Search

Pancreatic angiosarcoma is an exceedingly rare malignancy accounting for

To determine the effect of postoperative permissive anemia and high cardiovascular risk on postoperative outcomes.The Veterans Affairs Surgical Quality Improvement Program and Corporate Data Warehouse databases were queried for patients who underwent major vascular or general surgery operations. The status of cardiovascular risk was assessed by calculating the Revised Cardiac Risk Index. Primary endpoint was a composite of mortality, myocardial infarction, acute renal failure, coronary revascularization, or stroke within 90 days postoperatively.We analyzed 142,510 procedures performed from 2000 to 2015. Postoperative anemia was the strongest independent predictor of the primary endpoint whose odds increased by 43% for every g/dL drop in postoperative nadir Hb [95% confidence interval (95% CI): 41-45]. Cardiac risk status as described by the RCRI also independently predicted the primary endpoint, with an additive effect particularly evident at postoperative nadir Hb values below 10 gm/dL. Postoperative anemia, after age, was the second strongest independent predictor of long-term (12 years) mortality (hazard ratio: 1.18, 95% CI: 1.17-1.19).Postoperative anemia is strongly associated with postoperative ischemic events, 90-day mortality, and long-term mortality. Restrictive transfusion should be used cautiously after major general and vascular operations, particularly in patients at a high cardiovascular risk.

Introduction: Abdominal aortic aneurysm (AAA) screening efforts have had two shortcomings: (1) a high number needed to treat; and (2) persons categorized as black are less frequently identified prior to presenting with a ruptured AAA (rAAA). The goal of this analysis was to identify community-level factors that could be used to identify specific majority and minority populations in Texas that could benefit from directed screening efforts. Methods: The study sample was comprised of all patients who underwent surgical or endovascular treatment for intact AAA (iAAA) and rAAA at all non-federal Texas hospitals from 2006-2014, aggregated by county and by metropolitan statistical area (MSA). These were then combined with demographics and other community-level characteristics in multivariate analyses. Results: In total, 22,455 patients who underwent treatment of iAAA or rAAA were included. 47% of the variance in the rate of AAA or AAA repair among Texas counties was explained by just two variables: proportion elderly (p2 =0.58, p Conclusion: Readily-accessible, publicly-available data can be used to identify geographic areas and populations that could benefit from more intensive screening efforts. Directing ultrasound screening efforts at persons categorized as black in specific geographic areas may help increase equity in AAA care.

We compared the rates of stroke, death, and/or MI between men and women, stratified by symptomatic status and procedure type (carotid endarterectomy [CEA] or carotid artery stent [CAS]).Using the Nationwide Inpatient Sample, crude and propensity-matched rates of the composite end point of stroke/death/MI were estimated. Multivariable logistic regression was used to calculate the odds of stroke/death/MI associated with sex.Between 2005 and 2015, there were 1,242,688 carotid interventions performed (1,083,912 CEA; 158,776 CAS; 515,789 [41.5%] were female patients). Symptomatic admissions comprised 11.3% of the cohort. In-hospital stroke/death/MI rates were more prevalent in men compared with women (4.2% vs 3.9%; p0.01). Subgroup analysis revealed symptomatic women vs men had higher rates of stroke after CEA (7.7% vs 6.2%; p0.01) and CAS (9.9% vs 7.6%; p0.01). Asymptomatic women experienced the same rates of stroke after either CEA (0.3% vs 0.3%; p = 0.051) or CAS (0.4% vs 0.5%; p = 0.09). Propensity-matched logistic regression revealed that symptomatic males vs females had lower odds of stroke after CEA (odds ratio [OR] 0.81; 95% CI 0.72 to 0.91) and CAS (OR 0.72; 95% CI 0.57 to 0.90). Asymptomatic men and women had similar odds of stroke after both CEA (OR 0.95; 95% CI 0.79 to 1.14) and CAS (OR 0.70; 95% CI 0.43 to 1.13).This is the largest cohort study to date that demonstrates asymptomatic women undergoing CEA or CAS do not have a higher risk of perioperative stroke, death, or MI. Symptomatic men experience lower rates of stroke after CEA or CAS.

Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia mandates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reintervention, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, randomized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comorbidities and benefit from a multidisciplinary, team approach to care.

Background: Myointimal thickening and microvessel ingrowth are commonly observed in vein graft stenosis, which complicates a third of infrainguinal bypass procedures. But a direct correlation between these two features has not been established. Our purpose was to analyze the relationship between neovascularity and intimal thickness in human vein grafts. Study Design: Twenty-two explant stenotic vein grafts (STVG), 8 nonstenotic arterialized vein grafts (AVG), and 20 age-matched control greater saphenous veins (CGSV) were analyzed histologically and compared morphologically by light microscopy. Digitized computer image analysis was used to measure intimal thickness and quantitate microvessel ingrowth. Immunolocalization of endothelial cells around the lumen and in microvessels was determined using antibodies to factor VIII and to endothelial nitric oxide synthase (eNOS), respectively. Results: Focal areas of endothelial disruption and thrombus deposition were present in 23% (5 of 22) of stenotic vein grafts. The neointima of STVG grafts was two- and fourfold thicker than that of AVG and CGSV, respectively (p Conclusions: A fourfold increased neointimal thickness in critically stenotic vein grafts is associated with increased medial and adventitial neovascularization. Remodeling alone with doubling of the intimal thickness in nonstenotic arterialized vein grafts does not appear to be associated with enhancement of the graft microvasculature. More specific observations using an experimental model may allow us to further define the role of angiogenesis in vein graft stenosis and to determine the therapeutic implications of such observations.

The recently published guidelines of the National Kidney Foundation-Dialysis Outcome Quality Initiative have focused on improving patient outcomes and survival by providing recommendations for optimal clinical practice. These guidelines firmly endorse the establishment of autogenous hemodialysis access and recommend a 40% to 50% prevalence of autogenous fistulas among all hemodialysis patients. As surgeons strive to meet these guidelines it will be necessary to extend autogenous reconstruction to older individuals, diabetics, and patients with suitable vein only in the upper arm. These individuals are at increased risk for the development of the ischemic steal syndrome. It is paramount that surgeons who perform vascular access procedures have a firm understanding of the symptoms, diagnostic maneuvers, and treatment options for the ischemic steal syndrome after hemodialysis access procedures.

RATIONALE AND OBJECTIVES To evaluate the use of a new thrombus-specific ultrasound contrast agent, MRX-408, in the ultrasonic detection of thrombus in arteriovenous (AV) fistulae. METHODS Six purpose-bred mongrels with two AV fistulae each were imaged with gray-scale ultrasound 7 weeks after graft implantation before and after the intravenous bolus injection of MRX-408 (a GPIIb receptor-targeted ultrasound contrast agent). Pre- and postcontrast videotaped segments were randomized and reviewed by four radiologists blinded to the presence of thrombus in the grafts. RESULTS After the use of MRX-408, there was improved visualization of thrombus within the grafts (P < 0.0001). This was due to the enhancement of the thrombus (P < 0.0001). The improved visualization and contrast enhancement were more marked in the grafts that contained thrombus nonhyperechoic to surrounding soft tissues. CONCLUSIONS MRX-408 demonstrated better visualization of thrombus within AV fistulae. This was shown in both patent and occluded grafts. These results are encouraging and suggest that this contrast agent merits further development.

One hundred patients with ischemic finger ulceration had detailed prospective evaluation to determine the incidence of associated diseases, response to treatment, and natural history of the condition. A potentially serious associated disease was detected in each patient including autoimmune disease in 54%, Buerger's disease in 9%, arteriosclerosis obliterans in 9%, hypersensitivity angiitis in 22%, and miscellaneous diseases in 6%. Conservative treatment with soap and water scrubs, antibiotics, and local resection/debridement resulted in long-term healing without recurrence in 88% of patients. Most recurrences occurred in patients with autoimmune disease, usually scleroderma or CRST.