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Airway management practices in the intensive care unit (ICU) are still evolving, evidenced by an increasing proliferation of guidelines and algorithms in recent years. Specific considerations relate to the out-of-theatre environment and the physiological state in this patient population. Airway management in ICU is ultimately a multifaceted process spanning team training, simulation, preassessment, preparation, positioning of the patient, equipment decisions, guidelines/algorithm adherence and most recently the consideration of the coronavirus disease (COVID-19) pandemic. The use of video laryngoscopy has increased, as have the practices of apnoeic oxygenation and the use of checklists. Emergency front-of-neck access (FONA) should be taught to all staff and standardized equipment made available. This article highlights the factors a multidisciplinary team must navigate when approaching airway management in the ICU. [ABSTRACT FROM AUTHOR]

• Significant heterogeneity exists in the frailty index used and health care associated infections (HAI) definitions. • Frail surgical patients appear to have an increased risk of developing HAIs. • Further research in health care settings, with a uniform frailty index is required. Health care associated infections (HAIs) are a major health concern associated with significant morbidity and mortality. The relationship between frailty, a syndrome often associated with older individuals, and HAIs has not been investigated. To determine if frailty scoring systems can assist in predicting the risk of developing HAIs in health care settings. A directed search was conducted across 4 databases (MEDLINE, Cochrane, Scopus, and CINAHL) for articles published between 1 January 1990 and 31 December 2019. All articles were screened for relevance to the research aims. The Newcastle-Ottawa Scale was utilised to assess the study quality and risk of bias. The literature search yielded 290 results, with 14 articles meeting the inclusion criteria. Significant heterogeneity was present across the studies with regards to the frailty index employed and HAI definitions. Most studies were conducted in an acute health care setting (n = 12), while 2 studies were conducted in nursing homes. Eight studies demonstrated that frail individuals were at an increased risk of developing HAIs, in both surgical (n = 5) and medical patient populations (n = 2). Two of the 3 validated frailty scoring systems employed across the studies, the Clinical Frailty Scale and the Frailty Index demonstrated this relationship. The results of this review demonstrate a potential association between frailty and the development of HAIs. [ABSTRACT FROM AUTHOR]

Despite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention. Institutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications. There were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P =.01) and hypertension (P =.01). Protective factors were thoracoabdominal approach (P <.01) and aortounifemoral bypass (P <.01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P =.018), anticoagulation (2.59; CI, 1.01-8.37; P =.049), and previous iliac stents (2.60; CI, 1.36-4.94; P =.004). Whereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes. [ABSTRACT FROM AUTHOR]

Graphical abstract This paper describes a new solvothermal strategy for controlling the size and crystal phase of iron oxide nanocrystals. Decreasing the chain length of aliphatic carboxylate precursors produces smaller nanocrystals and tuning the concentration of water in the solvent enables controlled formation of the hematite or maghemite phases of iron(III) oxide. Abstract This paper describes a new method for controlling nanocrystal size and crystal phase in solvothermal syntheses of iron oxide nanocrystals by altering the carbon chain length of aliphatic iron(III) carboxylate precursors and reaction solvent composition, respectively. Hematite (α-Fe 2 O 3) nanocrystals were synthesized from iron(III) carboxylate precursors in a 2:1 water:ethanol mixture in the presence of free aliphatic carboxylic acids or aliphatic primary amine ligands. In the presence of amine, increasing the length of the carbon chain of the iron(III) carboxylate precursor from two to eighteen carbons produced pseudocubic nanocrystals with size dispersities of ∼10% and diameters that decreased from 65 nm to 25 nm. Changing the chain length of the amine does not affect the size of the nanocrystals. In contrast, free carboxylic acid ligands produce polydisperse, polycrystalline hematite nanoparticles. The crystal structure of the iron oxide nanocrystals synthesized by this method depends on the mole-fraction of water (x water) in the water/ethanol solvent mixture: x water = 0 produces maghemite (γ-Fe 2 O 3), x water = 0.67 produces hematite, and x water = 1 produces a mixture of goethite (α-FeOOH) and hematite. The dependence of the nanocrystal size on ligand chain length is attributed to decreasing solubility of partially hydrolyzed iron(III) carboxylate precursors in the reaction solvent mixture with increasing chain length. The dependence of nanocrystal phase on solvent composition is attributed to the different reactivities of water and ethanol toward hydrolysis of the iron(III) carboxylate precursors. [ABSTRACT FROM AUTHOR]

Objective Concomitant carotid bifurcation and proximal ipsilateral arch branch disease is uncommon. A combined approach using carotid endarterectomy (CEA) with ipsilateral proximal endovascular (IPE) intervention (CEA+IPE) has been proposed as safe and durable, with similar results to isolated CEA. This study was conducted to identify diagnostic modalities and outcomes of this uncommon procedure at our institution. Methods Operative records were used to identify patients who underwent CEA+IPE between May 2003 and July 2014. Patients were excluded if they underwent open retrograde access for endovascular intervention only, without CEA. The primary end points were freedom from neurologic event and need for reintervention. Results Twenty-three patients (15 women [65%]) underwent CEA+IPE. Mean clinical follow-up was 44 ± 35 months. Average age was 69 ± 9 years. Most patients (22 [96%]) were taking a statin and at least one antiplatelet agent. Bilateral internal carotid stenosis (>50%) was present in 12 patients (52%), and eight (35%) were symptomatic. Seven patients (30%) had prior ipsilateral CEA. All patients underwent preoperative carotid duplex and axial imaging. Computed tomography angiography was the initial imaging assessment in 10 patients (43%). The proximal lesion was identified in 19 (83%) by blunted waveforms on carotid duplex. Most bifurcation operations were CEA with patch (20 [87%]), and 21 (91%) underwent the bifurcation procedure first, followed by IPE. All IPE included balloon-expandable stenting (22 of 23 [96%] bare-metal, 7 [30%] innominate artery, 16 [70%] left common carotid artery). Electroencephalographic changes occurred in two patients (9%). Shunting was used in three (13%). Three vessel dissections (13%) occurred at the IPE site; two required further stenting and one was complicated by stroke and death. There were two perioperative strokes (9%) and one death (4%). Mean imaging follow-up was 30.6. ± 27.2 months, with restenosis identified in five patients (23%; four bifurcation, one IPE in-stent). One patient required open reintervention with subclavian-carotid bypass at 13 months for recurrent transient ischemic attack. The 4-year actuarial survival was 85%. Stroke-free survival and freedom from reintervention were 80% and 90% at 36 months, respectively. Conclusions The stroke and death rate for CEA+IPE is higher than that of isolated CEA at our institution. Duplex findings can suggest proximal stenosis; however, confirmation with physical examination in conjunction with axial imaging are integral. This combined treatment strategy should be reserved for those with evident hemodynamically significant proximal stenosis and approached with caution in asymptomatic patients. [ABSTRACT FROM AUTHOR]

