Search

Introduction: Published data on procalcitonin (PCT) levels after microsurgical interventions are very scarce, although infection within these patients is not only associated with severe morbidity but also significantly higher mortality rates., Material and Methods: Retrospective study on 20 patients, who were operated on by a single experienced plastic and reconstructive surgeon within one year (June 2017-June 2018). The authors included all patients, who received microvascular transplants for reconstruction of soft tissue defects. Furthermore, age above 18 years and appropriate documentation allowing sufficient data collection were defined as inclusion criteria. The authors excluded all patients with perioperative systemic inflammation and transplant loss, as our aim was to solely determine and evaluate potential alterations of serological PCT levels after microsurgical interventions., Results: The PCT cutoff level to differentiate physiological and pathological levels was defined as 0.1 μg/L. There was no detectable increase in procalcitonin in all of our 20 patients, for whom the authors performed microvascular transplantation to reconstruct soft tissue defects., Conclusion: Serological PCT levels remain stable after the considered surgical interventions and therefore PCT levels might be utilized to identify systemic inflammation, thus helping to reduce severe complications by early individualized antiinfective treatment strategies.

Objectives: The effect of superficial femoral artery (SFA) occlusion on long-term patency of aortofemoral bypasses (AFBs) for aortoiliac occlusive disease (AIOD) was examined., Methods: The AIOD database was reviewed to identify risk factors for AFB failure. The status of the SFA at AFB procedure was categorised as patent; diseased treated (DT), if the SFA occlusion was intervened on concomitant to AFB; or diseased untreated (DU), if the SFA was occluded but not revascularised. Censoring hierarchies for primary patency and patent graft survival time were constructed. Data were analysed by contingency table, Kaplan-Meier, and Cox regression analysis., Results: Between 2004 and 2015, 122 AFB (9 unifemoral, 113 bifemoral) for AIOD were performed. Seventy-five (61%) were female and the mean age was 60 ± 10 years. At the time of AFB, 50 (41%) had occluded SFAs (DT/DU). Of these, 15 had concomitant SFA revascularisation (i.e., DT) at the time of AFB. Patients with occluded SFAs had greater history of prior aortoiliac/infrainguinal procedures (aortoiliac 54% vs. 22%, infrainguinal 58% vs. 25%, both p < 0.001), Trans-Atlantic Inter-Society Consensus II classification of femoropopliteal type D lesions (78 vs. 10%, p < 0.001), Rutherford 4-6 categories (80% vs. 57%, p = 0.011), and longer hospital stay (median 11 vs. 7 days, p < 0.004). SFA status did not affect 30 day mortality (overall 9%); however, sub-analysis showed DT had significantly higher mortality than DU (p < 0.03). Over a median follow up of 7.7 (IQR 4.3-11.4) years, primary patency at one and five years was 98.3% and 91.2% in patients with patent SFAs, 87.9% and 82.7% in DU, and 72.7% and 43.6% in DT (p < 0.001), respectively. On multivariable analysis, low baseline glomerular filtration rate (HR 1.01, p = 0.022), DT (HR 3.7, p = 0.020), Rutherford 4-6 (HR 9.1, p = 0.048), and occluded SFA (HR 3.9, p = 0.009) adversely affected primary patency of AFBs. Long-term mortality was not different between the SFA status groups (p = 0.279)., Conclusion: Baseline SFA occlusion predicted a fourfold increased hazard of primary AFB failure. Concomitant SFA revascularisation did not improve AFB durability and was associated with increased in hospital mortality., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: We describe the feasibility and long-term outcomes of using femoral vein (FV) for arteriovenous fistula (AVF) and lower extremity bypass (LEB) creation., Methods: All patients undergoing AVF or LEB using autogenous FV by a single surgeon (April 2006 to September 2013) were reviewed. Perioperative (30-d) complications and long-term outcomes are described., Results: Forty-four patients underwent vascular reconstruction with FV (AVF = 27 and LEB = 17). Perioperative morbidity was 43.2%, including harvest site infection and or seroma in 15.9%. No patients suffered from compartment syndrome or venous thromboembolic event. At median follow-up of 50.0 mon, overall patency was 70.4% for AVF (primary = 37.0% and secondary = 70.3%) and 76.5% for LEB (primary = 70.6% and secondary = 76.5%). Long-term lower extremity swelling occurred in 18.2% of patients., Conclusions: Perioperative morbidity following FV harvest is high, but long-term patency rates are excellent. FV harvest is feasible and should be considered as a valid conduit in patients without useable great saphenous vein or other more commonly used sources of autogenous vein., (Copyright © 2018. Published by Elsevier Inc.)

