for ruptured cAAA from 2011 to 2017. Primary endpoint was 30-day mortality. Secondary endpoints included renal failure, pulmonary complications, ischemic colitis, cardiac complications, lower extremity ischemia, post-operative rupture, and intensive care unit (ICU) length of stay (LOS). EVAR and open repair were compared using inverse probability weights.Four hundred forty-six patients had a ruptured cAAA repair during the study years; 105 (23.7%) were repaired via EVAR and 338 (76.3%) received open repair. The distribution by aneurysm type was as follows: 253 juxtarenal (57.1%), 59 pararenal (13.3%), and 100 suprarenal (22.6%) AAA with 31 type IV TAAA (7.0%). Juxtarenal aneurysms were more likely to be performed open than EVAR (P 0.001) and pararenal were more likely to be performed endovascularly (P 0.001). There was no significant change in the proportion of EVAR versus open repair in the years evaluated (P = 0.16). Hemodynamic stability was nearly identical between the 2 groups, with 49.5% of the EVAR cohort suffering from preoperative hypotension or requiring vasopressors compared to 49.1% in the open surgical cohort (P = 1.0). No significant difference in death existed based on proximal aneurysmal extent (P = 0.42). Death within 30 days occurred in 135 (30.5%) of the total cohort with 25 (23.8%) deaths in the EVAR cohort and 110 (32.5%) deaths in the open cohort. The EVAR group suffered a 20.0% rate of postoperative renal failure requiring dialysis compared to 18.6% of the open cohort (P = 0.78). Pulmonary complications were more common after open repair (40.5% vs. 25.0%, P = 0.004). After propensity weighting and weighted logistic regression, the open cohort had 1.75 times the odds of death compared to the EVAR cohort (AOR: 1.8, 95% CI: 0.9-2.8; P = 0.06). There was no association between repair type and postoperative renal failure. Open repair was associated with greater odds of pulmonary complications, ischemic colitis, and longer ICU stays in survivors.Mortality after repair for ruptured cAAA is high; and treatment with EVAR may trend toward early survival advantage. Rates of renal failure were similar between each cohort. Open repair is associated with higher rates of pulmonary complications, ischemic colitis, and longer ICU stays.

Insurance coverage of vascular surgery patients may differ from patients with less chronic surgical pathologies. The goal of this study is to identify trends in insurance status of vascular surgery patients over the last 10 years at a busy academic center.All consecutive patient visits for a vascular procedure from 2006 to 2016 were retrospectively reviewed from a prospectively collected institutional database. Data points included insurance status, procedures performed, and date of admission. The insurance status was categorized as Medicare, Medicaid, and uninsured. Samples were divided between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, chi-squared test, and regression analysis were used to determine significant trends over the study period.From 2006 to 2016, 6,007 vascular surgery procedures were performed. Procedure volume increased significantly from 1,309 to 4,698 between the 2 timeframes (P 0.05), whereas the percentage of Medicaid and Medicare patients trended upward but did not achieve significance. There was a significant decrease in the percentage of uninsured patients between the cohorts (5.65% vs. 2.96%, P 0.05). In 2012, 10.14% of patients were uninsured compared with 2.56% in 2016 (P 0.05).Insurance status affects access to care and subsequent outcomes. In our busy academic center, insurance coverage for vascular surgery has significantly increased over the past decade. The number of Medicaid and Medicare patients has slowly increased, but a significant and continuing decline in uninsured patients was observed. Implementation of the Affordable Care Act during this time period may have played a role in providing coverage for patient needing vascular surgery.