Background: It has been suggested that the risk of oesophageal adenocarcinoma might be increased in patients with a history of eating disorders due to acidic damage to oesophageal mucosa caused by selfinduced vomiting practiced as a method of weight control. Eating disorders have also been associated with risk factors for squamous cell carcinoma of the oesophagus, including alcohol use disorders, as well as smoking and nutritional deficiencies, which have been associated with both main sub-types of oesophageal cancer. There have been several case reports of oesophageal cancer (both main sub-types) arising in patients with a history of eating disorders. Methods: We used linked records of hospitalisation, cancer registration and mortality in Scotland spanning 1981-2012 to investigate the risk of oesophageal cancer among patients with a prior history of hospitalisation with eating disorder. The cohort was restricted to patients aged 10 years and <60 years at the date of first admission with eating disorder. Disregarding the first year of follow-up, we calculated indirectly standardised incidence ratios using the general population as the reference group to generate expected numbers of cases (based on age-, sex-, socio-economic deprivation category-, and calendar period-specific rates of disease). Results: After exclusions, the cohort consisted of 3617 individuals contributing 52,455 person-years at risk. The median duration of follow-up was 13.9 years. Seven oesophageal cancers were identified, as compared with 1.14 expected, yielding a standardised incidence ratio of 6.1 (95% confidence interval: 2.5-12.6). All were squamous cell carcinomas arising in females with a prior history of anorexia nervosa. Conclusions: Patients hospitalised previously with eating disorders are at increased risk of developing oesophageal cancer. Confounding by established risk factors (alcohol, smoking, and nutritional deficiency) seems a more likely explanation than acidic damage through self-induced vomiting because none of the incident cases of oesophageal cancer were adenocarcinomas, and because the study cohort had higher than background rates of hospitalisation with alcohol-related conditions and chronic obstructive pulmonary disease. [ABSTRACT FROM AUTHOR]

Background: Cancers of unknown primary site (CUP) pose problems for diagnosis, treatment, and accurate prediction of prognosis. However, there are limited published data describing the epidemiology of this disease entity. Our aim was to describe the epidemiology of CUP in Scotland. Methods: Anonymised data, covering the period 1961-2010, were extracted from the Scottish Cancer Registry database, based on the following ICD-10 diagnostic codes: C26.0, C26.8, C26.9, C39, and C76- C80. Age-standardised incidence rates were calculated by direct standardisation to the World Standard Population. Estimates of observed survival were calculated by the Kaplan-Meier method. Results: Between 1961 and 2010, there were 50,941 registrations of CUP, representing 3.9% of all registrations of invasive cancers. Age-standardised rates increased to a peak in the early to mid-1990s, followed by a steeper decrease in rates. During 2001-2010, age-standardised rates of CUP were higher in the most compared with the least deprived fifth of the population. Observed survival was marginally higher in patients diagnosed during 2001-2010 (median 5.6 weeks) compared with those diagnosed in the previous two decades. During the most recent decade, survival decreased with age at diagnosis, and was higher in patients with squamous cell carcinoma and with lymph node metastases. Conclusion: Patterns of CUP in Scotland are largely consistent with those reported from the few other countries that have published data. However, in comparing studies, it is important to note that there is heterogeneity in terms of definition of CUP, as well as calendar period of diagnosis or death. Variation in the definition of CUP between different epidemiological studies suggests that there would be merit in seeking international agreement on guidelines for the registration of CUP as well as a standard grouping of diagnostic codes for analysis. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To assess the risk of death in patients who survive at least 5years after diagnosis of childhood, adolescent or young adult cancer. Patients and Methods: This was a population-based retrospective cohort study using linked national cancer registry and mortality records in Scotland. The study population consisted of 5229 individuals who were diagnosed with cancer before the age of 25years between 1981 and 2003, and who survived at least 5years after the date of diagnosis of their primary cancer. Indirect standardisation was used to calculate mortality ratios standardised for age and sex and absolute excess risks (AERs) compared to the general Scottish population. Results: During 58,358 person-years of follow-up, there were 359 deaths among the cohort of cancer survivors. The overall SMR was 6.1 (95% confidence interval (CI) 5.5–6.7) and AER 51 (45–58) per 10,000 person-years. Largely because of age- and sex-related differences in background mortality, SMRs were higher in patients diagnosed at 0–14years (SMR 11.0, 95% CI 9.3–12.9) than 15–24years (4.7, 4.1–5.3), and in females (9.2, 7.8–10.8) than males (4.8, 4.2–5.5). SMRs and AERs varied substantially by primary cancer and by underlying cause of death. In general, SMRs were little altered by standardisation for an area-based indicator of socio-economic deprivation. Adjusted for age and sex, the risk of death was significantly lower in five-year survivors diagnosed during 1998–2003 compared to those diagnosed during 1981–1985 (Relative hazard ratio, 0.54, 95% CI 0.36–0.81). Conclusion: Long-term survivors of cancer in childhood and young adulthood remain at higher risk of mortality than the general population, although the absolute risk of death is low and the excess risk has decreased over time. [Copyright &y& Elsevier]

Objective: As branched/fenestrated endografts expand endovascular options for juxtarenal abdominal aortic aneurysms (JAAAs), long-term durability will be compared to that of open JAAA repair, which has not been documented in large contemporary series. The goal of this study was to assess the late clinical and anatomic outcomes after open JAAA repair. Methods: From July 2001 to December 2007, 199 patients underwent open elective JAAA repair, as defined by a need for suprarenal clamping. End points included perioperative and late survival, long-term follow-up of renal function, and freedom from graft-related complications. Factors predictive of survival were determined by multivariate analysis. Results: The mean patient age was 74 years, 71% were men, and 20% had baseline renal insufficiency (Cr >1.5). Thirty-seven renal artery bypasses, for anatomic necessity or ostial stenosis, were performed in 36 patients. Overall 30-day mortality was 2.5%. Four patients (2.0%) required early dialysis; one patient recovered by discharge. Two additional patients progressed to dialysis over long-term follow-up. There was one graft infection involving one limb of a bifurcated graft. Surveillance imaging was obtained in 101 patients (72% of survivors) at a mean follow-up of 41 ± 28 months. Renal artery occlusion occurred in four patients (3% of imaged renal arteries; one native/three grafts). Two patients (2.0%) had aneurysmal degeneration of the aorta either proximal or distal to the repaired segment, but there were no anastomotic pseudoaneurysms. Remote aneurysms were found in 29 patients (29% of imaged patients), 14 of whom had descending thoracic aneurysm or TAAA. Four patients underwent subsequent thoracic endovascular aneurysm repair (TEVAR). Actuarial survival was 74 ± 3.3% at 5 years. Negative predictors of survival included increasing age at the time of operation (relative risk [RR], 1.05; P = .01), steroid use (RR, 2.20; P = .001), and elevated preoperative creatinine (RR, 1.73; P = .02). Conclusions: Open JAAA repair yields excellent long-term anatomic durability and preserves renal function. Perioperative renal insufficiency occurs in 8.5% of patients, but few of them progress to dialysis. Graft-related complications are rare (2% at 40 months); however, axial imaging revealed descending thoracic aneurysms in 14% of imaged patients, making continued surveillance for remote aneurysms prudent. These data provide a benchmark against which fenestrated/branched endovascular aneurysm repair (EVAR) outcomes can be compared. [Copyright &y& Elsevier]