Poly (propylene carbonate, PPC) is a new member of the aliphatic polyester family. An outstanding feature of PPC is that it produces mainly water and carbon dioxide when degraded in vivo, causing minimal side effects. This unique property together with excellent biocompatibility and biodegradability makes PPC a promising material for drug delivery. In this study, we explored the effect of the sirolimus (an inhibitor of cell growth)-eluting PPC mesh on graft stenosis and its possible mechanisms in a rat arteriovenous grafting model. The PPC mesh was prepared by electrospinning. A jugular vein to abdominal aortic autograft transplantation model was established in rats. The graft was then treated by wrapping with the drug mesh or the drug-free mesh or left untreated. Four weeks posttransplantation, neointima was measured with hematoxylin and eosin staining, matrix metalloproteinase-2 (MMP-2), and MMP-9, and proliferating cell nuclear antigen (PCNA) in the grafts were assayed by Western blotting and immunohistochemistry, respectively. In vitro rat aortic adventitial fibroblast cell (RAAFC) migration was assessed using the Boyden chamber assay, and phospho-mammalian target of rapamycin (mTOR) levels in RAAFCs were determined by Western blotting. Animals with the drug mesh had an intimal area index of 4.87% ± 0.98%, significantly lower than that of the blank group (14.21% ± 2.56%) or the PPC group (15.03% ± 2.35%, both P < .05). The sirolimus mesh markedly suppressed MMP-2 and MMP-9 expression, decreased PCNA-positive cell numbers, inhibited RAAFC migration, and reduced phospho-mTOR levels. Our data suggest that the sirolimus-eluting PPC mesh might be potentially applied for the management of grafting stenosis.

Background: Femoral-popliteal (F-P) bypass is the standard treatment for lower extremity peripheral artery disease with severe femoropopliteal (FP) artery lesions. However, in clinical settings, these patients are treated with endovascular therapy (EVT) because of frailty and difficulties with general anesthesia. We compared the clinical outcomes of F-P bypass and EVT for severe FP artery lesions and investigated the types of patients for whom EVT would be as appropriate as F-P bypass., Methods: This multicenter, retrospective study included 452 Trans-Atlantic Inter-Society Consensus (TASC) II C and D FP artery lesions in 352 patients. A total of 350 lesions in 260 patients (74 ± 9 years, 66% male, 60% claudication) were treated with EVT with nitinol self-expandable stents, and 102 lesions in 92 patients (71 ± 9 years, 75% male, 40% claudication) were treated with F-P bypass. The primary outcome measure was primary patency, and the influence of baseline characteristics on its association with the treatment strategy (EVT versus F-P bypass) was assessed using a Cox proportional hazards regression model., Results: Kaplan-Meier analysis indicated that the 3-year primary patency rate was significantly lower for EVT than F-P bypass (60% vs. 74%, P < 0.01). The body mass index (BMI) and C-reactive protein (CRP) levels significantly interacted with the treatment strategy for restenosis (P < 0.05). The adjusted hazard ratios of EVT versus F-P bypass for restenosis were 0.77 (P = 0.46) in cases with a low BMI (≤18 kg/m 2 ) or an elevated CRP level (≥1 mg/dL) and 3.35 (P < 0.01) in other cases. The 3-year primary patency rate was not significantly different between the EVT and F-P bypass groups in patients with BMI ≤ 18 kg/m 2 or CRP ≥ 1 mg/dL (57% vs. 45%, P = 0.84)., Conclusions: In TASC II C and D lesions, EVT appears to yield patency comparable to that of F-P bypass in patients with a low BMI or an elevated CRP level, but lower patency in other patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We report a 28-year-old female with no history of allergies and recent onset of Goodpasture syndrome who developed life-threatening bleeding immediately after placement of a polytetrafluoroethylene (PTFE) graft as an access for hemodialysis in the left upper limb by an experienced vascular surgeon. In spite of transfusing fresh frozen plasma, packed cells and cryoprecipitate, her prothrombin time (PT), activated partial thromboplastin time and international normalized ratio became progressively worse which were normal at the beginning of the surgery. She had profound hypotension and succumbed within 8 hours. We suspect a rare phenomenon of the interaction of her blood with the PTFE graft causing activation of bleeding and coagulation factors leading to disseminated intravascular coagulation (DIC)., (© 2018 International Society for Hemodialysis.)