Total knee replacement (TKR) and total hip replacement (THR) are associated with an increased risk of deep vein thrombosis (DVT). Advances in DVT prophylaxis over the past decade have led to a decrease in DVT-related morbidity, but gender, racial, and other demographic factors that contribute to a higher risk of DVT are incompletely characterized. This study aimed to determine the incidence of DVT over the past decade and identify factors that were associated with an increased risk of DVT.Patients who underwent TKR or THR between 2001 and 2011 were identified using the National Inpatient Sample. For patients who developed a DVT, their demographics (including age, gender, and race), comorbidities, and subsequent outcomes (including length of stay [LOS] and mortality) were determined. Differences between patients who developed a DVT and those who did not were determined using multivariate regression analysis. A Mann-Kendall analysis was done to evaluate all trends.Between 2001 and 2011, a total of 1.1 million patients underwent TKR, and 550,000 underwent THR. The overall incidence of DVT decreased for TKR from 0.86% in 2001 to 0.45% in 2011 and decreased for THR from 0.55% to 0.24% for the same period. Patients who developed a DVT after TKR were older (67.7 vs. 66.8, P 0.001); more likely to be African American (P 0.001); and more likely to have significant comorbidities including congestive heart failure, peripheral artery disease, and end-stage renal disease. Findings were similar for patients who developed a DVT after THR. Mortality was significantly greater for patients who developed a DVT (0.4% for TKR and 1.7% for THR), with an almost double LOS.A focus on DVT prophylaxis may have decreased national rates of DVT after TKR and THR. Older patients, African Americans, and patients with more comorbidities appear to be especially at risk for DVT. Mortality is almost 4 to 8 times higher for patients with DVT, and LOS is double. A focus on DVT prophylaxis and perhaps more aggressive management of the at-risk population may further help decrease the rate of DVT.

Background Rib resection in venous thoracic outlet syndrome (vTOS) may be approached via a transaxillary, supraclavicular, or infraclavicular approach based on surgeon preference. The purpose of this study was to evaluate long-term postoperative quality of life function after surgery for vTOS and to determine if there were long-term patency differences associated with the surgical approach or whether prophylactic postoperative venography was performed. Methods All patients with vTOS undergoing rib resection at a single institution were retrospectively reviewed. In 2012, we switched our approach to infraclavicular with postoperative venogram performed within 2 weeks of rib resection. Clinical records and imaging results were tabulated, and postoperative outcomes, complications, and long-term symptom follow up via the disabilities of the arm, shoulder, and hand score surveys. The disabilities of the arm, shoulder, and hand score ranges from 0 to 100 with lower numbers indicating better functional status (100 = worst). Results During the 19-year study period, we performed 109 rib resections in patients with vTOS (mean age, 29.8 years). From 2000 to 2012, 54 patients were approached via a supraclavicular approach, and from 2012 to 2018, 55 patients were approached via an infraclavicular approach. There was a significant decrease in the number of complications in the infraclavicular cohort compared with the supraclavicular group. There was no difference in patency between the 2 groups even with a higher rate of postoperative venogram in the infraclavicular cohort. There was no difference in long-term the disabilities of the arm, shoulder, and hand scores. There was an increased rate of complications in the supraclavicular cohort as compared with the infraclavicular group (P Conclusions The infraclavicular approach in patients with vTOS is associated with a lower rate of complications, but long-term quality of life outcomes and patency are not different between groups.

Background The Heli-FX EndoAnchor (EA) system is a transmural aortic fixation device with Federal Drug Administration (FDA) approval for treatment of endoleaks, endograft migration, or high-risk seal zones. Published data are primarily from industry-sponsored registries highlighting safety and efficacy. Our objective is to evaluate real-world outcomes of EA usage after FDA approval across a variety of stent grafts and indications at a single institution. Methods We retrospectively reviewed our prospectively maintained aneurysm database for patients undergoing endovascular aortic repair (EVAR) with Heli-FX EAs. Technical success was defined as successful EA deployment, while procedural success was defined as absence of endoleak on completion aortogram. Cohorts were divided by indication and outcomes assessed via review of clinical and radiographic data. Results From 2016 to 2018, 37 patients underwent EA fixation. We divided the cohort by indication: Group A (prior EVAR with endoleak), B (intraoperative type 1A endoleak), C (high-risk seal zone), and D (thoracic EVAR). In Group A (n = 11), all endoleaks were type 1A and a mean of 10 EAs were deployed with 100% technical and 45.4% procedural success. Two perioperative reinterventions were performed (translumbar coil embolization and proximal graft extension with bilateral renal artery stents). At a mean 10.6 months of follow-up, 45.4% of patients had persistent endoleaks, with 100% aortic-related survival. In Group B (n = 10), a mean of 8.7 EAs were used with 100% technical and procedural success. One immediate adverse event occurred (right iliac dissection from wire manipulation, treated with a covered stent). At 13.6-month mean follow-up, there was significant sac regression (mean 9.75 mm) with no type 1A endoleaks. In Group C (n = 10), a mean of 9.5 EAs were deployed with 100% technical and procedural success. At 11.2-month mean follow-up, there were no residual endoleaks and significant sac regression (mean 3.4 mm). Overall survival was 100%. In Group D (n = 6), a mean of 8.3 EAs were used with 83.3% technical and 66.6% procedural success. One immediate adverse event occurred, in which an EA embolized to the left renal artery. At 9.4-month mean follow-up, overall survival was 83.3% with a mean 2.2-mm increase in sac diameter. Conclusions Early experience suggests that EAs effectively treat intraoperative type 1A endoleaks and high-risk seal zones, with significant sac regression and no proximal endoleaks on follow-up. In patients treated for prior EVAR with postoperative type 1A endoleaks, fewer than half resolved after EA attempted repair. Further experience and longer term follow-up will be necessary to determine which patients most benefit from postoperative EA fixation.