Background: A consequence of endovascular aneurysm repair (EVAR) of anatomically straightforward infrarenal abdominal aortic aneurysm repair cohort (AAA) is that open aneurysm repair is more commonly performed for complex anatomy. Complex aneurysm repair with visceral vessel involvement (CAA) or combined aneurysm repair and visceral vessel reconstruction (VVR) has traditionally been considered to increase morbidity and mortality compared with repair of infrarenal AAA. This study evaluated contemporary outcomes of open abdominal aneurysm surgery, including AAA, CAA, and VVR using the National Surgical Quality Improvement Program (NSQIP) database. Methods: The NSQIP Participant Use File was queried by CPT code to identify patients undergoing AAA, CAA, and VVR (2005-2008). Comparative analysis of clinical features, technical details and 30-day outcomes was performed using univariate methods. Logistic regression analysis was used to identify predictors of morbidity and mortality. Results: A total of 2820 patients underwent AAA and 592 CAA. Renal insufficiency (ie, creatinine >1.4 mg/dL) rates were similar in AAA and CAA patients, however, more frequent in patients with VVR (51% vs 31% [no bypass]; P < .01). CAA was less likely to be performed urgently (6.3% vs 9.1%; P < .05) and was associated with increased operative time (254 ± 100 vs 224 ± 93; P < .01) compared with AAA. Univariate analysis showed that CAA did not increase mortality (5.7% vs 5.1%; P = .5). CAA slightly increased overall complications (32% vs 27%; P = .01) compared with AAA. 73 (2.5%) AAA and 84 (12%) CAA patients had simultaneous VVR and these patients exhibited a trend toward increased mortality (8.9% vs 5.2%; P = .07). VVR increased complications (43% (VVR) vs 26% [no bypass]; P < .01), including ventilation >48 hours (21% [VVR] vs 12% [no bypass]; P < .01), renal failure (7.6% [VVR] vs 4.1% [no bypass]; P = .04), and sepsis (13% [VVR] vs 6.3% ([no bypass]; P < .01). Multivariate analysis demonstrated that CAA (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.6]; P = .01) and VVR (OR, 2.2 [95% CI, 1.8-3.6]; P < .01) increased the odds of any complication. Independent predictors of mortality included dependent functional status (OR, 3.6 [95% CI, 2.3-5.4]; P < .01), elevated pre-op creatinine (OR, 2.9 [95% CI, 2.2-4.0]; P < .01), type II diabetes (OR, 1.6 [95% CI, 1.05-2.4]; P = .03), and age (OR, 1.06 [95% CI, 1.03-1.08]; P < .01). Neither CAA (OR, 1.2 [95% CI, 0.84-1.8]; P = .3) nor VVR (OR, 1.6 [95% CI, 0.89-2.9]; P = .11) were associated with increased mortality compared with AAA. Conclusion: In contemporary practice the migration of open repair to increasingly complex cases has been achieved with 30-day mortality essentially equivalent to open repair of infrarenal AAA. Patients who require VVR do sustain increased complications, in particular renal failure. These data also emphasize the importance of baseline renal insufficiency in clinical decision making. CAA and VVR are associated with increased morbidity in comparison to AAA repair; however, both procedures can be safely performed in patients without increased risk of operative mortality. [Copyright &y& Elsevier]

Objectives: Type IV thoracoabdominal aortic aneurysm (TAAA) repair, despite low risk of spinal cord ischemia (SCI), is reported to have significant morbidity and mortality. This has led some to apply adjuncts (eg, extracorporeal circulation) used in more extensive TAAA repair or to consider alternative approaches, such as hybrid operations. We have used a consistent, simplified surgical approach to type IV TAAA, and the goal of the present study is to review experience over 2 decades with such treatment and to identify correlates of surgical morbidity. Methods: All type IV repairs at Massachusetts General Hospital from January 1989 through September 2009 were evaluated for clinical features, technical operative details, and 30-day outcomes. Logistic regression identified predictors of morbidity. Survival was assessed using Kaplan-Meier analysis. Results: A total of 179 patients underwent type IV repair, with elective repair in 156 (87%) and urgent in 23 (13%). The clamp-and-sew technique was used for all operations, with routine hypothermic renal perfusion. Clinical features were age 73 ± 8 years, coronary artery disease in 89 (50%), and creatinine level >1.8 mg/dL defining chronic renal insufficiency (CRI) in 32 (18%). Operative reconstruction in 166 (93%) consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins (mean visceral clamp time, 36 ± 12 minutes) and a side-arm graft to the left renal artery. Technical details included previous abdominal aortic aneurysm (AAA) repair in 52 (29%), operative time of 290 ± 90 min, estimated blood loss of 2.7 ± 1.4 L, and splenectomy in 57 (32%). The 30-day outcomes were death in 5 (2.8%), myocardial infarction in 6 (3.4%), hemodialysis in 5 (2.8%), and any degree of SCI in 4 (2.2%). Regression analysis identified a history of CRI as an independent predictor of postoperative complication or death (odds ratio, 3.4; 95% confidence interval, 1.4-8). Survival rates at 1, 5, and 10 years were 89% ± 2%, 62% ± 4%, and 36% ± 5%, respectively. Conclusions: A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. These data refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. CRI should figure prominently in clinical decision making. Long-term survival equates that observed after routine AAA repair. [Copyright &y& Elsevier]

Objective: Persistent type 2 endoleaks (PT2, present ≥6 months) after endovascular aneurysm repair (EVAR) are associated with adverse outcomes. This study evaluated the preoperative risk factors and natural history of PT2 in order to define a population at high risk. Methods: From January 1999 to December 2007, 595 of 832 EVAR patients had long-term computed tomography follow-up and comprised the study cohort. Preoperative anatomic and clinical variables were correlated with PT2 using Cox regression. Composite hazard ratios (HRs) were constructed with clusters of high-risk preoperative variables. Primary end points, including spontaneous resolution, sac enlargement >5 mm, and freedom from reintervention, were evaluated using Kaplan-Meier analysis. Results: There were 136 PT2 patients (23%) with a median follow-up of 34.8 months (range, 6.4-121.2 months). Positive predictive factors included patent inferior mesenteric artery (IMA; HR, 4.00; 95% confidence interval [CI], 1.62-9.90; P = .003), increasing number of patent lumbar arteries (HR, 1.24; 95% CI, 1.10-1.41; P = .0006), increasing age (HR, 1.04; 95% CI, 1.01-1.06; P = .005), and increasing luminal diameter on CT-contrast opacified lumen (HR, 1.03; 95% CI, 1.02-1.05; P = .0001). During follow-up, spontaneous PT2 resolution occurred in 34 patients (25%), sac diameter remained stable in 63 (46%), and rupture occurred in 2 (1.5%). Kaplan-Meier analysis estimated that 35.2% ± 5.6% (95% CI, 23.8%-46.2%) of PT2 resolve spontaneously at 5 years after the index procedure. Freedom from sac enlargement >5 mm was 54.6% ± 7.2% (95% CI, 40.6%-69.4%) at 5 years. Fifty-nine reinterventions were performed in 39 patients with PT2. Freedom from reintervention was 67.3% ± 5.0% (95% CI, 57.0%-77.0%) at 5 years. The combination of a patent IMA and one risk factor of more than six patent lumbar arteries, maximum luminal diameter >30 mm, or age >70 years increased the odds of PT2 approximately ninefold. The combination of a patent IMA and any two risk factors increased the odds of PT2 approximately 18-fold. Conclusions: Several readily identifiable preoperative variables are associated with PT2 whose natural history was benign in but 35% of patients. On the basis of the composite high-risk HRs, there is accordingly a cohort of patients in whom perioperative interventions to preclude PT2 should be considered. [Copyright &y& Elsevier]

