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Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair.To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive.In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021.Presurgical consultation using a decision aid vs usual care.The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios.Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70).Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures.ClinicalTrials.gov Identifier: NCT03115346.

OBJECTIVE: Opioid use is common among patients with peripheral arterial disease (PAD), given that pain is a defining symptom. Unfortunately, long-term opioid use places patients at dramatically increased risk of overdose and death. Although surgical revascularization is extremely effective in alleviating ischemic pain related to PAD, it is unclear whether this practice results in the discontinuation of opioids after surgery. Therefore, we conducted the following study to investigate trends in opioid use before and after surgical bypass in patients with PAD, as well as the risk factors for continued opioid use after surgery. METHODS: We conducted a retrospective analysis of patients undergoing open lower extremity bypass for claudication or rest pain between June 1, 2017, and March 31, 2021. Patients were grouped according to whether they reported preoperative opioid use at the time of surgery. The primary outcome was continued opioid use at 30-day follow-up after discharge. A multivariable logistic regression was conducted to estimate the association of continued opioid use with patient characteristics, preoperative opioid use, and receiving a postoperative opioid prescription. RESULTS: Among 3873 patients undergoing surgery, the mean age was 65.7 (10.2) years and 2650 (68.4%) patients were male. There were 913 patients (23.6%) who used opioids preoperatively and hydrocodone was the most common preoperative opioid (583 [63.9%]). At discharge, 2506 patients (64.7%) received a postoperative opioid prescription. Postoperative opioid prescriptions were significantly more common for preoperative opioid users than opioid-naïve patients (813 [89.0%] vs 1693 [57.2%]; P < .001) and were significantly larger in size (24.3 [21.1] pills vs 19.9 [10.5] pills; P < .001). On 30-day follow-up, 522 preoperative opioid users (61.3%) and 616 opioid-naïve patients (28.4%) reported that they were still using opioids (P < .001). Continued opioid use at follow-up was associated with preoperative opioid use (adjusted odds ratio, 3.23; 95% confidence interval, 2.70–3.89) and receiving a postoperative opioid prescription (adjusted odds ratio, 10.83; 95% confidence interval, 7.96–15.06). CONCLUSIONS: Most patients with PAD who use opioids preoperatively do not discontinue opioids after lower extremity bypass. Moreover, a significant proportion of previously opioid-naïve patients are still using opioids 1 month after surgery. In both cases, postoperative opioid prescriptions had the strongest association with continued opioid use. These findings underscore the need for improved prescribing practice and increased attentiveness to discontinuation of unnecessary medications after surgery. (J Vasc Surg 2022;75:998–1007.)

Objective Tobacco use is common among vascular surgery patients and negatively impacts outcomes and longevity. In the second quarter of 2018, a statewide vascular quality collaborative launched an initiative across its 35 participating hospitals to promote smoking cessation at the time of surgery. This intervention was based on the Vascular Physician Offer and Report (VAPOR) trial and consisted of 3 components: brief physician-delivered advice, referral to telephone-based counseling, and nicotine replacement therapy. The goal of this study is to evaluate the results of this intervention. Methods We performed a retrospective analysis of patients undergoing vascular surgery between 2018 and 2020. Procedures included open abdominal aortic aneurysm repair, endovascular aneurysm repair, open vascular bypass, open thrombectomy, carotid endarterectomy, and carotid stenting. The primary explanatory variables were receipt of tobacco cessation interventions as documented in the medical record. The primary outcome was tobacco cessation, captured during 30-day and 1-year chart review and/or patient follow-up. A multivariable logistic regression model was calculated to estimate the association of covariates with smoking cessation while adjusting for patient and clinical characteristics. Results A total of 13,890 patients underwent surgery during the study period. The mean age was 69.4 ± 10 years; 4687 patients (34%) were female, and 5158 patients (37%) were current smokers. At least one smoking cessation component was delivered to 2245 patients (44% of smokers). The quit rate was 35% among 4671 patients with 30-day follow-up and 43% among 2936 patients with 1-year follow up. On multivariable regression, at 30 days, receiving two intervention components was associated with 1.29 (95% confidence interval [CI], 1.07-1.55) higher odds of quitting. At both time points, smoking cessation was also associated with undergoing an emergent procedure (30-day odds ratio [OR], 1.52; 95% CI, 1.16-1.99; 1-year OR, 1.41; 95% CI, 1.01-1.97) and undergoing open abdominal aortic aneurysm repair (30-day OR, 1.71; 95% CI, 1.20-2.43; 1-year OR, 1.75; 95% CI, 1.11-2.78). Conclusions In a cohort of vascular surgical patients where tobacco use was common, nearly one-half of patients quit smoking 1 year after surgery. Receiving two smoking cessation intervention components was associated with quitting at 30 days. Overall, these results demonstrate encouraging quit rates and identify an opportunity for longer-term intervention to maintain even greater 1-year tobacco cessation.

Background: Up to 50% of patients with proximal deep vein thrombosis (DVT) will develop the postthrombotic syndrome characterized by limb swelling and discomfort, hyperpigmentation, skin ulcers, and impaired quality of life. Although catheter-based interventions enabling the restoration of blood flow (RBF) have demonstrated little benefit on postthrombotic syndrome, the impact on the acuity of the thrombus and mechanisms underlying this finding remain obscure. In experimental and clinical studies, we examined whether RBF has a restricted time window for improving DVT resolution. Methods: First, experimental stasis DVT was generated in C57/BL6 mice (n=291) by inferior vena cava ligation. To promote RBF, mice underwent mechanical deligation with or without intravenous recombinant tissue plasminogen activator administered 2 days after deligation. RBF was assessed over time by ultrasonography and intravital microscopy. Resected thrombosed inferior vena cava specimens underwent thrombus and vein wall histological and gene expression assays. Next, in a clinical study, we conducted a post hoc analysis of the ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) pharmacomechanical catheter-directed thrombolysis (PCDT) trial (NCT00790335) to assess the effects of PCDT on Venous Insufficiency Epidemiological and Economic Study quality-of-life and Villalta scores for specific symptom-onset-to-randomization timeframes. Results: Mice that developed RBF by day 4, but not later, exhibited reduced day 8 thrombus burden parameters and reduced day 8 vein wall fibrosis and inflammation, compared with controls. In mice without RBF, recombinant tissue plasminogen activator administered at day 4, but not later, reduced day 8 thrombus burden and vein wall fibrosis. It is notable that, in mice already exhibiting RBF by day 4, recombinant tissue plasminogen activator administration did not further reduce thrombus burden or vein wall fibrosis. In the ATTRACT trial, patients receiving PCDT in an intermediate symptom-onset-to-randomization timeframe of 4 to 8 days demonstrated maximal benefits in Venous Insufficiency Epidemiological and Economic Study quality-of-life and Villalta scores (between-group difference=8.41 and 1.68, respectively, P 8 days. Conclusions: Taken together, these data illustrate that, within a restricted therapeutic window, RBF improves DVT resolution, and PCDT may improve clinical outcomes. Further studies are warranted to examine the value of time-restricted RBF strategies to reduce postthrombotic syndrome in patients with DVT.

Objective The objective of this study was to determine how electronic consults (eConsults) are used in vascular surgery in a veterans health care setting and whether their use is safe for patients. Methods A retrospective review was performed of all eConsults completed by the vascular surgery service at the Ann Arbor Veterans Affairs Healthcare System between October 10, 2012 and November 15, 2013. Patients' demographics and comorbidities were collected. eConsult recommendations and patient and provider compliance with recommendations were collected. Data on adverse outcomes up to 1 year after consultation and data on all-cause mortality at 1 year and 5 years were collected. Results Between October 10, 2012 and November 15, 2013, of 350 eConsults completed, 123 (35%) were for peripheral artery disease, 93 (27%) for carotid stenosis, and 57 (16%) for abdominal aortic aneurysm. Unique recommendations were made for 291 consults (83%). Medication recommendations were made in 140 consults (40%). The most commonly recommended medication was cilostazol. Compliance with medication recommendations ranged from 30% to 61%. Noninvasive imaging was recommended in 220 consults (60.3%). Procedures overall were recommended in only six consults (1.7%). Five-year all-cause mortality for categorized diagnoses ranged from 8.3% for nonabdominal aneurysm to 28.1% for abdominal aortic aneurysm. Conclusions Within the Veterans Affairs vascular surgery service, eConsults provide a safe and effective means of triaging and providing recommendations for patients with vascular disease. eConsults used to augment traditional consultations may provide an important means of reducing clinic congestion for providers and reducing time and cost for patients.