Background: Whilst autologous vein conduits have been heralded as the first-line approach for patients undergoing lower limb bypass grafting procedures, patients with peripheral arterial occlusive disease may have exhausted venous options given prior use for cardiac surgery, varicose vein surgery, or lower limb revascularization. Hence, the use of a radial artery graft may serve as a viable alternative., Methods: The systematic review was performed in accordance to the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. An electronic search was performed on the following databases: Medline (via PubMed); EMBASE; Cochrane library to search for relevant publications. A narrative analysis was conducted., Results: Four publications were included in this review including two retrospective cohort studies, one case series, and one case report, with a total of 43 patients. The most common indication for lower limb bypass grafting was critical limb ischemia, and the radial artery was chosen as graft conduit, most commonly due to the absence of suitable arm or leg vein. There was one case of 30-day mortality and 11 reinterventions., Conclusion: Despite the encouraging results, the paucity of high-quality studies prevents the establishment of any firm conclusion. This warrants the need for appropriately conducted randomized controlled trials to compare the radial artery graft to autologous vein grafts and prosthetic grafts for lower limb bypass grafting.

Objectives: Aortic endografting can cause aortic stiffening. We aimed to determine the chronic effect of thoracic endografting on cardiac afterload, function and remodelling., Methods: Eleven dogs were included, and all except 1 was successfully assessed [endograft, n = 5; sham operation (control), n = 5]. We deployed a stent graft in the descending aorta. The ascending aortic pressure and flow were measured, and aortic input impedance was obtained by frequency analysis to determine characteristic impedance and arterial compliance. Left ventricular pressure-volume relations were measured with an admittance catheter. Measurements were performed before, 10 min after and 3 months after endografting. Following euthanasia, we weighed the left ventricle of each dog and measured the cardiomyocyte cell size., Results: Arterial compliance decreased from 0.47 ± 0.07 to 0.36 ± 0.06 and to 0.31 ± 0.05 ml/mmHg (both P < 0.01 versus baseline), and characteristic impedance increased from 0.11 ± 0.04 to 0.19 ± 0.05 and to 0.21 ± 0.04 mmHg/ml/s (both P < 0.01 versus baseline) 10 min and 3 months after endografting, respectively. Pressure-volume relation analysis showed that arterial elastance increased from 5.3 ± 1.0 to 6.7 ± 1.6 (at 10 min) and to 6.8 ± 1.0 mmHg/ml (at 3 months) (both P < 0.05 versus baseline), but end-systolic elastance and ventriculo-arterial coupling remained unchanged. Left ventricular weight to body weight ratio and left ventricular cardiomyocyte cell width in the endograft group were larger compared with the control's results (5.06 ± 0.27 g/kg vs 4.20 ± 0.49 g/kg, P = 0.009, 15.1 ± 1.7 µm vs 13.9 ± 1.5 µm, P = 0.02, respectively)., Conclusions: The mid-term effect of the descending aortic endografting on left ventricular contractility and efficiency in canine normal hearts was minimal. However, endografting resulted in increased cardiac afterload and left ventricular hypertrophy., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Interpositional grafts can be used to reconstruct the digital artery during revascularization and replantation when primary repair is not possible. The purpose of this study was to determine the effect of using interpositional grafts on the rate of digit survival., Methods: A retrospective review of all patients from 2007 to 2016 that required revascularization and/or replantation of one or more digits was performed., Results: One hundred twenty-seven patients were identified with 171 affected digits (118 digital revascularizations and 53 digital replantations). A graft was used to repair the digital artery in 50 percent of revascularizations (59 of 118) and in 49 percent of replantations (26 of 53). There was no difference in digit survival with use of an interpositional graft for arterial repair versus primary repair in revascularization (91.5 percent in both groups) or replantation (48.1 percent versus 46.2 percent; p = 0.88). Regression analysis demonstrated no association between the use of interpositional grafts and digit survival. Interpositional grafting was more likely to be used in crush (62.5 percent) and avulsion injuries (72.2 percent) compared with sharp laceration injuries (11.1 percent), with a relative risk of 5.6 (p = 0.01) and 6.5 (p = 0.006), respectively., Conclusions: There was no difference in the survival rate of amputated digits that required interpositional grafting for arterial repair. The need for an interpositional graft in a large zone of injury should not be considered a contraindication to performing revascularization or replantation. Furthermore, hand surgeons should have a low threshold for using interpositional grafts, especially in crush or avulsion injuries., Clinical Question/level of Evidence: Therapeutic, III.