Objective: The role of thoracic endovascular aortic repair (TEVAR) in the management of acute type B aortic dissection remains undefined. Entry tear coverage during the acute phase is an appealing method to treat acute complications, and by inducing false lumen thrombosis, might also prevent late aneurysm formation. This study evaluated structural changes by serial computed tomography (CT) in the thoracic aorta after TEVAR performed for acute complicated aortic dissection. Methods: Between August 2005 and October 2007, 33 patients with complicated acute type B aortic dissection were treated with TEVAR (19 from a prospective industry sponsored trial, 14 from our institution). CT images obtained preprocedurally (PP), at 1 month (1M), and 1 year (1Y) were evaluated for each patient. Four patients with no postprocedural imaging were excluded. The largest diameters of the thoracic aorta, dissection true lumen, and false lumen were recorded at each time point. Canges in total aortic and true and false lumen diameters were evaluated using a mixed effect analysis of variance model of repeated measures. Results: The average age was 58 years (range, 38-87 years); 26 (81%) were male. Indications for TEVAR included malperfusion syndrome in 17 (53%), refractory hypertension in 14 (44%), impending rupture in 12 (28%), and refractory pain in 14 (44%); 19 (59%) had more than one indication. The average length of aorta covered was 19.5 cm (range, 10-29.3 cm). The maximum aortic diameter decreased over time (P = .04) and averaged 39.9 (PP), 41.3 (1M), and 34.8 mm (1Y). The true lumen diameter increased over time (P = .02) and averaged 23.7 (PP), 29.0 (1M), and 31.1 mm (1Y). The false lumen diameter decreased (P = .046) and averaged 19.5 (PP), 12.1 (1M), and 9.6 mm (1Y). Partial or complete thrombosis of the false lumen along the stented segment of aorta was recorded in 87% (PP), 93% (1M), and 88% (1Y). Conclusions: TEVAR of acute complicated aortic dissection appears to promote early aortic remodeling. Nearly 90% of patients maintained at least partial false lumen thrombosis at 1 year. Because continued false lumen patency correlates strongly with late aneurysm formation, such favorable remodeling is considered a surrogate for prevention of late aneurysm, but longer follow-up is required. [Copyright &y& Elsevier]

Abstract: In the management of pediatric trauma, certain principles that are practiced in children who have sustained injuries more commonly seen in adults are extrapolated from the adult trauma literature. The increased use of computer tomography angiograms in the diagnosis of penetrating vascular trauma and endovascular therapy in treating vascular trauma in the adult population is being extended to the pediatric population. We present a case of a 14-year-old male with an axillary artery injury that was diagnosed by computer tomography angiogram and treated with an endovascular Stent graft with 1-year follow-up. [Copyright &y& Elsevier]

Objective: We performed a device-specific comparison of long-term outcomes following endovascular abdominal aortic aneurysm repair (EVAR) to determine the effect(s) of device type on early and late clinical outcomes. In addition, the impact of performing EVAR both within and outside of specific instructions for use (IFU) for each device was examined. Methods: Between January 8, 1999 and December 31, 2005, 565 patients underwent EVAR utilizing one of three commercially available stent graft devices. Study outcomes included perioperative (≤30 days) mortality, intraoperative technical complications and need for adjunctive procedures, aneurysm rupture, aneurysm-related mortality, conversion to open repair, reintervention, development and/or resolution of endoleak, device related adverse events (migration, thrombosis, or kinking), and a combined endpoint of any graft-related adverse event (GRAE). Study outcomes were correlated by aneurysm morphology that was within or outside of the recommended device IFU. χ2 and Kaplan Meier methods were used for analysis. Results: Grafts implanted included 177 Cook Zenith (CZ, 31%), 111 Gore Excluder (GE, 20%), and 277 Medtronic AneuRx (MA, 49%); 39.3% of grafts were placed outside of at least one IFU parameter. Mean follow-up was 30 ± 21 months and was shorter for CZ (20 months CZ vs 35 and 31 months for GE and MA, respectively; P < .001). Overall actuarial 5-year freedom from aneurysm-related death, reintervention, and GRAE was similar among devices. CZ had a lower number of graft migration events (0 CZ vs 1 GE and 9 MA); however, there was no difference between devices on actuarial analysis. Combined GRAE was lowest for CZ (29% CZ, 35% GE, and 43% MA; P = .01). Graft placement outside of IFU was associated with similar 5-year freedom from aneurysm-related death, migration, and reintervention (P > .05), but a lower freedom from GRAE (74% outside IFU vs 86% within IFU; P = .021), likely related to a higher incidence of graft thrombosis (2.3% outside IFU vs 0.3% within IFU; P = .026). The differences in outcome for grafts placed within vs outside IFU were not device-specific. Conclusion: EVAR performed with three commercially available devices provided similar clinically relevant outcomes at 5 years, although no graft migration occurred with a suprarenal fixation device. As anticipated, application outside of anatomically specific IFU variables had an incremental negative effect on late results, indicating that adherence to such IFU guidelines is appropriate clinical practice. [Copyright &y& Elsevier]

Abstract: To investigate the laterality of cutaneous melanoma (ICD-10 C43), we obtained data spanning the period of diagnosis 1998–2003 from six population-based cancer registries: New South Wales, Australia; England; Finland; The Netherlands; Scotland; and the Surveillance Epidemiology and End Results (SEER) Program of the United States of America (restricted to ‘White’ race category only). For cases with laterality recorded, the overall ratios of left- to right-sided tumours were calculated. We found that left to right ratios were consistently greater than 1.00, ranging from 1.08 (New South Wales, Australia and US SEER ‘White’) to 1.18 (Scotland), with an overall ratio for all registries combined of 1.10 (95% confidence interval 1.08–1.11). There were no statistically significant differences by sex or age group for all sub-sites combined, or for upper limb or lower limb melanomas. The excess of left-sided tumours seems unlikely to be explained by chance or recording bias. The most likely explanations would appear to be either differences in sun exposure and/or asymmetry of melanocyte distribution or characteristics arising at the time of embryological development. [Copyright &y& Elsevier]