Volume-outcome relationships exist for many complex surgical procedures, prompting institutions to adopt surgical volume standards for credentialing. The current Leapfrog Group Hospital volume standard for open abdominal aortic aneurysm repair (OAR) is 15 per year. However, this is primarily based on data from the 1990s and may not be appropriate given the dramatic decline in OAR. We sought to quantify the proportion of hospitals meeting volume standards, the difference in perioperative outcomes between low-volume and high-volume hospitals, and the potential travel burden of volume credentialing on patients.We identified Medicare beneficiaries for individuals aged ≥65 years undergoing OAR in 2013-2014. Hospital "all-payer" annual volume was estimated based on the national proportion of patients undergoing OAR covered by Medicare in the Vascular Quality Initiative. Hospital annual OAR volume was characterized as5/year, 5-9/year, 10-14/year, and ≥15/year (high volume). Adjusted rates of postoperative morbidity, reoperation, failure to rescue, and mortality in 2014 were compared across volume cohorts. Distance between patients' home zip code and high-volume hospitals was calculated.A total of 21,191 OARs were performed at 1,445 hospitals between 2013 and 2014. The average hospital OAR annual volume was 7.8 (standard deviation [SD] ± 9.3) with a median of 4.5. Among the 1,445 hospitals, only 190 (13.1%) performed ≥15 OARs per year whereas 756 hospitals (53.3%) performed5 per year. Among patients who underwent OAR in 2014, 5,395 (53.3%) received care at a hospital that performed15 per year. There was no difference in complication, reoperation, or failure to rescue rates between high-volume and low-volume hospitals. Mortality did not significantly differ among OAR volume cohorts. Hospitals performing5 OARs per year had a mortality rate of 5.7% compared with 5.6% at high-volume hospitals (P = 0.817). One-quarter of patients who received care at a low-volume hospital would have had to travel more than 60 miles to reach a high-volume hospital.By conservative estimates, only 13% of hospitals performing OAR meet current volume standards. Triaging all patients to high-volume hospitals would require shifting over 5,000 patients annually with no associated improvement in perioperative outcomes. Implementation of the current OAR hospital volume standard may significantly burden patients and hospitals without improving surgical outcomes.

A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition that carries a high mortality rate. Recent guidelines have recommended a goal "door-to-intervention" time of ≤90 minutes despite a paucity of evidence to support this goal. The aim of this study was to analyze recent trends in door-to-intervention time for rAAAs and determine the effect of the 90-minute door-to-intervention benchmark on postoperative complications.A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of a rAAA in the Vascular Quality Initiative database (2003-2018) was performed. Variation in door-to-intervention time was analyzed at the patient and hospital level. Patients were dichotomized into ≤90 or90 minute door-to-intervention time cohorts. Hierarchical modeling controlling for the hospital random effect and multivariate logistic models was used to analyze the association on 30-day mortality and major in-hospital complications.A total of 3,630 operative cases for rAAA were identified (1696 OAR and 1934 EVAR). For the OAR cohort, 1035 patients (61%) had a door-to-intervention time of ≤90 minutes. However, at the hospital level, a minority of hospitals (49%) reliably achieved the OAR goal door-to-intervention time. For OARs, there was no difference in 30-day risk-adjusted major complications or mortality between the ≤90- and 90-minute cohorts. For EVAR, 1014 patients (53.8%) had a door-to-intervention time of ≤90 minutes and a minority of hospitals (40%) upheld the recommended ≤90 minute door-to-intervention threshold. In the EVAR group, patients with a ≤90 minute door-to-intervention time had higher rates of postoperative myocardial infarction (12.0% vs. 8.5%; P 0.05) but no difference in 30-day risk-adjusted mortality.A low percentage of rAAAs are being treated within the recommended door-to-intervention time. Despite this deficiency, the ≤90-minute benchmark has minimal impact on postoperative morbidity and mortality. Based on these findings, alternative quality metrics should be identified to improve the clinical care of patients with rAAA.

Venous thromboembolism (VTE) is a significant cause of mortality1, yet its genetic determinants remain incompletely defined. We performed a discovery genome-wide association study in the Million Veteran Program and UK Biobank testing ~13 million DNA sequence variants for association with VTE (26,066 cases; 624,053 controls) and meta-analyzed both studies, followed by independent replication with up to 17,672 VTE cases and 167,295 controls. We identified 22 novel loci, bringing the total number of VTE-associated loci to 33 and subsequently fine-mapped these associations. We developed a genome-wide polygenic risk score for VTE that identifies 5% of the population at equivalent incident VTE risk to carriers of the established F5 Leiden (p.R506Q) and prothrombin G20210A mutations. Our data provide new mechanistic insights into the genetic epidemiology of VTE and suggest a greater overlap among venous and arterial cardiovascular disease than previously suggested., Editorial summary Genome-wide analysis of venous thromboembolism identifies 22 new risk loci and facilitates construction of a polygenic risk score. Comparison to arterial vascular disease highlights shared pathophysiology and potential therapeutic strategies.

Recent vascular societal guidelines have recommended an abdominal aortic aneurysm (AAA) size threshold for elective intervention; however, limited data have documented how well these AAA diameter benchmarks are being met. The objective of this study was to analyze variation in management of AAAs based on diameter and to determine the physician's rationale for intervention on small AAAs in relation to recommended treatment guidelines.A retrospective review of a statewide vascular surgery registry of all elective endovascular or open surgical AAA repairs from January 2012 to January 2016 was performed. Patients were dichotomized on the basis of aortic diameter at time of intervention into either guideline size AAAs or small AAAs, which were defined as 5.5 cm in men, 5.0 cm in women, or with growth 1.0 cm/y. An internal review was conducted of all small AAAs to determine the physician's rationale for intervention. The primary outcomes were variation in adherence to recommended treatment guidelines and the physician's rationale for treatment of small AAAs. Risk-adjusted major complication and mortality rates were calculated at 30 days and 1 year using a propensity score matching analysis.Among the 3932 patients who underwent an elective AAA repair, 485 (12.3%) were repaired at diameters smaller than recommended by guidelines. The median AAA size in the small AAA cohort was 5.1 cm (interquartile range, 4.7-5.3 cm) vs 5.6 cm (interquartile range, 5.2-6.1 cm) in the guideline-based group. Percentage of small AAA repairs varied widely between hospitals from 1.4% to 44.4%. The physician's rationale for the majority of early interventions included the patient's anxiety (12.0%), combined aortoiliac occlusive disease (14.8%), aneurysm anatomy (28.2%), and does not adhere to guidelines (30%). The small AAA cohort had no significant difference in the 30-day or 1-year risk-adjusted mortality in comparison to guideline size AAAs.Despite well-established aortic diameter threshold guidelines, marked variation exists both at the hospital level and in terms of the physician's rationale for the management of elective AAA repairs. These findings demonstrate the challenge of providing uniform care for patients with AAAs despite established guidelines.

Background: The postthrombotic syndrome is a common, often morbid sequela of venous thrombosis (VT) that arises from thrombus persistence and inflammatory scarring of juxtaposed vein walls and valves. Noninvasive 18 F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging can measure neutrophil inflammation in VT. Here, we hypothesized (1) early fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) VT inflammation can predict subsequent vein wall scarring (VWS) and (2) statin therapy can reduce FDG-PET VT inflammation and subsequent VWS. Methods: C57BL/6J mice (n=75) underwent induction of stasis-induced VT of the inferior vena cava or jugular vein. Inferior vena cava VT mice (n=44) were randomized to daily oral rosuvastatin 5 mg/kg or saline starting at day −1. Subgroups of mice then underwent FDG-PET/CT 2 days after VT induction. On day 14, a subset of mice was euthanized, and VWS was assessed via histology. In vitro studies were further performed on bone marrow-derived neutrophils. Results: Statin therapy reduced early day 2 FDG-PET VT inflammation, thrombus neutrophil influx, and plasma IL (interleukin)-6 levels. At day 14, statin therapy reduced VWS but did not affect day 2 thrombus mass, cholesterol, or white blood counts, nor reduce day 2 glucose transporter 1 or myeloperoxidase expression in thrombus or in isolated neutrophils. In survival studies, the day 2 FDG-PET VT inflammation signal as measured by mean and maximum standardized uptake values predicted the extent of day 14 VWS (area under the receiver operating characteristic curve =0.82) with a strong correlation coefficient ( r ) of r =0.73 and r =0.74, respectively. Mediation analyses revealed that 40% of the statin-induced VWS reduction was mediated by reductions in VT inflammation as quantified by FDG-PET. Conclusions: Early noninvasive FDG-PET/CT imaging of VT inflammation predicts the magnitude of subsequent VWS and may provide a new translatable approach to identify individuals at risk for postthrombotic syndrome and to assess anti-inflammatory postthrombotic syndrome therapies, such as statins.

To evaluate the association between gender and long-term clinician-reported and patient-reported outcomes after endovenous ablation procedures.This retrospective cohort study of prospectively collected data from the Vascular Quality Initiative's Varicose Vein Registry included patients undergoing endovenous ablation procedures on truncal veins with or without treatment of perforating veins between 2015 and 2019. A univariate analysis included comparisons of preprocedural, postprocedural, and periprocedural change in Venous Clinical Severity Score (VCSS) and total symptom score by gender. Rates of complications including deep vein thrombosis, endovenous heat-induced thrombosis, leg pigmentation, blistering, paresthesia, incisional infection, and any postprocedural complications were reported by gender. Multivariable analysis leveraged linear regression to examine how gender affected the relationships between patient characteristics, complication rates, and periprocedural change in VCSS score and total symptom score.Of 9743 patients who met the inclusion criteria, 3090 (31.7%) were men and 6653 (68.2%) were women. The perioperative change in VCSS score was greater for men than women (average -4.46 for men vs -4.13 for women; P .0001). Perioperative change in total symptom score was greater for women than for men (average -10.64 for women vs -9.64 for men; P .0001). Women had lower incidence of any leg complication (6.1% vs 8.6%; P = .001) endovenous heat-induced thrombosis (1.1% vs 2.2%; P = .002), and infection (0.4% vs 0.7%; P = .001). In multivariable analysis, among patients with a body mass index of more than 40, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2, women had a greater periprocedural change in VCSS score than men.Women benefited from endovenous ablation similarly as men, with a lower incidence of postprocedural complications. Gender may be useful for patient selection and counseling for endovenous ablation, with particular usefulness among patients with a high body mass index, presence of deep reflux, and preoperative Clinical, Etiologic, Anatomic, and Physiologic classification of 2.