Background Endovascular aneurysm repair (EVAR) and Thoracic endovascular aortic repair (TEVAR) are commonly performed by interventional radiologists, cardiologists, general surgeons, cardiothoracic surgeons, and vascular surgeons, with each specialty having differences in residency structure, operative experience, and subspecialty training. The aim of this study is to evaluate the impact of surgeon specialty on outcomes following EVAR and TEVAR. Methods Patients who underwent EVAR and TEVAR were identified from the 2007 to 2009 Nationwide Inpatient Sample (NIS). Physician identifiers in the NIS were used to determine surgical specialty and operative experience. Multivariate analysis adjusted for mortality risk was used to compare differences in demographics, complications, outcomes, and hospital covariates. Results A total of 5147 EVARs were identified within the NIS, of which 88.3% were completed by vascular surgeons. There were no significant differences in demographics between the specialties. Cardiothoracic surgeons were more likely to have a postoperative stroke (3.1% vs. 0.2%, odds ratio [OR] 14.6, 95% confidence interval [CI] 1.8–117.8, P

Background: The study aimed to determine the association between race and patient variables, hospital covariates, and outcomes in patients presenting with advanced chronic venous insufficiency. Methods: The National Inpatient Sample was queried to identify all Caucasian and AfricanAmerican patients with a primary International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for venous stasis with ulceration (454.0), inflammation (454.1), or complications (454.2) from 1998 to 2011. CEAP scores were correlated with ICD-9 diagnosis. Demographics, CEAP classification, management, cost of care, length of stay (LOS), and inpatient mortality were compared between races. Statistical analysis was via descriptive statistics, Student’s t-test, and the Fisher’s exact test. Trend analysis was completed using the ManneKendall test. Results: A total of 20,648 patients were identified of which 85% were Caucasian and 15% were African-American. Debridement procedures had the highest costs at $6,096 followed by skin grafting at $4,089. There was an overall decrease in the number of ulcer debridements, vein stripping, and sclerotherapy procedures between 1998 and 2011 (P < 0.05) for both groups. However, African-American patients had significantly more ulcer debridements than their Caucasian counterparts. Conclusions: African-American patients with a primary diagnosis of venous stasis present with more advanced venous disease at a younger age compared with their Caucasian counterparts. This is associated with increased ulcer debridement, deep vein thrombosis rates and hospital charges in the African-American cohort. There are no differences in sclerotherapy or skin grafting procedures, LOS or inpatient mortality between races.

This study aimed to identify factors that drive increasing health-care costs associated with the management of critical limb ischemia in elective inpatients.Patients with a primary diagnosis code of critical limb ischemia (CLI) were identified from the 2001-2011 Nationwide Inpatient Sample. Demographics, CLI management, comorbidities, complications (bleeding, surgical site infection [SSI]), length of stay, and median in-hospital costs were reviewed. Statistical analysis was completed using Students' t-test and Mann-Kendall trend analysis. Costs are reported in 2011 US dollars corrected using the consumer price index.From 2001 to 2011, there were a total of 451,823 patients who underwent open elective revascularization as inpatients for CLI. Costs to treat CLI increased by 63% ($12,560 in 2001 to $20,517 in 2011, P 0.001 in trend analysis). Endovascular interventions were 20% more expensive compared with open surgery ($19,566 vs. $16,337, P 0.001). Age, gender, and insurance status did not affect the cost of care. From 2001 to 2011, the number of patient comorbidities (7.56-12.40) and percentage of endovascular cases (13.4% to 27.4%) increased, accounting for a 6% annual increase in total cost despite decreased median length of stay (6 to 5 days). Patients who developed SSI had total costs 83% greater than patients without SSIs ($30,949 vs. $16,939; P 0.001). Patients who developed bleeding complications had total costs 41% greater than nonbleeding patients ($23,779 vs. $16,821, P 0.001). Overall, there was a 32% reduction in SSI rates but unchanged rates of bleeding complications during this period.The cost of CLI treatment is increasing and driven by rising endovascular use, SSI, and bleeding in the in-patient population. Further efforts to reduce complications in this patient population may contribute to a reduction in health care-associated costs of treating CLI.