Objective: In multiple comparisons of open vs endovascular (EVAR) repair of abdominal aortic aneurysms, the prior assumption that open repair produced superior durability has been challenged by advocates of EVAR. Although focus on EVAR reintervention has been intense, few contemporary studies document late outcomes after open repair; this was the goal of this study. Methods: From January 1994 to December 1998 (chosen to ensure a minimum 5-year follow-up), 540 patients underwent elective open repair. Surveillance imaging (computed tomographic and magnetic resonance imaging scans) was obtained for 152 (57%) of the 269 patients who remained alive at a mean follow-up of 87 months. Study end points included freedom from graft-related interventions and aneurysm-related and overall survival (Kaplan-Meier test); factors predictive of these end points were determined by multivariate analysis. Results: The mean age at operation was 73 years. A total of 76% of patients were male; 11% had renal insufficiency (creatinine ≥1.5 mg/dL), and 13% had chronic obstructive pulmonary disease. The aortic cross-clamp position was suprarenal in 135 (25%) patients, and 284 (53%) of patients had bifurcated grafts placed. Operative mortality (30 days) was 3%, and the median length of hospital stay was 7 days. Postoperative complications occurred in 68 (13%) patients. Predictors of postoperative complications included a history of myocardial infarction (hazard ratio [HR], 2.0; P = .01) and renal insufficiency (HR, 2.5; P = .02). The mean follow-up for all patients was 87 months. Actuarial survival was 70.7% ± 2% and 44.3% ± 2.4% at 5 and 10 years, respectively. Negative predictors of long-term survival included advanced age (HR, 1.1; P < .001), history of myocardial infarction (HR, 1.37; P = .02), and renal insufficiency (HR, 1.5; P = .04). Freedom from graft-related reintervention was 98.2% ± 0.8% and 94.3% ± 3.4% at 5 and 10 years, respectively. There were 13 late graft-related complications in 11 (2%) patients (mean follow-up, 7.2 years). Findings included seven anastomotic pseudoaneurysms (five were repaired), four graft limb occlusions, and two graft infections. Aneurysms were identified in noncontiguous arterial segments in 68 (45%) of 152 patients, most of which involved the iliac arteries and required no treatment because of small size. Late aortic aneurysms proximal to the repair were identified in 24% of patients, and 29 (19%) patients had multiple late synchronous aneurysms. Conclusions: Open repair remains a safe and durable option for the management of abdominal aortic aneurysms, with an excellent associated 10-year survival in patients who undergo operation at 75 years of age or younger. In addition, the freedom from graft-related reintervention is superior to that of EVAR. Finally, continued surveillance after open repair is appropriate and should be directed toward the detection of other aneurysms. [Copyright &y& Elsevier]

Objective: Type 2 endoleak occurs in up to 20% of patients after endovascular aneurysm repair (EVAR), but its long-term significance is debated. We reviewed our experience to evaluate late outcomes associated with type 2 endoleak. Methods: During the interval January 1994 to December 2005, 873 patients underwent EVAR. Computed tomography (CT) scan assessment was performed ≤1 month of the operation and at least annually thereafter. Sequential 6-month CT scan follow-up was adopted for those patients with persistent type 2 endoleaks, and reintervention was limited to those with sac enlargement >5 mm. Study end points included overall survival, aneurysm sac growth, reintervention rate, conversion to open repair, and abdominal aortic aneurysm (AAA) rupture. Preoperative variables and anatomic factors potentially associated with these endpoints were assessed using multivariate analysis. Results: We identified 164 (18.9%) patients with early (at the first follow-up CT scan) type 2 endoleaks. Mean follow-up was 32.6 months. In 131 (79.9%) early type 2 endoleaks, complete and permanent leak resolution occurred ≤6 months. Endoleaks persisted in 33 patients (3.8% of total patients; 20.1% of early type 2 endoleaks) for >6 months. Transient type 2 endoleak (those that resolved ≤6 months of EVAR) was not associated with adverse late outcomes. In contrast, persistent endoleak was associated with several adverse outcomes. AAA-related death was not significantly different between patients with and without a type 2 endoleak (P = .78). When evaluating patients with no early endoleak vs persistent endoleak, freedom from sac expansion at 1, 3, and 5 years was 99.2%, 97.6%, and 94.9% (no leak) vs 88.1%, 48.0%, and 28.0% (persistent) (P < .001). Patients with persistent endoleak were at increased risk for aneurysm sac growth vs patients without endoleak (odds ratio [OR], 25.9; 95% confidence interval [CI] 11.8 to 57.4; P < .001). Patients with a persistent endoleak also had a significantly increased rate of reintervention (OR, 19.0; 95% CI, 8.0 to 44.7); P < .001). Finally, aneurysm rupture occurred in 4 patients with type 2 endoleaks. Freedom from rupture at 1, 3, and 5 years for patients with a persistent type 2 endoleak was 96.8%, 96.8%, and 91.1% vs 99.8%, 98.5%, and 97.4% for patients without a type 2 endoleak. Multivariate analysis demonstrated persistent type 2 endoleak to be a significant predictor of aneurysm rupture (P = .03). Conclusions: Persistent type 2 endoleak is associated with an increased incidence of adverse outcomes, including aneurysm sac growth, the need for conversion to open repair, reintervention rate, and rupture. These data suggest that patients with persistent type 2 endoleak (>6 months) should be considered for more frequent follow-up or a more aggressive approach to reintervention. [Copyright &y& Elsevier]

Introduction: Endovascular therapy (percutaneous transluminal angioplasty [PTA] with stenting) has been increasingly applied in patients with chronic mesenteric ischemia (CMI) to avoid morbidities associated with open repair (OR). The purpose of this study was to compare outcomes of PTA/Stent vs OR in patients with symptomatic CMI. Methods: During the interval of January 1991 to December 2005, 80 consecutive patients presenting with symptomatic CMI underwent elective revascularization. Patients with acute mesenteric ischemia or those with mesenteric revascularization performed as part of complex aneurysm repair were excluded. PTA/Stent (with stenting in 87%) was the initial procedure in 31 patients (42 vessels). OR was performed in 49 patients (88 vessels) and consisted of bypass grafting in 31 (63%), transaortic endarterectomy in 7 (14%), patch angioplasty in 4 (8%), or combined in 7 (15%). Mean follow-up was 15 months in the PTA/Stent group and 42 months in the OR cohort. Study end points included perioperative morbidity, mortality, late survival (Kaplan-Meier), and symptomatic and radiographic recurrence. Results: Baseline comorbidities, with the exception of heart disease (P = .025) and serum albumin <3.5 g/dL (P = .025), were similar between PTA/Stent and OR patients. The PTA/Stent group had fewer vessels revascularized (1.5 vs 1.8 vessels, P = .001). Hospital length of stay was less for the PTA/Stent group (5.6 vs 16.7 days, P = .001). No difference was noted in in-hospital major morbidity (4/31 vs 2/49, P = .23) or mortality (1/31 vs 1/49, P = .74). Actuarial survival at 2 years was similar between the groups (88% PTA/Stent vs 74% OR, P = .28). There was no difference in the incidence of symptomatic (7/31 [23%] vs 11/49 [22%], P =.98) or radiographic recurrence (10/31 [32%] vs 18/49 [37%], P =.40) between the two groups. Radiographic primary patency (58% vs 90%, P = .001) and primary assisted patency (65% vs 96%, P < .001) at 1 year were lower in the PTA/Stent group compared with OR. Five (16%) of 31 PTA/Stent patients compared with 11 (22%) of 49 OR patients required a second intervention on at least one index vessel at any time (P = .49). Conclusions: Symptomatic recurrence requiring reintervention is common (overall 16/80 [20%]) after open and endovascular treatment for CMI. PTA/Stent was associated with decreased primary patency, primary assisted patency, and the need for earlier reintervention. In-hospital mortality or major morbidity were similar in patients undergoing PTA/Stent and OR. These findings suggest that OR and PTA/Stent should be applied selectively in CMI patients in accordance with individual patient anatomic and comorbidity considerations. [Copyright &y& Elsevier]