Background Cigarette smoking, hypertension, dyslipidemia, diabetes, and obesity are conventional risk factors (RFs) for coronary artery disease (CAD). Population trends for these RFs have varied in recent decades. Consequently, the risk factor profile for patients presenting with a new diagnosis of CAD in contemporary practice remains unknown. Objectives To examine the prevalence of RFs and their temporal trends among patients without a history of myocardial infarction or revascularization who underwent their first percutaneous coronary intervention (PCI). Methods We examined the prevalence and temporal trends of RFs among patients without a history of prior myocardial infarction, PCI, or coronary artery bypass graft surgery who underwent PCI at 47 non-federal hospitals in Michigan between 1/1/2010 and 3/31/2018. Results Of 69,571 men and 38,930 women in the study cohort, 95.5% of patients had 1 or more RFs and nearly half (55.2% of women and 48.7% of men) had ≥3 RFs. The gap in the mean age at the time of presentation between men and women narrowed as the number of RFs increased with a gap of 6 years among those with 2 RFs to Conclusions Modifiable RFs are widely prevalent among patients undergoing their first PCI. Smoking and obesity are associated with an earlier age of presentation. Population-level interventions aimed at preventing obesity and smoking could significantly delay the onset of CAD and the need for PCI.

IMPORTANCE: Patients undergoing vascular surgery are at high risk of postoperative myocardial infarction (POMI). Postoperative myocardial infarction is independently associated with significant risk of in-hospital mortality. OBJECTIVE: To examine the association of patient and procedural characteristics with the risk of POMI after vascular surgery and determine the association of evidence-based therapies with longer-term outcomes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of prospectively collected data within a statewide quality improvement collaborative database between January 2012 and December 2017. Patient demographics, comorbid conditions, and perioperative medications were captured. Patients were grouped according to occurrence of POMI. Univariate analysis and logistic regression were used to identify factors associated with POMI. The collaborative collects data from private and academic hospitals in Michigan. Patients undergoing major vascular surgery, defined as endovascular aortic aneurysm repair, open abdominal aortic aneurysm, peripheral bypass, carotid endarterectomy, or carotid artery stenting were included. Analysis began December 2018. MAIN OUTCOMES AND MEASURES: The presence of a POMI and 1-year mortality. RESULTS: Of 26 231 patients identified, 16 989 (65.8%) were men and the overall mean (SD) age was 69.35 (9.89) years. A total of 410 individuals (1.6%) experienced a POMI. Factors associated with higher rates of POMI were age (odds ratio [OR], 1.032 [95% CI, 1.019-1.045]; P

Among patients undergoing noncardiac surgery, major vascular surgery is associated with a high risk of perioperative myocardial infarction (MI). Currently, there are no perioperative MI risk calculators accounting for intraoperative and postoperative risk factors in vascular surgery patients. We aimed to investigate specific risk factors for perioperative MI after major open vascular surgery to determine which patients are at highest risk of MI and the association of perioperative MI with perioperative transfusion.This statewide, retrospective cohort study analyzed risk factors for perioperative MI in major open vascular surgery between July 2012 and December 2015 using the Michigan Surgical Quality Collaborative, a multicenter quality collaborative. Patients were identified using current procedure terminology codes including open abdominal aortic aneurysm repairs (oAAA), aortobifemoral bypasses (AFB), and lower extremity bypasses (LEB). Rates of myocardial infarction were described for each procedure. A priori, preoperative, intraoperative, and postoperative variables were evaluated using univariate and multivariable statistics after adjusting for intraoperative factors including anesthesia type, intraoperative blood loss, intraoperative transfusion, and intraoperative vasopressor medications.A total of 3,689 patients underwent major open vascular surgery, including 375 oAAA, 392 AFB, and 2,922 LEB procedures. The overall incidence of MI was 2.4%, varying from 1.8% for aortobifemoral bypass, 2.4% for lower extremity bypass, and 3.7% for open abdominal aortic aneurysm repair. Although preoperative risk factors for myocardial infarction included age, American Society of Anesthesiologists score, diabetes, coronary artery disease, congestive heart failure, use of beta blocker, lower preoperative hematocrit, and surgical priority (urgent/emergent cases), after adjusting for intraoperative risk factors, all preoperative risk factors were not significant with the exception of surgical priority. After adjusting for intraoperative factors, only surgical priority (odds ratio [OR] = 1.70, 95% confidence interval [CI] [1.01-2.85], P 0.001) and postoperative transfusion (OR = 2.65, 95% CI [1.59-4.44], P 0.001) was associated with myocardial infarction, and higher nadir hematocrit was inversely associated with myocardial infarction (OR = 0.89, 95% CI [0.85-0.94], P 0.001).Among vascular surgery patients undergoing major open vascular surgery, surgical priority was the only preoperative risk factors independently associated with MI, and only postoperative variables such as nadir hematocrit and postoperative transfusion were associated with MI. This suggests minimizing intraoperative blood loss and prioritizing early intraoperative transfusion may be the potential targets for process improvement.

This study sought to describe the distribution of pre-intervention treated-limb ankle-brachial indices (ABIs) among patients with critical limb ischemia (CLI) undergoing percutaneous vascular intervention (PVI) or surgical revascularization (SR).CLI is diagnosed by the presence of rest pain, tissue ulceration, or gangrene due to chronic arterial insufficiency. It is unclear what fraction of patients with suspected CLI have severe peripheral artery disease (PAD) on noninvasive functional testing.The study included patients who underwent lower extremity revascularization for CLI in a multicenter registry in Michigan from January 2012 through June 2015. ABIs were classified as normal (ABI: 0.91 to 1.40), mild-moderate (ABI: 0.41 to 0.90), and severe (ABI: ≤0.40). Pre- and post-intervention Peripheral Artery Questionnaire summary scores were assessed in a subset of patients.Among 10,756 patients with signs or symptoms of CLI, 9,113 (84.7%) underwent PVI and 1,643 (15.3%) underwent SR. ABIs were recorded in 4,972 (54.6%) PVI and 1,012 (61.6%) SR patients. Patients undergoing PVI had higher ABIs than those undergoing SR, with substantial variation in both groups (PVI: 0.72 ± 0.29 vs. SR: 0.61 ± 0.29; p 0.001). Nearly a quarter of patients with compressible arteries had normal ABIs (24.0%), whereas severe PAD was uncommon (16.5%). A significant improvement in Peripheral Artery Questionnaire scores was noted after intervention across all ABI categories.Among patients undergoing revascularization for CLI in contemporary practice, the authors found substantial heterogeneity in pre-intervention ABIs. The disconnect between ABI results and clinical diagnosis calls into question the utility of ABIs in this population and suggests the need for standardization of functional PAD testing.

SummaryVenous thromboembolism is a major cause of death during and immediately post-sepsis. Venous thrombosis (VT) is mediated by cell adhesion molecules and leukocytes, including neutrophil extracellular traps (NETs). Sepsis, or experimentally, endotoxaemia, shares similar characteristics and is modulated via toll like receptor 4 (TLR4). This study was undertaken to determine if endotoxaemia potentiates early stasis thrombogenesis, and secondarily to determine the role of VT TLR4, ICAM-1 and neutrophils (PMNs). Wild-type (WT), ICAM-1-/- and TLR4-/- mice underwent treatment with saline or LPS (10 mg/kg i.p.) alone, or followed by inferior vena cava (IVC) ligation to generate stasis VT. In vivo microscopy of leukocyte trafficking was performed in non-thrombosed mice, and tissue and plasma were harvested during early VT formation. Pre-thrombosis, circulating ICAM-1 was elevated and increased leukocyte adhesion and rolling occurred on the IVC of LPS-treated mice. Post-thrombosis, endotoxaemic mice formed larger, platelet-poor thrombi. Endotoxaemic TLR4-/- mice did not have an augmented thrombotic response and exhibited significantly decreased circulating ICAM-1 compared to endotoxaemic WT controls. Endotoxaemic ICAM-1-/- mice had significantly smaller thrombi compared to controls. Hypothesising that PMNs localised to the inflamed endothelium were promoting thrombosis, PMN depletion using anti-Ly6G antibody was performed. Paradoxically, VT formed without PMNs was amplified, potentially related to endotoxaemia induced elevation of PAI-1 and circulating FXIII, and decreased uPA. Endotoxaemia enhanced early VT occurs in a TLR-4 and ICAM-1 dependent fashion, and is potentiated by neutropenia. ICAM-1 and/or TLR-4 inhibition may be a unique strategy to prevent sepsis-associated VT.Supplementary Material to this article is available online at www.thrombosis-online.com.

Although New York's Medicaid expansion increased coverage in 2001, little is known regarding changes in surgical care utilization among patients with vascular disease. We sought to measure the impact of expansion on the rates of both vascular procedures and amputations.A retrospective analysis was performed using the State Inpatient Databases of New York and Arizona, 1998-2006. Patients aged 18-64 who underwent lower extremity vascular surgery procedures or amputations between 1998 and 2006 were included. Outcomes included rates of total vascular, open vascular, and endovascular procedures, in addition to rates of amputation. A difference-in-difference analysis measured changes in the rates of procedure types, while adjusting for temporal trends in both states.In this cohort (n = 112,624), Medicaid expansion was not associated with a change in mortality (odds ratio 0.92, P = 0.5). Expansion was associated with a lower incidence of total vascular procedures (incidence rate ratio [IRR] 0.65, P 0.001) and open vascular procedures (IRR 0.92, P = 0.002), but a higher incidence of endovascular procedures (IRR 1.13, P 0.001). There was no change in the rate of amputations (IRR 1.02, P = 0.58). In patients with chronic limb-threatening ischemia (n = 12,668), expansion was associated with a lower incidence of total procedures (IRR 0.59, P 0.001) and endovascular procedures (IRR 0.59, P 0.001) but a higher incidence of amputations (IRR 1.43, P = 0.001) and higher odds of mortality (odds ratio 2.21, P = 0.032).After Medicaid expansion, the rates of total vascular procedures decreased, with no impact on amputations rates. Furthermore, the utilization of limb-saving procedures in patients with chronic limb-threatening ischemia did not increase.

