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Objective Surgical frailty and its assessment have become essential considerations in perioperative management for the modern aging surgical population. The risk analysis index is a validated frailty score that has been proven to predict short-term outcomes and long-term mortality in several surgical subspecialties and high-risk procedures. We examined the association of risk analysis index scores with postoperative outcomes in a retrospective nationwide database of patients who underwent lower extremity amputation in the Veterans Health Administration Health Care System. Methods The Veteran Affairs Surgical Quality Improvement Program data was queried across the Veteran Affairs Health Care System with institutional review board approval for lower extremity amputations. Records of above and below knee amputation, Current Procedural Terminology codes 27590, 27591, 27592, 27594, 27596 and 27880, 27881, 27882, 27884, and 27886, respectively, from 1999 to 2018 were obtained. Incomplete and traumatic entries were removed. Risk Analysis Index score was calculated from preoperative variables and patients were separated into five score cohorts (≤15, 16-25, 26-35, 36-45, ≥46). The χ2 test and analysis of variance were used to compare the cohorts. Forward binary logistic regression modeling was used to determine covariate-adjusted odds ratios for outcomes in each cohort (SPSS software; version 25, IBM Corp). Results A total of 47,197 patients (98.9% male) with an average age of 66.4 ± 10.6 years underwent nontraumatic lower extremity amputation, including 27,098 below knee and 20,099 above knee amputations, during the study period. Frailty was associated with increased rates of deep vein thrombosis, sepsis, cardiac arrest, myocardial infarction, pneumonia, intubation for more than 48 hours, pulmonary embolism, reintubation, acute kidney injury, renal failure, increased length of stay, overall complications, and death. Increases in the frailty score were associated with up to three times the likelihood for the occurrence of a postoperative complication and up to 32 times likelihood to perish within 30 days than those with low frailty scores. Conclusions Risk analysis index assessment of frailty was found to be associated with several postoperative outcomes in a dose-dependent manner in patients undergoing lower extremity amputation in the Veterans Health Care System, with higher scores associated with higher rates of death and major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean vent, reintubation), and renal (renal insufficiency, renal failure) complications. We recommend the use of risk analysis index score as a frailty screening tool for patients undergoing lower extremity amputation to enable providers to adequately inform and counsel patients regarding potential significant risks.

Background Functional popliteal artery entrapment syndrome (FPAES) is a rare disorder described in young, physically active adults that can be limb or performance threatening if untreated. We used provocative computed tomography angiography (CTA) in these patients to guide partial debulking of the anterolateral quadrant of the medial head of the gastrocnemius muscle for FPAES and reviewed the outcomes of this technique in this highly specialized cohort. Methods Athletes referred with symptoms of FPAES underwent a CTA protocol with provocative plantarflexion and dorsiflexion to confirm compression and were offered surgery. All patients underwent posterior approach operative exposure of the popliteal artery, adhesiolysis, side branch ligation, and partial excision of the gastrocnemius muscle with or without fasciotomies. Preoperative imaging, operative findings, and midterm follow-up, including return to baseline function and return to competitive function, as well as symptom recurrence, were retrospectively reviewed. Results Thirty-six athletes had a total of 56 limbs treated. The average patient age was 26.9 years and the majority were female (56%). Thirty-one percent of patients were referred after already having undergone prior fasciotomies. Sports involved included track and field or running (47%), soccer (25%), water sports (8%), basketball (6%), lacrosse (6%), climbing (3%), skiing (3%), and gymnastics (3%). Of the patients, 27 (75%) had bilateral symptoms and evidence of entrapment; however, only 20 of the 36 (56%) underwent bilateral surgical treatment for symptom resolution. The mean amount of gastrocnemius muscle removed was 7.6 cm 3 . Nine percent of limbs underwent a bypass along with debulking owing to arterial occlusion at presentation. Postoperatively, there were no nerve or vascular complications noted, although two patients had wound/seroma complications (6%). At the first follow-up, all patients reported mild symptom improvement, but at the midterm follow-up (mean follow-up time, 16 months), six (17%) reported mild to moderate recurrence of symptoms. Of the patients, 78% were able to fully return to their previous competitive levels of sports. All patients were able to resume their athletic endeavor at a recreational level. Conclusions More than three-fourths of athletes limited by FPAES demonstrate full return to prior competitive levels with fasciotomy and surgical debulking of the anterolateral quadrant of the medial gastrocnemius muscle. Provocative CTA protocols can help to guide the location of muscle debulking to alleviate the functional entrapment that occurs in these athletes with exercise. This technique is a viable option in athletes with FPAES looking to return to competitive athletics.