Objective: Compare long-term results of endovascular treatment and standard open repair of abdominal aortic aneurysms in a multicenter, concurrent-controlled trial. Methods: 334 subjects were treated with standard open repair (control, n = 99) or the original EXCLUDER Bifurcated Endoprosthesis (test, n = 235). Five-year clinical evaluations and corelab radiographic results are analyzed. Results: Overall and aneurysm-related survival are similar. There have been ten open conversions, most frequently for enlarging sacs without endoleak. Two patients died after conversion. Including reinterventions and complications of reinterventions as adverse events, there is significant, persistent long-term reduction in major adverse events. At 5 years, corelab reported 0% limb narrowing, 0% trunk migration, 0% component (contralateral leg, aortic extender, and iliac extender) migration, 0% fracture, endoleak in 3% (2 type II/68), and aneurysm growth (>5 mm compared to baseline) in 38% (30/78) of the test group. There are no aneurysm ruptures in either test or control group. Conclusions: After 5 years follow-up, endovascular repair is a safer and effective treatment compared with open surgical repair for abdominal aortic aneurysms. Major adverse events are less frequent with the endograft despite the need for late reinterventions. Aneurysm expansion is observed in nearly two-fifths of patients but is not associated with endoleak or aneurysm rupture. Multicenter clinical trials are evaluating a newer version of this device designed to avoid this high rate of sac expansion. [Copyright &y& Elsevier]

Objective: Pivotal and comparative trial data are emerging for stent graft (SG) vs open repair of the thoracic aorta. We reviewed procedure-related perioperative morbidity, mortality, and mid-term outcomes in a contemporary series of patients treated with SG of the thoracic aorta. The data were compared with those of a patient cohort concurrently treated with open surgical repair confined to the descending aorta. Methods: A review of patients undergoing SG procedures and open surgery of the thoracic aorta from January 1, 1996, to November 30, 2005, was performed from a prospectively compiled database. Study end points included perioperative complications, late survival, freedom from reinterventions, and graft-related complications. Multivariate methods were used to assess variables potentially associated with study end points; late outcomes were compared with actuarial methods. Results: In 105 patients (mean age, 70 years; 66 male [62.9%]) SG repairs were done for 68 degenerative aneurysms (64.7%), 12 penetrating ulcers (11.4%), 15 pseudoaneurysms (14.3%), 9 traumatic tears (8.6%), and 1 acute dissection (0.9%). Mean follow-up was 22 months (range, 0 to 101 months). Eighty-nine (84.8%) SG patients were asymptomatic at presentation and underwent elective repair, whereas 16 (15.2%) presented with acute conditions and underwent urgent repair. Perioperative mortality was 7.6% (8/105), and actuarial survival at 48 months was 54% ± 7%. The perioperative mortality rate among SG patients treated for degenerative pathology was 10.4% (8/77). Seven (6.7%) of 105 patients experienced spinal cord ischemic complications, including 2 patients with transient paraparesis that resolved by the time of discharge. Reinterventions were performed in 10.5% of patients (11/105), with freedom from reintervention approaching 81% by 48 months. Over the same interval, 93 patients were treated with open-surgical repair for descending thoracic aneurysm (anastomosis cephalad to the celiac axis). Perioperative mortality in the open cohort was 15.1% (14/93; P = .09 vs SG repair), and the 48-month actuarial survival was 64% ± 6%. The incidence of spinal cord ischemic complications was 8.6% (8/93), including 4 patients with transient paraparesis (P = .44 vs SG repair). Nine patients (9.7%) required surgical reintervention during the follow-up period, with 48-month freedom from reintervention approaching 79% (P = .73 vs SG repair). Conclusions: Operative mortality was halved with SG, with similar late survival for both cohorts. Reinterventions were required at a nearly identical rate for open repair and SG, and both groups experienced similar rates of spinal cord ischemic complications. [Copyright &y& Elsevier]

Background: Percutaneous endovascular therapy is becoming a primary option for managing infrainguinal occlusive disease. This study examined the results of femoropopliteal percutaneous transluminal angioplasty (PTA) with intermediate (mean, 24 months) follow-up in a contemporary series of patients presenting with critical limb ischemia or claudication. Methods: Femoropopliteal PTA was performed on 238 consecutive limbs (208 patients) from January 2002 to July 2004. Study end points, including primary patency, assisted patency, and limb salvage (Society of Vascular Surgery reporting standards), were assessed by Kaplan-Meier life-table analysis, and factors predictive of hemodynamic or clinical failure, or both, were evaluated by univariate and multivariate methods. Results: Clinical and demographic features included a mean age, 72 years; male (62%); critical limb ischemia (46%); diabetes mellitus (49%); and renal insufficiency (creatinine ≥ 1.5 mg/dL) (29%). Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A (11%), B (43%), C (41%), and D (5%). PTA was confined to the femoropopliteal segment in 77 patients (33%), and 161 (67%) underwent concurrent interventions in other anatomic locations. Femoropopliteal interventions included angioplasty only in 183 (78%), and the remaining 53 (22%) received at least one stent. Technical success was achieved in 97% of patients, with no deaths and a major morbidity rate of 3%. The 36-month actuarial primary patency was 54.3%, and assisted patency was 92.6% (37 peripheral reinterventions), resulting in a limb preservation rate of 95.4% in all patients regardless of clinical presentation. Interval conversion to bypass surgery occurred in 19 patients (8%). Comparison between critical limb ischemia and claudication revealed a primary patency of 40.8% vs 64.8%, assisted patency of 93.8% vs 92.6%, and limb salvage of 89.7% vs 100%, respectively. Negative predictors of primary patency determined by multivariate analysis included history of congestive heart failure (P = .02) and TASC C/D (P = .02). However, further evaluation of TASC C/D vs A/B revealed an assisted patency of 89.7% vs 94.3% (P = .37) and limb salvage of 94.3% vs 96.4% (P = .58). Conclusions: Femoropopliteal PTA can be performed with a low perioperative morbidity and mortality. Intermediate primary patency is directly related to TASC classification. Although secondary intervention is often necessary to maintain patency in TASC C/D lesions, these data suggest that it would be appropriate to use PTA as initial therapy for chronic femoropopliteal occlusive disease regardless of clinical classification at presentation or TASC category of lesion severity. [Copyright &y& Elsevier]