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

OBJECTIVE: Few studies have investigated outcomes after truncal endovenous ablation in patients with combined deep and superficial reflux and no studies have evaluated patient-reported outcomes. METHODS: We investigated the short- and long-term clinical and patient-reported outcomes among patients with and without deep venous reflux undergoing truncal endovenous ablation from 2015 to 2019 in the Vascular Quality Initiative. Preprocedural and postprocedural comparisons were performed using the t-test, χ(2), or their nonparametric counterpart when appropriate. Multivariable logistic regression models were used to assess for confounding. RESULTS: A total of 4881 patients were included, of which 2254 (46.2%) had combined deep and superficial reflux. The median follow-up was 336.5 days. Patients with deep reflux were less likely to be female (65.9% vs 69.9%; P = .003), more likely to be Caucasian (90.2% vs 86.5%; P = .003) and had no difference in BMI (30.6 ± 7.5 vs 30.6 6 7.2; P = .904). Additionally, no difference was seen in rates of prior varicose vein treatments, number of pregnancies, or history of deep venous thrombosis; however, patients without deep reflux were more likely to be on anticoagulation at the time of the procedure (10.9% vs 8.1%; P < .001). Patients without deep reflux had slightly higher median preprocedural Venous Clinical Severity Score (VCSS) scores (8 [interquartile range (IQR), 6–10]) vs 7 [IQR, 6–10]; P = .005) as well as postprocedural VCSS scores (5 [IQR, 3–7] vs 4 [IQR, 2–6]; P < .001). The median change in VCSS from before to after the procedure was lower for patients without deep reflux (3 [IQR, 1.0–5.5] vs 3.5 [IQR, 1–6]; P = .006). Total symptom score was higher for patients without deep reflux both before (median, 14 [IQR, 10–19] vs median, 13.5 [IQR, 9.5–18]; P = .005) and postprocedurally (median, 4 [IQR, 1–9] vs median, 3.25 [IQR, 1–7]; P < .001), but no difference was seen in change in symptom score (median, 8 [IQR, 4–13] vs median, 9 [IQR, 4–13]; P = .172). Patients with deep reflux had substantially higher rates of complications (10.4% vs 3.0%; P < .001), with a particular increase in proximal thrombus extension (3.1% vs 1.1%; P < .001). After controlling for confounding, this estimate of effect size for any complication increased (odds ratio, 5.72; 95% confidence interval, 2.21–14.81; P < .001). CONCLUSIONS: No significant difference is seen in total symptom improvement when patients undergo truncal endovenous ablation with concomitant deep venous reflux, although a greater improvement was seen in VCSS score in these patients. Patients with deep venous reflux had a significantly increased rate of complications, independent of confounding variables, and should be counseled appropriately before the decision for treatment.

Complex abdominal aortic aneurysms (AAAs) have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option. Hospital procedural volume to outcome relationship for OSR of complex AAAs has been well established, but the impact of procedural volume on FEVAR outcomes remains undefined. This study investigated the outcomes of OSR and FEVAR for the treatment of complex AAAs and examined the hospital volume-outcome relationship for these procedures.A retrospective review of a statewide vascular surgery registry was queried for all patients between 2012 and 2018 who underwent elective repair of a juxtarenal/pararenal AAA with FEVAR or OSR. The primary outcomes were 30-day mortality, myocardial infarction, and new dialysis. Secondary end points included postoperative pneumonia, renal dysfunction (creatine concentration increase of2 mg/dL from preoperative baseline), major bleeding, early procedural complications, length of stay, and need for reintervention. To evaluate procedural volume-outcomes relationship, hospitals were stratified into low- and high-volume aortic centers based on a FEVAR annual procedural volume. To account for baseline differences, we calculated propensity scores and employed inverse probability of treatment weighting in comparing outcomes between treatment groups.A total of 589 patients underwent FEVAR (n = 186) or OSR (n = 403) for a complex AAA. After adjustment, OSR was associated with higher rates of 30-day mortality (10.7% vs 2.9%; P .001) and need for dialysis (11.3% vs 1.8; P .001). Postoperative pneumonia (6.8% vs 0.3%; P .001) and need for transfusion (39.4% vs 10.4%; P .001) were also significantly higher in the OSR cohort. The median length of stay for OSR and FEVAR was 9 days and 3 days, respectively. For those who underwent FEVAR, endoleaks were present in 12.1% of patients at 30 days and 6.1% of patients at 1 year, with the majority being type II. With a median follow-up period of 331 days (229-378 days), 1% of FEVAR patients required a secondary procedure, and there were no FEVAR conversions to an open aortic repair. Hospitals were divided into low- and high-volume aortic centers based on their annual FEVAR volume of complex AAAs. After adjustment, hospital FEVAR procedural volume was not associated with 30-day mortality or myocardial infarction.FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs. Procedural FEVAR volume outcome analysis suggests limited differences in 30-day morbidity, although long-term durability warrants further research.

Background Endovascular (EV) techniques are being advocated as the preferred method for mesenteric interventions because of their safety profile. However, midterm and long-term results are thought to be inferior to open interventions. We sought to compare our institutional experience with treatment of acute and chronic mesenteric ischemia (AMI and CMI, respectively) using EV and open techniques. Methods The medical records of open and EV mesenteric procedures performed at a single center were queried from 2002 to 2012. Demographic, perioperative, and follow-up data were extracted and analyzed. Results Thirty-eight patients underwent EV mesenteric interventions, whereas 77 patients underwent open revascularization. The demographic and perioperative characteristics for patients were similar. Most EV procedures (89.2%) comprised stenting, whereas open procedures included 25 (32.1%) antegrade bypasses, 38 (48.7%) retrograde bypasses, 8 (10.3%) thromboembolectomies, and 7 (9%) transaortic endarterectomies. Postoperative complications, overall 30-day morbidity and mortality were not significantly different in the open and EV groups for AMI or CMI. Thirty-day mortality in AMI (n = 34) was 38.2% (EV: 45.5% vs. open: 34.8%; P = nonsignificant). There was no mortality in either group for CMI patients. Mean follow-up was much longer for the open procedures (34.9 vs. 12.7 months, P = 0.004). Primary and secondary patency rates were better for open revascularization for CMI patients. Conclusions Open revascularizations are equally safe as EV interventions for AMI and CMI. Patency of open revascularization for CMI is better than EV procedures at midterm follow-up.

Purpose: Autogenous arteriovenous fistulas are the preferred access for hemodialysis. Yet when created, fistulas often fail to mature, requiring surgical or radiologic interventions before their use. This pilot study measures the vascular wall elasticity and flow gradient using an open-source ultrasound software program designed to aid in assessing fistula maturation. Methods: A total of seven end-stage renal disease patients were enrolled for our study after providing informed consent. Ultrasound scanning was performed for the inflow artery, post-arterial anastomotic segment, and outflow vein at initial and follow-up evaluation. Conventional digital imaging and communications in medicine data were collected from the ultrasound machine. The vessel diameter and distensibility of artery, post-arterial anastomotic segment, and vein were computed from the digital imaging and communications in medicine data using an open-source ultrasound software program. Results: The vessel diameter of artery and vein increased from 4.6 ± 1.1 mm to 6.0 ± 1.1 mm and from 5.8 ± 0.7 mm to 7.5 ± 0.9 mm from 1 to 6 weeks post-operation, respectively. Conversely, the vessel diameter of post-arterial anastomotic segment decreased from 4.2 ± 1.0 mm to 3.5 ± 0.9 mm from 1 to 6 weeks post-operation. The distensibility of artery and post-arterial anastomotic segment increased from 3.4% ± 0% to 5.9% ± 1.1% and 3.7% ± 1.2% to 4.9% ± 1.4%, respectively, while the distensibility of vein decreased from 5.0% ± 1.3% to 2.6% ± 0.4% from 1 to 6 weeks post-operation. Conclusion: This study demonstrates that the change in vessel diameter and distensibility related to the healthy remodeling as the vein dilates during maturation.

Background An association between increased venous thromboembolism (VTE) events and influenza A H1N1 (H1N1) was noted in the first 10 patients with severe acute respiratory distress syndrome (ARDS). An empirical systemic anticoagulation protocol (heparin intravenous infusion) was initiated when autopsy of patients with severe hypoxemia confirmed multiple primary pulmonary thrombi and emboli. The purpose of this study was to examine the relationship between H1N1 and VTE events and to assess the efficacy of empirical systemic heparin anticoagulation in preventing VTE and death in H1N1 severe ARDS patients. Methods An observational cohort study of critically ill severe ARDS patients with possible H1N1 viral pneumonia was performed in a surgical intensive care unit in a single 990-bed academic tertiary care center. Early empirical systemic heparin anticoagulation for all severe ARDS patients with possible H1N1 viral pneumonia was initiated as a VTE preventive strategy. Results Univariate comparisons and multivariate logistic regression were used to identify risk factors for VTE. Independent risk factors for VTE included H1N1, culture-positive bacterial pneumonia, and vasopressor requirement. Independent risk factors for pulmonary embolism included H1N1, culture-positive bacterial pneumonia, and male sex. H1N1 ARDS patients had 23.3-fold higher risk for pulmonary embolism and 17.9-fold increased risk for VTE. Kaplan-Meier analysis and log-rank test confirmed that empirical systemic heparin anticoagulation provided significant protection from thrombotic events in the H1N1-positive but not in the H1N1-negative critically ill ARDs patients. In multivariate analysis, adjusting for H1N1 status, patients without empirical systemic anticoagulation were 33 times more likely to have any VTE compared with those treated with empirical systemic heparin anticoagulation (P = .01). Conclusions Critically ill patients with H1N1 ARDS have increased risk of venous thrombotic complications, particularly pulmonary thromboembolism. Empirical systemic heparin anticoagulation in this cohort of patients significantly reduced VTE incidence without increased hemorrhagic complications.