Background This study aimed to determine the association between geniculate artery flow on admission computed tomography (CT) angiography and limb salvage outcomes in patients with lower extremity arterial injury. Methods All injured patients at a level I trauma center with CT angiogram (CTA) confirmed limited or no flow to the tibial vessels were included. Demographics, injury severity score (ISS), mechanism of injury, physiological parameters, the presence of geniculate artery collateral circulation (superior medial, superior lateral, medial, inferior medial, inferior lateral), and 30-day limb salvage outcome were recorded. Statistical analysis was completed using descriptive statistics and the chi-squared tests. Results From 2009 to 2012, a total of 84 patients with lower extremity arterial injury underwent diagnostic evaluation with CTA on admission that confirmed limited or no flow to the tibial vessels. A total of 10 patients (12%) underwent amputation. Primary amputation was performed in 3 (4%) patients, and secondary amputation was performed in 7 (8%) patients. There was no difference in age, gender, ISS, extremity abbreviated injury score, mechanism of injury, admission systolic blood pressure, heart rate, respiratory rate, transfusion volume, or type of vascular interventions between patients who had successful limb salvage and those who received an amputation. The number of patent geniculate arterial vessels was inversely associated with amputation with 3.3 patent geniculate arteries in the limb salvage group compared to 2.1 in the amputation group (P

This report describes the rapid expansion of a previously excluded abdominal aortic aneurysm (AAA) following type A aortic dissection repair in a 74-year-old male. Following successful Hemiarch replacement, CT angiography (CTA) showed residual dissection throughout the thoracoabdominal aorta, which had created a proximal endoleak at the prior endovascular stent graft resulting in the rapid growth of the residual AAA sac. Urgent thoracic endovascular aortic repair (TEVAR) did not fully obliterate false lumen flow allowing further unstable expansion of the AAA and abdominal pain. This was ultimately managed with an open replacement of the infrarenal neck with a Dacron interposition graft sewn to the prior EVAR. Postoperative CTA showed resolution of the false lumen communication to the infrarenal AAA and no further endoleak. Open interposition AAA neck replacement is a possible treatment for new-onset endoleak in patients with aortic dissection following prior infrarenal EVAR.

Background This study details 2-year outcomes of a modified gracilis muscle flap (GMF) technique in providing tissue coverage for groin complications after arterial bypass surgery with synthetic graft. Methods All patients who developed groin infections after lower extremity arterial bypass with synthetic graft who underwent a GMF technique were included from June 2014 to March 2017 from a prospectively collected, purpose-built institutional database. Modifications to the standard technique included identification of the muscle using ultrasound to ensure precise skip incisions, preservation of the segmental blood supply, widening of the tunnel through which the muscle is retroflexed, placement of a wound vacuum-assisted closure for healing, and lifelong antibiotics. Demographics, laboratory values, bypass procedure, length of stay (LOS), disposition, and 1-, 3-, 6-, 12-, and 24-month follow-up data were collected. Analysis was performed via descriptive statistics. Results Over the 3-year study period, 22 patients underwent GMF after complications resulted from arterial bypass surgery. Types of bypass included aortobifemoral (32%), axillobifemoral (14%), femoral-femoral (23%), femoral-popliteal or mixed distal (27%), and thigh graft for dialysis (4%). Forty-five percentage of patients presented with graft infection, 50% with wound dehiscence, and 5% with graft disruption and bleeding. Only 23% of patients were candidates for sartorius muscle flap at the time of their initial procedure. The average case length was 64 + 19 min. Sixty-four percentage of patients were discharged home with home health care and the remainder to a skilled nursing facility. The average LOS was 6.1 + 3.4 days. Fifty-four percentages of wounds were healed at 1 month and 100% at 3 months with adjunctive vacuum-assisted closure therapy and lifelong antibiotics. Sixty percentage of patients were still alive at 24 months, with 33% of grafts still patent at that time. Median survival was 18.1 months, and median graft patency was 17.9 months. Conclusions GMF is a safe and effective treatment for groin complications after arterial bypass surgery with synthetic graft. Owing to its versatility, area of coverage, ease of use, and durability, it potentially should be considered as a primary form of muscle coverage for groin complications.