Objective: Acute ischaemia due to thrombosed popliteal artery aneurysm (PAA) is associated with a high risk of limb loss. The aim of this study was to analyse the outcome, in particular the limb salvage rate in patients undergoing urgent open surgery for acute ischaemia due to thrombosed PAA., Methods: This was a retrospective analysis of consecutive patients undergoing urgent open surgery for acute limb ischaemia (Rutherford category ≥ II) due to thrombosed popliteal artery aneurysm between January 2007 and December 2016 at a tertiary referral centre., Results: Fifty-one patients (92% male), median age 75 years (range 46-97 years), were identified. Twenty patients (39%) presented with category IIa acute limb ischaemia, 20 (39%) with category IIb, and 11 (22%) with category III. Four patients (8%) underwent primary major amputation. Forty-seven (92%) underwent bypass surgery, 43/47 (91%) using great saphenous vein. One vessel runoff was present in 27/47 patients (57%). Thirty day mortality was 4% (n = 2). Four patients needed major amputation within 30 days, resulting in an overall 30 day major amputation rate of 16% (8/51, 95% confidence interval 7.0-28.6). No further major amputations were necessary during a median follow up of 41 months (range 4-114 months) resulting in an estimated 4 year limb salvage of 84%. The one year primary assisted and secondary bypass patency rates were 90% and 95%, respectively. The estimated four year primary assisted and secondary patency rates were 82% and 87%, respectively., Conclusion: Rapid open surgical revascularisation in patients with acute limb ischaemia due to a thrombosed popliteal artery aneurysm results in good long-term limb salvage rates, especially Rutherford category IIa and IIb acute ischaemia. Revascularisation may be attempted in clinically severe cases not fulfilling all criteria to be classified as category III. Such patients may, in fact, be borderline between IIb and III. Despite poor runoff, good bypass patency rates and low rates of claudication can be achieved., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The optimal time for flap anastomosis to an arteriovenous loop remains controversial. Whether perforator flaps and axially vascularized muscle or fasciocutaneous flaps lead to comparable outcomes in conjunction with arteriovenous loops has not been investigated., Methods: Medical records from 103 patients undergoing arteriovenous loop reconstruction (76 one-stage and 27 two-stage) between 2007 and 2017 were reviewed. Postoperative outcomes were compared between one- and two-stage arteriovenous loop reconstructions and different types of free flaps., Results: Rates of flap thrombosis, major wound complications, and flap failure did not differ significantly between one- and two-stage arteriovenous loop reconstructions (14.47 percent versus 11.11 percent, p = 1.00; 30.26 percent versus 25.93 percent, p = 0.67; and 10.53 percent versus 7.41 percent, p = 1.00). For two-stage arteriovenous loop reconstructions, the time interval between arteriovenous loop placement and flap anastomosis was a predictor for thrombotic events (OR, 1.31; p < 0.05). Anterolateral thigh flaps in conjunction with arteriovenous loops showed higher failure rates (33.33 percent) compared with all other flaps (6.59 percent) (p < 0.05) and combined latissimus dorsi and parascapular flaps (0 percent) (p < 0.05). Thrombosis rates were higher in anterolateral thigh flaps (33.33 percent) compared with all other flaps (10.99 percent; p = 0.056), and combined latissimus dorsi and parascapular flaps (0 percent; p < 0.05)., Conclusions: Two-stage arteriovenous loop reconstructions do not lead to increased postoperative complications compared to one-stage arteriovenous loop reconstructions and may be favorable in complicated cases because of shorter operative times. To avoid an increased thrombosis risk, flap anastomosis should not be delayed beyond 10 days in two-stage arteriovenous loop reconstructions. Anterolateral thigh flaps are less suitable for arteriovenous loop reconstructions because of higher complication rates., Clinical Question/level of Evidence: Therapeutic, III.