To evaluate the clinical features and outcomes of patients with anemia undergoing percutaneous peripheral vascular intervention (PVI) in a contemporary registry.We evaluated the differences in the clinical features and outcomes of patients with and without anemia undergoing PVI in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2 VIC) registry. Anemia was defined using World Health Organization criteria.Baseline anemia was present in 42.3% of 15,683 patients undergoing PVI. Compared to patients without anemia, those with anemia were older (mean age, 67 years vs 71 years), were more often black (16% vs 29%), and had higher comorbidities. Anemic patients were twice as likely to present with acute limb ischemia (5% vs 11%) and undergo urgent PVI (6% vs 15%) or below-the-knee PVI (18% vs 35%). Many in-hospital adverse events were higher in anemic patients. In a propensity-matched cohort, any adverse outcome (3.4% vs 8.4%; odds ratio [OR], 2.58; 95% confidence interval [CI], 1.94-3.42) or major cardiovascular event, defined as death, myocardial infarction, stroke, or amputation (1.1% vs 3.2%; OR, 2.96; 95% CI, 1.83-4.79) was more likely in anemic patients. Of all adverse events, the highest odds were observed for post-PVI transfusions and amputations in anemic patients. Multivariable logistic regression showed that baseline hemoglobin (1 g/dL below the normal value) was associated with greater risk of any adverse event (OR, 1.57; 95% CI, 1.47-1.68).The prevalence of anemia was high among PVI patients and was associated with significantly greater likelihood of amputation, any adverse event, and major cardiovascular events. Whether preprocedure correction of anemia has the potential to decrease post-PVI adverse events remains to be studied.

OBJECTIVE To understand statewide variation in preoperative cardiology consultation prior to major vascular surgery and to determine whether consultation was associated with differences in perioperative myocardial infarction (poMI). SUMMARY BACKGROUND DATA Medical consultation prior to major vascular surgery is obtained to reduce perioperative risk. Despite perceived benefit of preoperative consultation, evidence is lacking specifically for major vascular surgery on the effect of preoperative cardiac consultation. METHODS Patient and clinical data were obtained from a statewide vascular surgery registry between January 2012 and December 2014. Patients were risk stratified by revised cardiac risk index category and compared poMI between patients who did or did not receive a preoperative cardiology consultation. We then used logistic regression analysis to compare the rate of poMI across hospitals grouped into quartiles by rate of preoperative cardiology consultation. RESULTS Our study population comprised 5191 patients undergoing open peripheral arterial bypass (n = 3037), open abdominal aortic aneurysm repair (n = 332), or endovascular aneurysm repair (n = 1822) at 29 hospitals. At the patient level, after risk-stratification by revised cardiac risk index category, there was no association between cardiac consultation and poMI. At the hospital level, preoperative cardiac consultation varied substantially between hospitals (6.9%-87.5%, P 66%) had a reduction in poMI (OR, 0.52; confidence interval: 0.28-0.98; P

OBJECTIVES Major life stressors, including major surgeries, are often followed by psychiatric symptoms and disorders. Prior retrospective work found abdominal aortic aneurysm (AAA) repair is followed by increased psychiatric morbidity, which may adversely influence physical and functional recovery. Identifying risk factors before surgery, such as dysregulation in stress response systems, might be useful in improving preventative intervention. METHODS Two hundred sixteen patients receiving open AAA or aortofemoral bypass surgeries, endovascular AAA repair, or nonsurgical AAA treatment were recruited from two vascular surgery services. Psychiatric symptoms and salivary cortisol measures (waking, 4 PM, and 11 PM, before and after low-dose dexamethasone) were obtained at intake and 3- and 9-month follow-ups. RESULTS After open surgeries, 18% of patients had new psychiatric disorders, compared with 4% of patients receiving endovascular AAA repair or nonsurgical treatment (odds ratio = 6.0, 95% confidence interval = 1.6-22.1, p = .007). Having a history of major depression predicted the onset of new disorders in surgical patients. Presurgical cortisol levels were associated with both baseline (r = 0.23, p < .05) and 9-month (r = 0.32, p < .01) psychiatric symptoms (cortisol B = 1.0, standard error = 0.48, p < .05, in repeated-measures mixed model). CONCLUSIONS Open AAA repair surgery is prospectively linked to the development of psychiatric morbidity, and history of depression elevates risk. Cortisol measures before surgery are associated with current and future psychological functioning, suggesting potential neurobiological mechanisms that may contribute to vulnerability. These results can help identify surgical patients at risk and point to potential targets for risk reduction interventions.

Trauma patients are at high risk for life-threatening venous thromboembolic (VTE) events. We examined the relationship between prophylactic inferior vena cava (IVC) filter use, mortality, and VTE.The prevalence of prophylactic placement of IVC filters has increased among trauma patients. However, there exists little data on the overall efficacy of prophylactic IVC filters with regard to outcomes.Trauma quality collaborative data from 2010 to 2014 were analyzed. Patients were excluded with no signs of life, Injury Severity Score9, hospitalization3 days, or who received IVC filter after occurrence of VTE event. Risk-adjusted rates of IVC filter placement were calculated and hospitals placed into quartiles of IVC filter use. Mortality rates by quartile were compared. We also determined the association of deep venous thrombosis (DVT) with the presence of an IVC filter, accounting for type and timing of initiation of pharmacological VTE prophylaxis.A prophylactic IVC filter was placed in 803 (2%) of 39,456 patients. Hospitals exhibited significant variability (0.6% to 9.6%) in adjusted rates of IVC filter utilization. Rates of IVC placement within quartiles were 0.7%, 1.3%, 2.1%, and 4.6%, respectively. IVC filter use quartiles showed no variation in mortality. Adjusting for pharmacological VTE prophylaxis and patient factors, prophylactic IVC filter placement was associated with an increased incidence of DVT (OR = 1.83; 95% CI, 1.15-2.93, P-value = 0.01).High rates of prophylactic IVC filter placement have no effect on reducing trauma patient mortality and are associated with an increase in DVT events.

We evaluated the impact of the prescription of evidence-based medical therapy (EBMT) including aspirin (ASA), beta-blockers (BB), ACE-inhibitors or angiotensin receptor blockade (ACE/ARB), and statins prior to discharge after peripheral vascular intervention (PVI) on long-term medication utilization in a large multi-specialty, multicenter quality improvement collaborative. Among patients undergoing coronary revascularization, use of the component medications of EBMT at hospital discharge is a major predictor of long-term utilization. Predictors of EBMT use after PVI are largely unknown. A total of 10,169 patients undergoing PVI between 1 January 2008 and 31 December 2011 were included. Post-PVI discharge and 6-month medication utilization in patients without contra-indications to ASA, BB, ACE/ARB, and statins were compared. ASA was prescribed at discharge to 9345 (92%) patients, BB to 7012 (69%), ACE/ARB to 6424 (63%), and statins to 8342 (82%), and all four component drugs of EBMT in 3953 (39%). Compared with patients not discharged on the appropriate medications, post-procedural use was associated (all p

Objectives: To identify the patient-level effects of blood transfusion on postoperative outcomes and to estimate the effects of different transfusion practices on hospital-level risk-adjusted outcomes. Background: Postoperative transfusion practices and their effects on short-term outcomes in patients undergoing noncardiac surgery are not well understood. Methods: Demographic, operative, and outcomes data for 48,720 patients undergoing general or vascular surgery at 52 hospitals between July 2012 and April 2014 were obtained. The main exposure variable was receipt of any blood transfusion within 72 hours after surgery. Thirty-day mortality, any morbidity, infectious complications, and postoperative myocardial infarction were the outcomes of interest. Propensity score matching was used to minimize confounding by indication. Hospitals were categorized as having a restrictive, average, or liberal transfusion practice based on average trigger hemoglobin values. Results: A total of 2243 (4.6%) patients received a postoperative blood transfusion. After propensity matching, a postoperative transfusion was associated with increased 30-day mortality (3.6% excess absolute risk), any morbidity (4.4% excess absolute risk), and infectious morbidity (1.0% excess absolute risk). However, a transfusion was associated with 3.5% absolute risk reduction in postoperative myocardial infarction. At the hospital level, there was a wide variation in transfusion practices. Hospitals with liberal practices were twice as likely to transfuse patients and had higher risk-adjusted mortality rates than restrictive hospitals (3.1% vs 2.2%; P = 0.002). Conclusions and Relevance: Postoperative transfusions after noncardiac surgery are associated with increased adverse postoperative outcomes, with the exception of postoperative myocardial infarction. Hospitals that are liberal in their transfusion practices have higher 30-day mortality rates, suggesting potential interventions for quality improvement.