Background Thoracic outlet syndrome (TOS) is a constellation of signs and symptoms caused by compression of the neurovascular structures in the thoracic outlet. These structures include the brachial plexus, the subclavian vein, and the subclavian artery, resulting in neurogenic (NTOS), venous (VTOS), and arterial (ATOS) types of TOS, respectively. The purpose of this study was to evaluate the outcomes of paraclavicular surgical decompression for TOS. Methods A prospective analysis of patients who underwent surgical decompression for TOS at a newly established center was performed. Diagnosis of TOS was based on clinical history, a physical examination, and additional diagnostic studies. The indication for surgery in patients diagnosed with NTOS was the presence of persistent symptoms after a trial of physical therapy. Primary outcomes were assessed according to Derkash's classification as excellent, good, fair, and poor. Secondary outcomes included mortality, complications, and duration of hospital stay. Results Between August 2004 and June 2011, 40 paraclavicular decompression procedures were performed on 36 patients (16 men) with TOS. The mean age was 36.5 years (range: 15–68). Bilateral decompression was performed on 4 patients. The types were NTOS (n = 19; 48%), VTOS (n = 16; 40%), and ATOS (n = 5; 12%). In addition to pain, the most common presenting symptom was numbness in NTOS, swelling in VTOS, and coolness in ATOS. A history of trauma was present in 22.2%. Two patients suffered from recurrent symptoms after previous transaxillary first rib resection for VTOS at another institution. Diagnostic tests performed included nerve conduction studies (43%), venogram (40%), and arteriogram (20%). All patients underwent paraclavicular decompression, which included radical anterior and partial middle scalenectomy, brachial plexus neurolysis, and first rib resection. The first rib resection was partial, through a supraclavicular only approach in NTOS and ATOS patients (60%) or complete, through a supra- and infraclavicular approach for VTOS patients (40%). Functional outcomes were excellent, good, fair, and poor in 74.4%, 15.4%, 10.3%, and 0% of cases, respectively. One patient was lost to follow-up. Two patients with incomplete relief of symptoms after paraclavicular decompression for NTOS underwent pectoralis minor decompression. There were no deaths. Complications included pleural effusion requiring evacuation (n = 4), neuropraxia (n = 1), and lymph leak (n = 1) treated with tube thoracostomy. No patients experienced injury to the long thoracic or phrenic nerves. The mean duration of hospital stay was 4.4 days. The mean follow-up was 10.3 months. Conclusions In our experience, surgical paraclavicular decompression can provide safe and effective relief of NTOS, VTOS, and ATOS symptoms. Functional outcomes were excellent or good in the majority of patients, with minimal complications.

Background Pregnancy is a hypercoagulable state associated with a fivefold increase in the risk of venous thromboembolism. Thrombolysis is the preferred level of care for patients with acute iliofemoral deep vein thrombosis (DVT); however, most studies exclude pregnant patients, highlighting the lack of data regarding the efficacy and safety of thrombolytic therapy for mother and fetus. Methods We describe the successful use of thrombolytic therapy in conjunction with ultrasound to remove a large ileofemoral DVT in a first-trimester patient with phlegmasia cerulea dolens. The procedure was performed safely for both mother and fetus. Results No radiation or contrast dye was used, and intravascular ultrasound confirmed patency of the entirety of the venous system. She delivered a healthy term baby after the procedure and had no further sequalae. Conclusion Thrombolysis with intravascular ultrasound may be considered in first-trimester pregnant patients with threatened limb due to DVT.

This study aimed to determine the body mass index (BMI) at which duplex ultrasonography does not accurately detect deep vein thrombosis.This is a retrospective review of all patients who underwent lower extremity venous duplex examination at a single institution, tertiary vascular laboratory from January 2011 to June 2011. Demographics, BMI, operator years of experience, and duplex ultrasound study quality were recorded. Duplex ultrasound study quality was divided into "adequate" or "inadequate."A total of 495 patients were included in this study, of which 435 (88%) patients were adequate and 60 (12%) inadequate. One hundred ninety-eight (40%) patients of the overall study cohort were men and 297 (60%) women. Limited studies were performed in 21 (11%) men and 39 (13%) women (P = 0.48). There was an inverse relationship between the years of operator experience and the percent of studies classified as limited (P0.01). The mean BMI of patients in the adequate group versus the inadequate group was 30.3 ± 8.9 (median 28.9) versus 39.8 ± 15.1 (median 38.4), respectively (P0.0001). Univariate analysis identified tech A (least experience) (3×) and increased BMI40 (6×) as independent variables associated with having a limited duplex ultrasound study.These results suggest that patients with BMI40 may require an alternative imaging modality to objectively diagnose the presence of venous thromboembolism as an increased BMI is associated with an indeterminate study.