Introduction: Although lower-extremity bypass grafting has been the gold standard for infrainguinal revascularization, endovascular therapies have been increasingly applied to avoid operative morbidities. This study addresses the initial results of an implementation of infrainguinal percutaneous transluminal angioplasty (PTA) performed by vascular surgeons to treat lower-extremity ischemia. Methods: From January 2002 to July 2003, 95 consecutive patients presenting with the spectrum of lower-extremity ischemic manifestations, in whom infrainguinal PTA was the initial choice of treatment, were assessed for treatment efficacy by clinical and noninvasive evaluation. Study end points of angiographic, hemodynamic, and clinical successes (Society of Vascular Surgery reporting standards) were recorded, and variables associated with ischemic category improvement were analyzed by univariate and multivariate analysis. During the same study interval, 87 patients underwent bypass grafting (not further considered). Results: PTA was used to treat 100 limbs in 95 consecutive patients: 63 limbs (63%) had femoropopliteal PTA, 17 limbs (17%) had tibioperoneal PTA, and 20 limbs (20%) had multilevel PTA. Tissue-threatening ischemia was present in 47% of patients, and 53% were treated for claudication. Complications (no mortality) included one myocardial infarction (1%) and two access site hematomas (2%). Angiographic and hemodynamic success (a .10 increase in ankle-brachial index) was obtained in 97% and 90% of the treated limbs, respectively. With a mean follow-up of 14 months, clinical success was obtained in 85% of the treated limbs, and limb salvage for critical ischemia was achieved in 75% (30/40 limbs). Of the PTA failures, five patients (5%) underwent bypass grafting, and five patients (5%) underwent major amputation because of no further reconstructive options or extensive necrosis. Insulin-dependent diabetes mellitus (risk ratio [RR], 3.1; 95% confidence interval [CI], 1.1 to 8.7, P = .02), poor runoff into the foot (RR, 3.7; 95% CI, 1.6 to 8.6, P = .001), and renal insufficiency (serum creatinine >1.5 mg/dL) (RR, 3.7; 95% CI, 1.8 to 7.6, P = .001) were predictive of PTA failure. Conclusion: Infrainguinal percutaneous transluminal angioplasty for lower-extremity ischemia is feasible, safe and provides acceptable hemodynamic and clinical results. PTA will become the initial treatment for most patients requiring lower-extremity revascularization. [Copyright &y& Elsevier]

Background: Reoperative carotid endarterectomy (CEA) is an accepted treatment for recurrent carotid stenosis. With reports of a higher operative morbidity than primary CEA and the advent of carotid stenting, catheter-based therapy has been advocated as the primary treatment for this reportedly “high-risk” subgroup. This study reviews a contemporary experience with reoperative CEA to validate the high-risk categorization of these patients. Methods: From 1989 to 2002, 153 consecutive, isolated (excluding CEA/coronary artery bypass graft and carotid bypass operations) reoperative CEA procedures were reviewed. Clinical and demographic variables potentially associated with the end points of perioperative morbidity, long-term durability, and late survival were assessed with multivariate analysis. Results: There were 153 reoperative CEA procedures in 145 patients (56% men, 36% symptomatic) with an average age of 69 ± 1.3 years. The average time from primary CEA (68% primary closure, 23% prosthetic, 9% vein patch) to reoperative CEA was 6.1 ± 0.4 years (range, 0.3 to 20.4 years). At reoperation, patch reconstruction was undertaken in 93% of cases. The perioperative stroke rate was 1.9%, with no deaths or cardiac complications. Other complications included cranial nerve injury (1.3%) and hematoma (3.2%). Average follow-up after reoperative CEA was 4.4 ± 0.3 years (range, 0.1 to 12.7 years), with an overall total stroke-free rate of 96% and a restenosis rate (>50%) by carotid duplex of 9.2%. Among variables assessed for association with restenosis after reoperative CEA, only younger age was found to be significant (66 ± 2.5 years vs 70 ± 0.7 years, P < .05). The all-cause long-term mortality rate was 29%. Multivariate analysis of long-term survival identified diabetes mellitus as having a negative impact (hazard ratio, 3.4 ± 0.3, P < .05) and lipid-lowering agents as having a protective effect (hazard ratio, 0.42 ± 0.4, P < .05) on survival. Conclusion: Reoperative CEA is a safe and durable procedure, comparable to reported standards for primary CEA, for long-term protection from stroke. These data do not support the contention that patients who require reoperative CEA constitute a “high-risk” subgroup in whom reoperative therapy should be avoided. [Copyright &y& Elsevier]

Popliteal artery embolism has been a focus of study at the Massachusetts General Hospital for over 60 years. It is a formidable vascular problem with significant limb loss and mortality. To assess the impact of advances in cardiac and vascular therapies, we reviewed our outcomes over 12 years. A retrospective review from our databases identified 66 patients with 72 popliteal artery emboli between January 1989 and October 2000. Patients undergoing nonsurgical therapy or with in situ atherosclerotic thrombosis were excluded. Demographics, comorbidities, presentation, duration, etiology, treatment, and outcomes were analyzed. Patients were classified into those with acute (AP; symptoms <7 days; 59 of 72, 82%) or delayed (DP; symptoms <7days; 13 of 72, 18%) presentation. The presentation was typically acute ischemia (85%) in the AP group and claudication (69%), rest pain (15.5%), or gangrene (15.5%) in the DP group. The most common etiology was embolism secondary to atrial fibrillation (17 of 72, 24%). Femoral artery access (15 of 72, 21%) was more prevalent than in our prior experience. In the AP group, 9 of 59 (15%) were treated with a femoral artery approach, 44 of 59 (75%) with a popliteal artery approach, and 6 of 59 (10%) with bypass. In the DP group, 11 of 13 (85%) were treated with a popliteal approach and 2 of 13 (15%) with bypass. Completion angiography was done in 17 cases (24%). Limb salvage rate was 88% (88% AP, 85% DP); the rate was 94% with angiography and 85% without it (p > 0.1). There were seven deaths (10%). The mortality rate was 33% after amputation and 7% after limb salvage (p < 0.05). Except for a greater prevalence of femoral artery access as an etiology, the demographics of patients with popliteal embolism were similar to those of prior reports. Although a femoral approach may be appropriate in select AP cases, a popliteal approach is preferred in most patients and is necessary in DP cases. Completion angiography should be performed to ensure adequacy of the embolectomy. Outcomes are unchanged. Future therapies should aim to improve limb salvage and mortality rates. [ABSTRACT FROM AUTHOR]