Background Postthrombotic intraluminal tissue causing postthrombotic syndrome (PTS) has not been well described. This study defines its histological characteristics and assess whether tissue function evolves over time. Methods Specimens from 18 common femoral veins (CFV) from 16 patients obtained during CFV endovenectomy and iliocaval recanalization were examined. Phase 1 used hematoxylin and eosin and Masson’s trichrome stains for collagen, immunohistochemical, and Von Kossa stains. Phase 2 examined young (≤ one year) and mature (≥ 10 years from acute DVT) specimens to evaluate evolution of endothelial function. Antibodies to four biomarkers were used to examine specific functions of endothelial cells lining neovessels and recanalization channels (RC). Results Phase 1: S pecimens demonstrated 80-90% of collagen type I, 10-20% of collagen type III, and dystrophic calcification. Neovessels and RC were in close proximity to each other. Thrombus and smooth muscle cells were absent, but white blood cells were present. Phase 2: VEGFR2 receptor uptake was more abundant in neovessels than RC and more prominent in younger specimens. Neovascular, nonchannel cells were observed more frequently in young specimens. CD-31 was similar in young and mature specimens. TIE-2 and von Willebrand factor antibodies had greater uptake in mature specimens. Conclusion Tissue causing chronic postthrombotic venous obstruction is predominantly type I collagen. Neovascularization and recanalization occur in close proximity. The biomarker for neovascularization and angiogenesis (VEGFR2) was more prominent in young specimens whereas TIE-2, a stabilizing biomarker and vWF were more frequently observed in mature specimens.

Sequential compression devices (SCDs) reduce deep venous thrombosis in postsurgical patients, but the use is hindered by poor compliance.General and orthopedic surgery patients (n = 67) were randomized to standard- or battery-powered SCDs. Compliance was documented hourly. Nurses and patients were issued a survey to assess barriers to compliance and device satisfaction.Compliance with standard SCDs was 47% compared with 85% with battery-powered SCDs (P.001). The most common barriers identified by nurses and patients were ambulation and transfers, which were mitigated with the battery-powered device. A majority (79%) of those issued a battery-powered device reported no major problems compared with only 14% of patients issued a standard device (P.005).The dual venous thromboembolism prevention strategies of early mobilization and SCD utilization can be met with the appropriate equipment.

SummaryDeep-vein thrombosis (DVT) resolves via a sterile inflammatory response. Defining the inflammatory response of DVT may allow for new therapies that do not involve anticoagulation. Previously, we have shown that Toll-like receptor 9 (Tlr9) gene deleted mice had impaired venous thrombosis (VT) resolution. Here, we further characterise the role of Tlr9 signalling and sterile inflammation in chronic VT and vein wall responses. First, we found a human precedent exists with Tlr9 + cells present in chronic post thrombotic intraluminal tissue. Second, in a stasis VT mouse model, endogenous danger signal mediators of uric acid, HMGB-1, and neutrophil extracellular traps marker of citrullinated histone-3 (and extracellular DNA) were greater in Tlr9-/- thrombi as compared with wild-type (WT), corresponding with larger VT at 8 and 21 days. Fewer M1 type (CCR2+) monocyte/macrophages (MØ) were present in Tlr9-/- thrombi than WT controls at 8 days, suggesting an impaired inflammatory cell influx. Using bone marrow-derived monocyte (BMMØ) cell culture, we found decreased fibrinolytic gene expression with exposure to several endogenous danger signals. Next, adoptive transfer of cultured Tlr9+/+ BMMØ to Tlr9-/- mice normalised VT resolution at 8 days. Lastly, although the VT size was larger at 21 days in Tlr9-/- mice and correlated with decreased endothelial antigen markers, no difference in fibrosis was found. These data suggest that Tlr9 signalling in MØ is critical for later VT resolution, is associated with necrosis clearance, but does not affect later vein wall fibrosis. These findings provide insight into the Tlr9 MØ mechanisms of sterile inflammation in this disease process.

Acute limb ischemia (ALI) of the lower extremity is a potentially devastating condition that requires urgent and definitive management. This challenging scenario is often treated with endovascular, open surgical, or hybrid revascularization (HyR) in an urgent basis, but the comparative effects of such therapies remain poorly defined. The purpose of this study was to compare the outcomes of endovascular, open surgical, and HyR for ALI in the contemporary era.A large statewide cardiovascular consortium of 45 hospitals was queried for patients between January 2012 and June 2015 who underwent an endovascular, open surgical, or HyR for ALI deemed at high risk of limb loss if not treated within 24 hr (Rutherford class IIA or IIB). A propensity score weighted analysis was performed controlling for demographics, medical history, and procedure type for patients. The primary outcomes were 30-day morbidity and mortality.A total of 1,480 patients underwent endovascular revascularization (ER; n = 818), open surgical revascularization (OSR; n = 195), or hybrid revascularization (HyR; n = 467) for ALI. The mean age was similar across revascularization technique with an increased predominance of male gender in open surgery cohort. Comorbidities for all groups were consistent with peripheral arterial disease. The most common endovascular procedures were angioplasty (93%) and thrombolysis (49.8%), whereas the most common surgical revascularization was femoral to popliteal bypass (32.8%), femoral to tibial bypass (28.2%), and thrombectomy (19.0%); ER as compared with OSR and HyR procedures was associated with less transfusion (OSR versus ER, odds ratio [OR] 2.7; HyR versus ER, OR 2.8; P 0.001) and major amputation (OSR versus ER, OR 3.4; HyR versus ER, OR 4.0; P 0.001) within 30 days of intervention. There was no difference in 30-day freedom from reintervention, myocardial infarction (MI), or mortality.Among patients requiring urgent revascularization for Rutherford grade IIA and IIB ischemia, ER has lower 30-day morbidity but similar mortality and rates of reintervention. Although long-term patency rates were not compared, ER may offer superior short-term outcomes compared with open surgery and hybrid revascularization.

OBJECTIVE: Wound monocyte-derived macrophage plasticity controls the initiation and resolution of inflammation that are critical for proper healing, however, in diabetes, the resolution of inflammation fails to occur. In diabetic wounds, the kinetics of blood-monocyte recruitment and the mechanisms that control in vivo monocyte/macrophage differentiation remain unknown. APPROACH AND RESULTS: Here, we characterized the kinetics and function of Ly6C(Hi)[Lin(−) (CD3(−)CD19(−)NK1.1(−)Ter-119(−))Ly6G(−)CD11b(+)] and Ly6C(Lo)[Lin(−) (CD3(−)CD19(−)NK1.1(−)Ter-119(−))Ly6G(−)CD11b(+)] monocyte/macrophage subsets in normal and diabetic wounds. Using flow-sorted tdTomato-labeled Ly6C(Hi) monocyte/macrophages, we show Ly6C(Hi) cells transition to a Ly6C(Lo)- phenotype in normal wounds, whereas in diabetic wounds, there is a late, second influx of Ly6C(Hi) cells that fail transition to Ly6C(Lo). The second wave of Ly6C(Hi) cells in diabetic wounds corresponded to a spike in MCP-1 and selective administration of anti-MCP-1 reversed the second Ly6C(Hi) influx and improved wound healing. To examine the in vivo phenotype of wound monocyte/macrophages, RNA-seq-based transcriptome profiling was performed on flow-sorted Ly6C(Hi)[Lin(−)Ly6G(−)CD11b(+)] and Ly6C(Lo)[Lin(−)Ly6G(−)CD11b(+)] cells from normal and diabetic wounds. Gene transcriptome profiling of diabetic wound Ly6C(Hi) cells demonstrated differences in pro-inflammatory and pro-fibrotic genes compared to controls. CONCLUSIONS: Collectively, these data identify kinetic and functional differences in diabetic wound monocyte/macrophages and demonstrate that selective targeting of CD11b(+)Ly6C(Hi) monocyte/macrophages is a viable therapeutic strategy for inflammation in diabetic wounds.

Blood transfusions are associated with adverse events. We examined perioperative transfusion practices and associated complications following open vascular procedures nationwide in the Vascular Quality Initiative (VQI).Adults undergoing open abdominal aortic aneurysm repair (OAR) and lower extremity arterial bypass (Bypass) within VQI (2003-2016) were identified. All emergent cases, patients with preoperative hemoglobin7 g/dL, preoperative hospitalization1 day, or a return to operating room during the index hospitalization were excluded. Units of red blood cells transfused were the primary outcome. Secondary outcomes were postoperative myocardial infarction (MI) and death. Patient, center, and procedural factors were evaluated. Multivariable mixed effects negative binomial regression and multivariable logistic regression were performed.We identified 24,131 procedures (OAR 3885, 16.1%; Bypass 20,246, 83.9%) among 22,532 patients (10.1% had1 procedure). Overall, 37.5% of OAR and 19.5% of Bypass were transfused. Transfusion rates varied across estimated blood loss quartiles and across various preoperative hemoglobin levels. The overall rate of postoperative MI and death was 4.0% and 1.8% for OAR, and 2.2% and 0.7% for Bypass, respectively. In univariate and multivariable analysis, transfusions were associated with an increased risk of postoperative MI and death. A mixed effects negative binomial model demonstrated variation in transfusions across centers (P 0.001). Female gender and preoperative anemia were significantly associated with transfusions.Blood transfusions are variable across centers in VQI. Transfusions are associated with a higher postoperative MI and death after OAR and Bypass. Efforts to reduce transfusion may focus on center variability, gender, and preoperative anemia.