Numerous case reports have highlighted the relationship between bacillus Calmette-Guérin (BCG) therapy and development of systemic mycotic aneurysms but none have established a management algorithm in patients with suspected vascular dissemination of Mycobacterium bovis. Delay in diagnosis of this disease process will lead to delays in initiation of antimycobacterium treatment to prevent dissemination into other arterial beds and potentially complicate effective surgical treatment leading to aneurysmal rupture and other devastating vascular consequences. Given the increasing number of reported cases in the literature and the ongoing, standard of care utilization of BCG for bladder cancer, we believe that a systematic approach to the management of patients with suspected BCG-related mycotic aneurysms should be set in place to prevent misdiagnosis and delays in treatment. In this report, we discuss the presentation, work-up, and report our treatment algorithm of a patient who developed diffuse peripheral mycotic aneurysms following BCG therapy for bladder cancer.

The objective was to evaluate the difference in timing (if any) of in-hospital carotid endarterectomy (CEA) or outcomes of CEA based on sex among men and women hospitalized for carotid artery disease.This was a retrospective cross-sectional study using the Nationwide Inpatient Sample Database. All patients from 2000-2009 who underwent CEA during their hospitalization were examined. International Classification of Diseases, 9th revision codes were used to identify patients who underwent CEA during hospitalization, stratify asymptomatic and symptomatic patients, determine time in days from admission to CEA, and examine in-hospital complications, including perioperative stroke, cardiac events, and death. Statistical analysis was performed with chi-squared and t-tests. Linear and logistic regression models were used to evaluate relationships between sex and outcomes. The main outcome measures were time from admission to surgery, in-hospital mortality, complications, mean duration of stay, and discharge disposition.Two hundred twenty-one thousand two hundred fifty three patients underwent CEA during hospitalization. More than 9% (9.2%) had symptomatic carotid artery disease. Among symptomatic patients, bivariate analysis found that women had a longer mean time from admission to surgery (2.8 vs. 2.6 days; P0.001) and a longer duration of hospital stay (6.4 vs. 5.9 days; P0.001) than their male counterparts. However, there was no difference between men and women with regard to rates of perioperative stroke, cardiac complications, myocardial infarction, or death. Among asymptomatic patients, women had a longer mean time from admission to surgery (0.53 vs. 0.48 days; P0.001) and a trend toward increased perioperative stroke (0.6% vs. 0.5%; P = 0.06), but a lower rate of cardiac complications (1.5% vs. 1.7%; P = 0.01) and in-hospital mortality (0.26% vs. 0.31%; P = 0.05). However, on multivariable analysis adjusting for differences in age, elective status, insurance, race, hospital location, hospital region, and hospital teaching status, there was no sex disparity in time from admission to surgery, regardless of symptomatic status. In addition, asymptomatic women were less likely than men to have a cardiac complication (odds ratio [OR]: 0.90; 95% confidence interval [CI]: 0.83-0.97) or in-hospital mortality (OR: 0.83; 95% CI: 0.70-0.98). Symptomatic women were also less likely than men to have a cardiac complication (OR: 0.78; 95% CI: 0.63-0.97).In this decade-long national population-based study of hospitalized patients undergoing CEA, women had lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical, and hospital factors, there is no discernible difference in timing of CEA based on sex.