Aneurysmal disease can affect any segment of the aorta, from the aortic root to the aortic bifurcation. The treatment of aortic aneurysms has evolved dramatically in the past 3 decades, with the introduction of endovascular aneurysm repair using stent grafts causing a major paradigm shift in the field of aortic aneurysm surgery. While the technical details of the management of aortic aneurysms vary greatly depending on the location of an aneurysm, the principles remain the same. Successful aortic aneurysm treatment depends on either open replacement or endovascular exclusion of the aneurysmal segment with healthy artery proximal and distal to the repair. Major aortic branches of the arch and visceral segment add additional technical complexity to aneurysms involving these regions. Even as endovascular repair becomes the primary treatment modality for most aortic aneurysms, open repair remains an essential treatment modality in many circumstances. Additionally, long-term results of endovascular repair suggest that younger patients with long life expectancy and low-perioperative risk may benefit more from open repair. Therefore, technical expertise in both endovascular and open treatment is necessary for a comprehensive aortic aneurysm surgery practice.

Background: The decision to utilize portal or systemic venous drainage in pancreas transplantation is surgeon- and center-dependent. Information regarding the superior method is based on single-center reports and animal models., Methods: UNOS data on adults receiving pancreas and kidney-pancreas transplants from 1987 to 2016 were analyzed (n = 29 078). The groups analyzed were: systemic venous pancreas graft drainage (SVD, n = 24 512) or portal venous pancreas graft drainage (PVD, n = 4566). A Cox proportional hazard model compared patient and allograft survival between groups., Results: No statistically significant differences were observed for patient and allograft survival at 1, 3, 5, 10, or 15 years post-transplant at each time interval and cumulatively (patient - HR:1.041; 95% CI:0.989-1.095; allograft - HR:0.951; 95% CI:0.881-1.027). PVD reduced the risk of death by 22.0% (P = 0.017) compared to SVD for patients undergoing pancreas after kidney transplant (PAK); no statistically significant difference was found for patients undergoing other types of transplants., Conclusion: There is no significant clinical difference in patient or allograft survival between PVD and SVD in pancreas transplantation for the majority of patients. For the subgroup of PAK, PVD was associated with decreased mortality. For individual surgeons, center and patient scenarios should dictate which technique is performed., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Angiosarcoma (AS) is a type of malignancy within sarcomas affecting soft tissue and bone. It presents a very heterogeneous distribution in the human body, and it can appear in multiple locations, from breast to liver or skin. The incidence of this type of tumor is low; however, it is aggressive and requires an early diagnosis to initiate the treatment as soon as possible. In the present article, we report the case of a male patient who was diagnosed with epithelioid AS of popliteal artery after an aneurysm popliteal surgery, as well as its treatment and evolution. This kind of tumors has controversial treatment and poor survival rates in the early years., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background: Based on prospective vein bypass trials for lower leg ischemia, objective performance goals (OPG) were established by the Society for Vascular Surgery (SVS) and are used as a benchmark tool for open and endovascular treatments. This study aims to analyze OPG of all patients with critical limb ischemia (CLI) treated by open revascularization techniques at a tertiary care facility in routine practice., Methods: From January 2005 to March 2013, 315 patients (mean age 72 years) with CLI were retrospectively included in this study. Inclusion criteria were patients with Fontaine stage III and IV, realized revascularization with open surgical procedures (bypass grafting or endarterectomy), or hybrid method (open + endovascular). Exclusion criteria were primary major amputations, patients with revascularization treatments of the index leg within the last 3 months, and missing aftercare. Primary end point was "amputation-free survival" (AFS), and secondary end point was "freedom from major adverse limb event + perioperative death (30 days)" (MALE + POD) according to the SVS. The technical end point was primary patency. Mean follow-up was 34 months. The following variables were studied: clinical stage (Fontaine), previous interventions, bypass material used, and site of the distal anastomosis. The statistical evaluation and preparation was carried out using the Kaplan-Meier estimator and the log-rank test. A multivariate analysis was performed using the Cox proportional hazards model. A P value ≤0.05 was considered to be statistically significant., Results: A total of 128 patients (31%) fulfilling the adjusted SVS OPG criteria showed significantly better results for AFS, MALE + POD, and primary patency (P = 0.013, P = 0.015, P = 0.002, respectively). Regarding the AFS (1 year: 74%), multivariate analysis displayed significant worse results for patients with end-stage renal disease (hazard ratio [HR] 2.90, 95% confidence interval [CI] 1.83-4.60, P < 0.001) and Fontaine stage IV (HR 1.69, 95% CI 1.11-2.57, P = 0.015). Regarding MALE + POD (1 year: 64%), male patients (HR 0.64, 95% CI 0.46-0.90, P = 0.011) showed a significantly better outcome and patients without previous interventions of the index leg (HR 1.51, 95% CI 1.09-2.09, P = 0.013) showed a significantly worse outcome., Conclusions: In this study, we were able to show that it is possible to reach the efficacy of OPGs set by SVS in a surgically treated all-comers cohort of CLI patients. Nevertheless, patients who did not fulfill the SVS OPG criteria showed significantly worse results for AFS and MALE + POD., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We present a case of chronic, severe, intermittent hematuria found to be associated with a ureteral to aorto-femoral bypass fistulization. The graft was directly visualized on ureteroscopy and identified as the source of hematuria during exploratory laparotomy. Ureteral fistulization is a rare etiology of hematuria. Ureteral fistulization to an arterial graft has been reported several times in past decades. However, no cases have reported direct visualization of the dacron graft on ureteroscopy., (Copyright © 2018. Published by Elsevier Inc.)