Objectives The relationship between preoperative medical consultations and postoperative complications has not been extensively studied. Thus, we investigated the impact of preoperative consultation on postoperative morbidity following elective abdominal aortic aneurysm repair. Methods A retrospective review was conducted on 469 patients (mean age 72 years, 20% female) who underwent elective abdominal aortic aneurysm repair from June 2007 to July 2014. Data elements included detailed medical history, preoperative cardiology consultation, and postoperative complications. Primary outcomes included 30-day morbidity, consult-specific morbidity, and mortality. A bivariate probit regression model accounting for the endogeneity of binary preoperative medical consult and patient variability was estimated with a maximum likelihood function. Results Eighty patients had preoperative medical consults (85% cardiology); thus, our analysis focuses on the effect of cardiac-related preoperative consults. Hyperlipidemia, increased aneurysm size, and increased revised cardiac risk index increased likelihood of referral to cardiology preoperatively. Surgery type (endovascular versus open repair) was not significant in development of postoperative complications when controlling for revised cardiac risk index ( p = 0.295). After controlling for patient comorbidities, there was no difference in postoperative cardiac-related complications between patients who did and did not undergo cardiology consultation preoperatively ( p = 0.386). Conclusions When controlling for patient disease severity using revised cardiac risk index risk stratification, preoperative cardiology consultation is not associated with postoperative cardiac morbidity.

Given the very ill nature of patients with critical limb ischemia (CLI), the use of percutaneous vascular interventions (PVIs) for limb salvage may or may not be efficacious; in particular, for those with polyvascular arterial disease. Herein, we reviewed large, multi-institutional outcomes of PVI in polyvascular and peripheral arterial disease (PAD) patients with CLI. An 18-hospital consortium collected prospective data on patients undergoing endovascular interventions for PAD with 6-month follow-up from January 2008 to December 2011. The patient cohort included 4459 patients with CLI; of those, 3141 patients had polyvascular (coronary artery disease, cerebrovascular disease and PAD) disease, whereas 1318 patients suffered from only PAD. All patients were elderly and with significant comorbidities. The mean ankle–brachial index (ABI) was 0.44 and was not different between those with and without polyvascular disease. Polyvascular patients had more femoropopliteal and infra-inguinal interventions and less aortoiliac interventions than PAD patients. Pre- and post-procedural cardioprotective medication use was less in the PAD patients as compared with polyvascular patients. Vascular complications requiring surgery were higher in PAD patients whereas other access complications were similar between groups. At 6-month follow-up, death was more common in the polyvascular group (6.7% vs 4.1%, p

Surgical intensive care unit (SICU) patients are known to be at high risk for venous thromboembolism (VTE). The 2005 Caprini Risk Assessment Model (RAM) predicts VTE risk in surgical patients. However, a physician's ability to accurately complete this RAM and the effect that inaccurate RAM completion might have on VTE risk remain unknown.Between 2009 and 2012, physicians completed a 2005 Caprini score for all SICU admissions at our institution. For comparison, we used a previously validated, computer-generated score. Regression-based techniques examined the effect of inadequate risk stratification on inpatient VTE risk, when controlling for other confounders.Among 3,338 consecutive SICU admissions, 55.2% had computer-generated scores that were higher than the physician-reported score, and 20.6% of scores were equal. Computer-generated scores were higher than physician-reported scores for both median (6 vs 5) and interquartile range (5 to 8 vs 3 to 7). Inter-rater reliability between the 2 scores was poor (kappa = 0.238). Risk score underestimation by ≥2 points was significantly associated with inpatient VTE (7.67% vs 4.59%, p = 0.002). Regression analysis demonstrated that each additional day's delay in chemoprophylaxis (odds ratio [OR] 1.05, 95% CI 1.01 to 1.08, p = 0.011) and under-risk stratification by ≥2 points (OR 2.46, 95% CI 1.53 to 3.96, p0.001) were independent predictors of inpatient VTE, as were higher admission APACHE score, personal history of VTE, recent pneumonia, and younger age.Physicians under-risk stratify SICU patients when using the 2005 Caprini RAM. As hospitals incorporate electronic medical records into daily practice, computer-calculated Caprini scores may result in more accurate VTE risk stratification. Inadequate VTE risk assessment and delay to chemoprophylaxis carry independent and significant increased risk for VTE.

Objective— Deep vein thrombosis (VT) can result in vein wall injury, which clinically manifests as post-thrombotic syndrome. Postinjury fibrosis may be modulated in part through cellular cysteine-cysteine receptor 7 (CCR7)–mediated events. We tested the hypothesis that late vein wall fibrotic remodeling is dependent on CCR7. Approach and Results— CCR7 −/− and C57BL/6 wild-type mice had inferior vena cava VT induced by nonstasis or stasis mechanisms. In both models, VT size was largest at day 1 and trended down by day 21, and CCR7 + cells peaked at day 8 in wild-type mice. No significant differences in VT resolution were found in CCR7 −/− as compared with wild type in either model. In the nonstasis VT model, vein wall changes consistent with fibrotic injury were evidenced by significant increases in collagen I, III, matrix metalloproteinase 2, and transforming growth factor-β gene expression, increases in α-smooth muscle actin and fibroblast specific protein-1 antigen, and total collagen at 8 days. Correspondingly, SM22α and fibroblast specific protein-1, but not DDR2 + cells, were increased at 8 days. Early wild-type thrombus exposure inhibited profibrotic gene expression in CCR7 −/− in ex vivo vein wall culture. Bone marrow chimera experiments further showed that circulating CCR7 + leukocytes partially rescued midterm profibrotic changes in CCR7 −/− mice. In human histological sections of chronic thrombosed femoral veins, CCR7 + cells were present in the fibrotic areas. Conclusions— Post-thrombotic vein wall remodeling is impaired in CCR7 −/− mice, with a profibrotic phenotype, is dependent on the thrombotic mechanism, and is mediated by circulating CCR7 + cells. Unlike other postinjury fibrotic responses, CCR7 + signaling may be important for positive vein wall remodeling after VT.

It is hypothesized that differential AKT phosphorylation between sexes is important in abdominal aortic aneurysm (AAA) formation. Male C57BL/6 mice undergoing elastase treatment showed a typical AAA phenotype (80% over baseline, P < 0.001) and significantly increased phosphorylated AKT-308 (p308) and total-AKT (T-AKT) at day 14 compared with female mice. Elastase-treated Raw cells produced increased p308 and significant amounts of matrix metalloproteinase 9 (MMP-9), and these effects were suppressed by LY294002 treatment, a known AKT inhibitor. Male and female rat aortic smooth muscle cells treated with elastase for 1, 6, or 24 hours demonstrated that the p308/T-AKT and AKT-Ser-473/T-AKT ratios peaked at 6 hours and were significantly higher in the elastase-treated cells compared with controls. Similarly, male cells had higher phosphorylated AKT/T-AKT levels than female cells. LY294002 also inhibited elastase-induced p308 formation more in female smooth muscle cells than in males, and the corresponding cell media had less pro–MMP-9. AKT siRNA significantly decreased secretion of pro–MMP-9, as well as pro–MMP-2 and active MMP-2 from elastase-treated male rat aortic smooth muscle cells. IHC of male mice AAA aortas showed increased p308, AKT-Ser-473, and T-AKT compared with female mice. Aortas from male AAA patients had a significantly higher p308/T-AKT ratio than female AAA tissues. These data suggest that AKT phosphorylation is important in the upstream regulation of MMP activity, and that differential phosphorylation may be important in sex differences in AAA.

Background The incidence, risk factors, and outcomes associated with Contrast-induced nephropathy (CIN) after Percutaneous Vascular Intervention (PVI) in contemporary medical practice are largely unknown. Methods A total of 13 126 patients undergoing PVI were included in the analysis. CIN was defined as an increase in serum creatinine from pre-PVI baseline to post-PVI peak Cr of ≥0.5 mg/dL. Results CIN occurred in 3% (400 patients) of the cohort, and 26 patients (6.5%) required dialysis. Independent predictors of CIN were high and low body weight, diabetes, heart failure, anemia, baseline renal dysfunction, critical limb ischemia, and a higher acuity of the PVI procedure and a contrast dose that was greater than three times the calculated creatinine clearance (CCC) (adjusted OR 1.4, 95% CI: 1.1-1.8, P = 0.003). CIN was strongly associated with adverse outcome including in-hospital death (adjusted OR 18.1, CI 10.7-30.6, P

Macrophage plasticity is critical for normal tissue repair to ensure transition from the inflammatory to the proliferative phase of healing. We examined macrophages isolated from wounds of patients afflicted with diabetes and of healthy controls and found differential expression of the methyltransferase Setdb2. Myeloid-specific deletion of Setdb2 impaired the transition of macrophages from an inflammatory phenotype to a reparative one in normal wound healing. Mechanistically, Setdb2 trimethylated histone 3 at NF-κB binding sites on inflammatory cytokine gene promoters to suppress transcription. Setdb2 expression in wound macrophages was regulated by interferon (IFN) β, and under diabetic conditions, this IFNβ-Setdb2 axis was impaired, leading to a persistent inflammatory macrophage phenotype in diabetic wounds. Setdb2 regulated the expression of xanthine oxidase and thereby the uric acid (UA) pathway of purine catabolism in macrophages, and pharmacologic targeting of Setdb2 or the UA pathway improved healing. Thus, Setdb2 regulates macrophage plasticity during normal and pathologic wound repair and is a target for therapeutic manipulation.