Significantly reduced amputation rates for traumatic popliteal artery injuries have been achieved with improved revascularization and resuscitative techniques. Predictive scores have failed to accurately predict outcomes in patients who sustain popliteal artery damage. This study aimed to identify predictors of limb salvage in a civilian cohort after popliteal artery trauma.A single-institution, retrospective review was performed of all patients with popliteal artery trauma presenting between January 2002 and June 2009. Data were compiled using the institutional trauma registry, with demographics, mechanism of injury, associated injury, fasciotomy, Mangled Extremity Severity Score (MESS), and Injury Severity Score (ISS) all documented. Statistical analysis included descriptive statistics, univariate analysis, and multiple exact logistic regression.Seventy traumatic popliteal artery injuries were identified in 68 patients with a mean age of 33 years (range: 5-88 years). The majority of patients were male (n = 57; 81%), and 73% sustained blunt injury. Associated venous injury was present in 16 (23%) cases. Associated orthopedic injuries included 19 (27%) dislocations and 49 (70%) fractures. The median MESS was 5 (range: 2-9) and the median ISS was 9 (range: 4-41). Revascularization was performed in 62 cases (89%). Twenty-three percent of patients had compartment syndrome and 56% underwent fasciotomy. Fifteen (21%) patients required amputation, 11% of which were primary and 10% secondary. Variables associated with amputation included ISS10 compared to ISS9 (odds ratio [OR]: 7.4; P 0.045), blunt injury (OR: 10.7; P = 0.009), MESS 7 (OR: 2.4; P 0.0001), and fractures (OR: 0.13; P 0.045). In a multiple exact logistic regression analysis, a MESS7 (P 0.05) was the only significant predictor of amputation.Patients with traumatic popliteal artery injury are at high risk for amputation. Blunt injury, fractures, ISS9, and MESS7 were associated with an increased odds of amputation. Although in our data, MESS was the strongest predictor of amputation, we recognize that MESS was previously invalidated as a scoring system. New methods to determine limb viability in the mangled extremity are needed.

We sought to evaluate the incidence, epidemiology, and factors associated with surgical site infections (SSIs) after lower extremity revascularization procedures involving groin incisions and determine outcomes based on SSI status.This is a single-institution, retrospective cohort study of 106 patients who underwent lower extremity revascularization procedures involving femoral artery exposure through a groin incision at a tertiary referral hospital. The primary outcome was occurrence of SSI at the groin wound. The duration of hospital stay, reoperation within 30 days, discharge disposition, and 30-day mortality were also evaluated. Independent variables included patient demographics and operative variables (i.e., procedure type, transfusion requirements, preoperative antibiotics, intraoperative vasopressors, and operative duration). Statistical analysis included chi-squared tests, t-tests, and multivariable regression analysis.Of the 106 patients who underwent a lower extremity revascularization procedure with a groin incision for femoral artery exposure, 62% were male, and the mean age was 62 years. Comorbidities included hypertension (93%), dyslipidemia (65%), statin use (63%), active smoker (50%), diabetes (24%), and chronic obstructive pulmonary disease (23%). All patients received preoperative antibiotics, 50% required intraoperative pressors, 21% received a blood transfusion, and the mean operative time was 296 min. The overall duration of stay was 10.7 days, the 30-day reoperation rate was 18%, and the 30-day mortality rate was 12%. Overall, 22% developed a seroma or hematoma, and 31% developed a SSI. Patients who developed an SSI compared with those who did not were more likely to have a postoperative seroma or hematoma (55% vs 5%) and to receive a blood transfusion (33% vs 15%), but less likely to be treated with a statin (47% vs 69%) or carry a diagnosis of dyslipidemia (50% vs 72%), respectively, all P 0.05. Patients with an SSI had a longer duration of stay (14.5 vs 8.7 days) and a higher reoperative rate (49% vs 4%), but had a lower 30-day mortality (0% vs 18%) than those who did not develop an SSI (all P 0.05). On multivariable regression analysis adjusting for differences in patient and operative variables, the occurrence of a wound seroma or hematoma remained an independent predictor for SSI (odd ratio: 27.6; 95% confidence interval: 5.4-139.6).The incidence of postoperative surgical site complications after lower extremity revascularization procedures involving a groin incision was 31% and was significantly associated with blood transfusion, postoperative seroma or hematoma, dyslipidemia, and statin usage. After adjusting for differences in patient and operative variables, postoperative seroma or hematoma was an independent predictor of SSI. Patients with a SSI have a longer duration of hospitalization and higher reoperative rate. Additional prospective cohort studies are warranted to delineate ways to decrease the rate of SSI.

Traumatic renal arteriovenous fistula involving the inferior vena cava (IVC) are exceptionally rare, but if left untreated can have devastating clinical consequences, including development of renovascular hypertension, cardiomegaly, and congestive heart failure. We report a rare, pediatric case of a renal-caval arteriovenous fistula that developed after a gunshot wound to the abdomen and its subsequent treatment with endovascular means. We review our case and the world literature on the evaluation and management of trauma-related renal-caval arteriovenous fistulae.