Background In 2002, Oakes et al described a novel procedure designed to salvage the distal cephalic venous outflow of a Brescia-Cimino fistula by placing a prosthetic graft between the brachial artery in the antecubital space and the cephalic vein at the wrist. In this fashion, the more proximal veins were saved for future procedures. Their approach was reported and found to be successful in the short term, but the long-term durability of the Oakes procedure has not been described. This study aimed to determine the long-term primary, primary-assisted, and secondary patency rates of the brachial to distal cephalic vein Oakes procedure. Methods This is a retrospective review of a prospective database in a large, single institution. All patients who underwent the Oakes procedure from 1998 to 2012 were followed up to 2018. We reviewed the time to intervention, type of intervention, patency rates, and mortality of this patient population. Results Over the 5-year study period, 14 patients were identified who underwent the Oakes procedure, of whom seven (50%) were female. The average age was 55.7 years (range, 38-73 years). All patients had a previously placed Brescia-Cimino that was not suitable for dialysis but was patent. The average number of days to placement of an Oakes brachial to distal cephalic graft was 396 (range, 119-1167) days. A total of 71% (10) of patients underwent an intervention to maintain the graft, of whom 50% (5) underwent an angioplasty and 50% (5) had a thrombectomy/revision procedure. The average number of days to first intervention was 367.3 (range, 21-1048) days from Oakes placement. Of this cohort, 30% (3) of patients had a second intervention, of whom one (33%) underwent an angioplasty and two (66%) had revisions. One patient had a third and a fourth intervention at 39 days and 74 days, respectively, that were both angioplasties. The overall number of days the Oakes procedure remained usable from placement was 843.6 (range, 21-3790) days or 2.3 years. Conclusions This study concluded that the Oakes procedure may extend the use of the distal dialysis access site by 2.3 years without increasing infection and is hence a durable solution that should be considered in patients requiring dialysis access.

Objective Surgical frailty is strongly associated with increased perioperative morbidity and mortality. The Risk Analysis Index (RAI) is a validated frailty score system that has been shown to predict short-term outcomes and long-term mortality in various surgical subspecialties. This study applies the frailty score to the veteran aneurysm population undergoing non-emergent endovascular aortic aneurysm repair (EVAR). Methods After obtaining IRB approval, Veteran Affairs Surgical Quality Improvement Program (VASQIP) data was queried for endovascular repair of infrarenal abdominal aortic aneurysm or dissection CPT codes (34800, 34803, and 34805) from 2001 to 2018. Preoperative variables were used to calculate a RAI score. Patients were placed into six cohorts based on RAI score (≤20, 21-25, 26-30, 31-35, 35-40, and ≥41). Chi-squared test and ANOVA test were used compare cohorts. Forward logistic regression modeling was used to determine risks of each cohort. Results Between 2001 and 2018, 5,568 patients underwent EVAR. 99.6% of patients were male with a mean age of 71 ± 8 years. The cohorts contained 4.5%, 43.8%, 33.9%, 11.7%, 4.2%, and 1.8% for RAI scores ≤20, 21-25, 26-30, 31-35, 35-40, and ≥41 respectively. Frailty was associated with increased rates of overall complications, death, and increased length of stay. When risk adjusted, frailty at the highest vs lowest level was associated 2.7 times the odds of having any complication and 4.4 times the odds of having a mortality in 30 days. Conclusions Frailty as determined by RAI was associated with post-operative outcomes in a dose-dependent manner. Frailty was associated with higher rates of major cardiac (MI, cardiac arrest), pulmonary (pneumonia, failure to wean vent, reintubation), renal (renal failure), overall complications, length of stay, and death. We recommend the use of this frailty index as a screening tool to guide discussions with patients undergoing endovascular aortic aneurysm repair.