Widespread adoption of direct oral anticoagulants (DOACs) for atrial fibrillation and venous thromboembolism treatment has resulted in peripheral bypass patients receiving therapeutic anticoagulation with DOACs postoperatively. This study was undertaken to evaluate patient outcomes after open peripheral bypass based on anticoagulation treatment.Postoperative treatment and outcomes of patients undergoing peripheral bypass operations between January 2012 and December 2017 from a statewide multicenter quality improvement registry were examined. Surgeons participating in the registry were surveyed on practice patterns regarding DOACs in bypass patients. Multivariate logistic regression was performed for 30-day transfusion outcomes, and multiple linear regression was performed for length of stay.Among 9682 patients, 7685 patients received no anticoagulation, whereas 1379 received a vitamin K antagonist (VKA) and 618 received a DOAC postoperatively. Patients receiving anticoagulation compared with no anticoagulation had a higher body mass index and were more likely to have preoperative anemia, congestive heart failure, and atrial fibrillation (all P .001). Compared with patients receiving VKAs, patients receiving DOACs were less likely to have chronic kidney disease (P = .002) and more likely to have atrial fibrillation (P .001). The shortest length of stay was among patients receiving no anticoagulation (median, 5 days; interquartile range, 3-9 days; P .001), followed by DOACs (median, 6 days; interquartile range 3-11 days; P .001) and VKAs (median, 8 days; interquartile range, 5-13 days; P .001). Compared with patients receiving VKAs postoperatively, there was no difference in readmission for anticoagulation complications, bypass thrombectomy or thrombolysis, major amputation, or graft patency at 1 year among patients receiving DOACs. On multivariate logistic regression, patients receiving a DOAC (odds ratio, 0.743; confidence interval, 0.59-0.94; P = .011) or no anticoagulation (odds ratio, 0.792; confidence interval, 0.69-0.91; P = .001) were less likely to require transfusion within 30 days than patients taking VKAs. Approximately 70% of the surveyed surgeons reported that they "sometimes" or "always" use DOACs instead of VKAs for protection of a high-risk bypass.Among patients undergoing lower extremity surgical bypass, those receiving a DOAC postoperatively had a shorter length of stay and were less likely to receive a transfusion in 30 days without compromising graft patency and readmission for anticoagulation complications, thrombectomy, or thrombolysis or affecting amputation rate compared with those receiving a VKA. A majority of surgeons within the quality collaborative have adopted the use of DOACs after peripheral bypass, suggesting the need for a prospective trial evaluating DOAC safety and efficacy in patients requiring anticoagulation for high-risk bypass grafts.

As research increasingly challenges the diagnostic accuracy of advanced imaging for lumbar spinal stenosis, the impression gleaned from the office evaluation becomes more important. Neurogenic claudication is a hallmark of lumbar spinal stenosis, but the reliability of clinical impression of claudication has not been studied.To determine the reliability of the clinical examination for neurogenic claudication in an idealized setting.Prospective masked controlled trial.Persons aged 55 to 90 years were recruited to form three groups: those offered surgery for spinal stenosis by academic spine surgeons, those who had peripheral vascular symptoms and positive ankle-brachial index (ABI), and those who were asymptomatic. All were extensively screened against confounding diseases. Forty-three neurogenic, 12 vascular, and 35 asymptomatic recruits were tested.Clinical impression of neurogenic claudication.A neurosurgeon and a vascular surgeon, masked to each other's findings, imaging, and recruitment status, performed a codified but unconstrained comprehensive spine and vascular history and physical examination for each subject. The surgeon's impression was recorded.Masked surgeons strongly agreed with the recruitment diagnosis (neurosurgeon kappa 0.761, vascular surgeon kappa 0.803, both p.001) and with each other (kappa 0.717, p.001). However, disagreements did occur between examiners and recruitment diagnosis (neurosurgeon n=13 cases, vascular surgeon n=10) and between examiners (n=14 cases). Pain level and marginally some measures of disability related to the agreement, but specific aspects of the physical examination, showed poor interrater reliability and did not contribute to the agreement.The clinical impression of neurogenic claudication is a reliable construct. The history, but not the poorly reproduced physical examination, contributes to reliability. The level of disagreement between experts in this simplified, yet severely involved, population raises concern about the risk of misdiagnosis in individual cases. Thus, surgical and other consequential decisions about diagnosis may require ancillary tests such as electromyography or ABI.

Background With the growing prevalence of endovascular repair for abdominal aortic aneurysm (AAA), the number of patients requiring graft explantation is increasing. Therefore, knowledge related to outcomes after explantation may lead to improvement in surgical options. In this study we compare our experience with explantation of aortic endografts, based on indication. Methods The medical records of all aortic procedures performed at our center were queried during the period from 2002 to 2012. Relevant data from patients needing explantation of aortic endografts were analyzed using Fisher’s exact test, t-test, and Kaplan-Meier analysis. Results Thirty-nine patients underwent aortic endograft explantation (64.1% men). Mean age was 71.9 years with a mean aneurysm size of 6.8 cm (range 3.5–10.7 cm). Hypertension (97.4%), hyperlipidemia (76.9%), and history of smoking (82%) were the most prevalent risk factors. Mean time to explant was 41.7 months (range 2.2–118.4 months). The primary explant indication was endoleak in 27 (69.2%) and infection in 12 (30.8%) patients. The endoleak group consisted of 13 type I, 8 type II, 1 type III, 4 endotension, 1 rupture, and 4 patients with multiple endoleaks. Seven patients were symptomatic, whereas 2 had ruptured aneurysms. Half of the patients in the infection group required supraceliac clamping for explantation. Operative blood loss (P = 0.08) and need for transfusion (P = 0.005) were significantly higher in the infection group. Thirty-day morbidity was 51.8% for the endoleak group and 83% for the infection group (P = 0.08). There were only 2 deaths in the cohort within 30 days, both in the infection group. Twenty-seven patients were alive at a mean follow-up of 1.9 years (range 0.1–8.4 years). Conclusions Endograft explantation is a challenging operation with high morbidity and mortality. Furthermore, patients with an infectious etiology have significantly worse outcomes than those requiring explantation for endoleaks.

Post thrombotic syndrome therapy is primarily palliative, and the associated vein wall inflammatory mechanisms are unclear. Vein wall fibrotic injury following deep venous thrombosis (VT) is associated with elevated matrix metalloproteinases (MMPs). Whether and by what mechanism MMP9 directly contributes to vein wall remodeling after VT is unknown.WT and MMP9 -/- mice underwent stasis VT by ligation of the inferior vena cava (IVC) and tissue was harvested at 2, 8, and 21days. Assessment of thrombus size, and gene, protein and structural vein wall determinations were done.VT resolution was increased in MMP9-/- mice as compared with controls at 21d only. The primary phenotypic fibrotic vein wall differences occurred at 8d post VT, with significantly less vein wall collagen content as assessed by Picosirius red staining in MMP9 -/- mice as compared with WT. Increased monocytic vein wall influx with less IL-1b and TGFb was found in MMP9 -/- vein walls as compared with WT. Corresponding levels of PAI-1 were increased in MMP9 -/- compared with WT, and no difference in FSP-1+cells as compared with controls.In stasis VT, MMP9 modulates midterm vein wall collagen content, with an altered local inflammatory and profibrotic environment, likely directed by monocytes. Thus, MMP9 plays a role in both vein wall responses as well as late thrombus resolution.

SummaryPreviously, we presented the electrolytic inferior vena cava (IVC) model (EIM) during acute venous thrombosis (VT). Here, we present our evaluation of the EIM for chronic VT time points in order to determine whether this model allows for the study of thrombus resolution. C57BL/6 mice (n=191) were utilised. In this model a copper-wire, inserted into a 25-gauge needle, is placed in the distal IVC and another subcutaneously. An electrical current (250 Amp/15 minutes) activates the endothelial cells, inducing thrombogenesis. Ultrasound, thrombus weight (TW), vein wall leukocyte counts, vein wall thickness/ fibrosis scoring, thrombus area and soluble P-selectin (sP-sel) were performed at baseline, days 1, 2, 4, 6, 9, 11 and 14, post EIM. A correlation between TW and sP-sel was also determined. A thrombus formed in each mouse undergoing EIM. Blood flow was documented by ultrasound at all time points. IVC thrombus size increased up to day 2 and then decreased over time, as shown by ultrasound, TW, and sP-sel levels. TW and sP-sel showed a strong positive correlation (r=0.48, pNote: Results were presented, in part, at the 24th American Venous Forum Annual Meeting 2012 in Orlando, FL, USA.

The objective of this study was to test a novel model of inducing abdominal aortic aneurysms (AAAs) in different mouse strains and genders.Male and female C57BL/6 and B6129 mice (n = 5 per group) underwent periaortic dissection and porcine pancreatic elastase (30 μL) or inactivated elastase application (5 min) to the aorta. Aortic measurements were taken on days 0 and 14. Aortic samples were analyzed for histology and zymography for matrix metalloproteinase (MMP) activity. Comparison statistics were performed using unpaired t-test.AAA phenotype (50% aortic increase) occurred in external elastase-treated males (100%) and females (90%). No control animals developed AAAs. The aortic diameter was larger in C57BL/6 and B6129 elastase-treated versus control males (P = 0.0028 and P0.0001, respectively) and females (P0.0001 and P = 0.0458, respectively). Histology verified phenotype via disrupted internal elastic laminae. Macrophage counts in elastase-treated animals were6-fold higher than in controls (all groups significant). MMP9 activity was greater in elastase-treated males and females in C57BL/6 (P = 0.0031, P = 0.0004) and B6129 (P = 0.025, P = 0.2) mice; MMP2 activity was greater in C57BL/6 versus B6129 male elastase-treated mice.This rodent model produced AAAs in both genders and strains of mice. This model is simple, has little variability, and occurs in the infrarenal aorta, substantiating the external elastase model for future studies.