Purpose: To determine the prevalence of new renal perfusion defects and the association of these events with aneurysm neck atheroma during endovascular stent-graft repair of abdominal aortic aneurysm (AAA).Materials and Methods: A retrospective review was performed of 50 patients who underwent AAA repair with bifurcated endovascular stent-grafts without suprarenal components between June 1998 and May 1999. Pre- and postprocedural computed tomographic (CT) angiograms were reviewed to determine the prevalence of new renal perfusion defects. The percent volume of atheroma of the aneurysm neck was determined by three-dimensional volumetric reformation and correlated with prevalence of new postprocedural renal perfusion defects. Follow-up CT angiography was performed between 6 months and 2 years after the procedure and used to evaluate the presence of residual defects and interval changes.Results: Of 50 subjects, 18% (n = 9) had new perfusion defects presumed to be embolic in origin. Follow-up was available for four patients: scarring and cortical thinning consistent with infarction developed in two, whereas the defects resolved in the other two. Analysis of aneurysm neck revealed an average percentage of atheroma of 32% and a range of 0%-73%. In subjects with >/=40% neck atheroma, the prevalence of new renal perfusion defects was 45.4% (five of 11), compared to 10.3% (four of 39) in subjects with <40% neck atheroma. This difference was significant (P =.0170).Conclusions: In this series, the frequency of renal embolic events associated with AAA endovascular repair was 18%. Prevalence of renal embolic perfusion defects was shown to correlate with volume of aneurysm neck atheroma. [ABSTRACT FROM AUTHOR]

Despite advancements, aortofemoral bypass (AFB) remains the most durable option for aortoiliac occlusive disease. Although runoff has been shown to be associated with AFB patency, the association of the Society for Vascular Surgery (SVS) thigh runoff scoring system with patency has not been assessed. The aim of the present study was to evaluate the association between the SVS runoff scoring system and limb-based primary patency after AFB. Institutional data for patients undergoing AFB with preoperative runoff imaging available from 2000 to 2017 were queried. Runoff scores were assigned according to the presence of occlusive disease in the superficial femoral artery and profunda femoris artery (minimum, 1; maximum, 10) as described by the 1997 SVS reporting standards for lower extremity ischemia. Limb-based patency was the primary endpoint. Kaplan-Meier analysis was used to compare the long-term limb-based patency and freedom from reintervention between limbs with runoff scores ≥6 and those with runoff scores <6. Propensity score-weighted Cox proportional hazards modeling was used to evaluate the association between a runoff score of ≥6 and primary patency loss, controlling for other factors associated with primary patency. In 161 patients, 316 limbs had undergone revascularization. The mean patient age was 66.7 ± 11.3 years, and 51.6% were women. Most limbs had undergone revascularization for claudication (56.5%). Most (89.4%) had TransAtlantic InterSociety Consensus class D lesions, 27.3% had required suprarenal or higher clamping, and 11.2% had undergone concomitant mesenteric intervention. A femoral outflow adjunct and concurrent lower extremity bypass was required in 41.8% and 2.9% of limbs, respectively. Those with a runoff score of ≥6 had experienced greater rates of 30-day myocardial infarction (11% vs 1%; P =.005), respiratory failure (11% vs 1%; P =.005), and mortality (8% vs 0%; P ≤.006). The median follow-up period was 4.0 years (interquartile range, 6.5 years). The 1-, 3-, and 5-year primary patency was 94.6% (95% confidence interval [CI], 91.9%-97.3%), 89.2% (95% CI, 85.4%-93.2%), and 81.4% (95% CI, 76.0%-87.1%), respectively. The 5-year primary-assisted patency, secondary patency, and freedom from reintervention were 84.9% (95% CI, 79.7%-90.5%), 91.7% (95% CI, 87.3%-96.3%), and 83.3% (95% CI, 78.3%-88.7%), respectively. Patients with a runoff score of ≥6 had lower primary (log-rank P <.01), primary-assisted (P <.01), and secondary patency (P =.01). The factors associated with the loss of primary patency included a high runoff score (runoff score of ≥6: hazard ratio [HR], 4.1; 95% CI, 2.1-8.0; P <.01), simultaneous mesenteric endarterectomy (HR, 13.5; 95% CI, 1.9-97.8; P =.01), and chronic kidney disease (HR, 4.6; 95% CI, 1.5-14.6; P =.01). Increasing age (HR, 0.94 per year; 95% CI, 0.91-0.97; P <.01) and hyperlipidemia (HR, 0.44; 95% CI, 0.23-0.85; P =.01) were protective. The SVS femoral runoff score is an important factor associated with long-term AFB limb patency. Scores of ≥6 portend for worse limb outcomes and a greater incidence of operative complications. The SVS score can be determined from preoperative axial imaging studies and serve as a guide in decision-making and operative planning. [Display omitted] [ABSTRACT FROM AUTHOR]

Presents a study on the theory that there is less amino acid oxidation and higher concentrations of acute phase proteins. Information on children with kwashiorkor; Definition of acute infection; Indepth look at the methodology used to conduct the study; Information on the results of the study; Discussion on the results of the study.

Evaluates the hypothesis that whole body protein kinetics remain low in children with edematous malnutrition and acute infection. Determinants of protein kinetics; Calculation of rates of whole-body protein synthesis; Effects of proteins in response to acute infection; Estimates of leucine oxidation rate.

Abstract: Completeness of ascertainment of breast cancer cases by the Scottish Cancer Registry (SCR) was assessed by independent comparison with five clinical trials databases, comprising 2621 patients and spanning the total period of diagnosis 1978–2000. Overall, ascertainment was estimated to exceed 98%, although 0.3% of matched cases were misclassified as carcinoma in situ by the SCR. These results support the validity of national estimates of incidence of, and survival from, breast cancer in Scotland. [Copyright &y& Elsevier]

'Just-in-time training' is an innovative approach to nursing education. It has demonstrated positive outcomes in other industries, such as manufacturing and aviation, but it has limited published application in the acute-care setting. We aimed to implement and evaluate a nursing 'just-in-time training' program for the recognition and response to patient deterioration. To promote consistency, one Clinical Deterioration Educator provided education to nursing staff in both recognising the need for escalation and providing subsequent care for the deteriorating ward patient. Nurses' perception of the 'just-in-time training' program was determined using electronic questionnaire responses. Medical Emergency Team call prevalence and outcome data was compared before and after the program implementation for further evaluation. The 'just-in-time training' program was implemented in a 508-bed acute metropolitan private hospital over a 12-month period. Education was provided in general medical and surgical wards, not specialty areas. Nurses received the just-in-time training based on their patients' perceived risk of deterioration, therefore, participants are not randomised. A quantitative research study investigated nurses' self-perceived confidence after receiving just-in-time training. Medical Emergency Team call frequency data was also examined to identify trends. The 'just-in-time training' program consisted of 534 bedside nursing encounters over 12 months. During the study, the need for the educator to recommend that nurses escalate care reduced in prevalence from 20% to 5.5%. Questionnaire responses demonstrated a self-perceived confidence following intervention of 4.32/5.0. Medical Emergency Team call prevalence, per 1000 patient bed days, increased from 13.6 pre-intervention to 15.4 post-intervention. Just-in-time training' can be effectively implemented to educate ward nursing staff in recognising and responding to the deteriorating patient. The program is well received by nursing staff and leads to high self-perceived confidence to recognise and appropriately care for a deteriorating patient. [ABSTRACT FROM AUTHOR]