Objective:: This population-based retrospective cohort study investigates long-term results of femoropopliteal bypass and femoropopliteal endovascular intervention (PTA) in patients with critical ischemia, with focus on limb salvage and amputation-free survival., Methods:: All patients who underwent femoropopliteal bypass or femoropopliteal PTA for critical ischemia without other simultaneous intervention between 1999 and 2013 were included. Stratification was according to treatment modality and symptoms, rest pain, or ischemic ulcer/gangrene. We assessed technical success, 30-day complications, length of stay, recurrent interventions, limb salvage, survival, and amputation-free survival in all patients., Results:: We identified 292 operations in 264 patients, 140 bypass and 152 PTA. In 32 PTA cases, the patients were explicitly deemed unfit for bypass surgery. This group had significantly inferior technical success and limb salvage ( P = .00). In other patients, technical success was 96% for bypass and 93% for PTA, while limb salvage after 5 years was 78% for bypass and 81% for PTA. Reoperation for local complications was performed in 16% after bypass and 2% after PTA ( P = .00). Mean length of stay was 8 days after bypass and 1.9 days after PTA ( P = .00)., Conclusions:: Long-term follow-up showed similar technical success and good limb salvage for both PTA and bypass patients in this clinical cohort. Patients who were unfit for bypass surgery had significantly inferior technical success and limb salvage. PTA was associated with shorter hospital stay and fewer reoperations for local complications. The findings support a PTA first strategy in all cases where technical success is likely.

Background: Hemodialysis (HD) guidelines recommend permanent vascular access (PVA) in children unlikely to receive kidney transplant within 1 year of starting HD. We aimed to determine predictors of primary and secondary patency of PVA in pediatric HD patients., Methods: Retrospective chart reviews were performed for first PVAs in 20 participating centers. Variables collected included patient demographics, complications, interventions, and final outcome., Results: There were 103 arterio-venous fistulae (AVF) and 14 AV grafts (AVG). AVF demonstrated superior primary (p = 0.0391) and secondary patency (p = 0.0227) compared to AVG. Primary failure occurred in 16 PVA (13.6%) and secondary failure in 14 PVA (12.2%). AVF were more likely to have primary failure (odds ratio (OR) = 2.10) and AVG had more secondary failure (OR = 3.33). No demographic, clinical, or laboratory variable predicted primary failure of PVA. Anatomical location of PVA was predictive of secondary failure, with radial having the lowest risk compared to brachial (OR = 12.425) or femoral PVA (OR = 118.618). Intervention-free survival was predictive of secondary patency for all PVA (p = 0.0252) and directly correlated with overall survival of AVF (p = 0.0197) but not AVG. Study center demonstrated statistically significant effect only on intervention-free AVF survival (p = 0.0082), but not number of complications or interventions, or outcomes., Conclusions: In this multi-center pediatric HD cohort, AVF demonstrated primary and secondary patency advantages over AVG. Radial PVA was least likely to develop secondary failure. Intervention-free survival was the only predictor of secondary patency for AVF and directly correlated with overall access survival. The study center effect on intervention-free survival of AVF deserves further investigation.

Background: The incidence of cardiovascular and limb-specific adverse outcomes is higher in peripheral arterial disease (PAD) patients with diabetes. Metformin is associated with improved cardiovascular morbidity and mortality. However, the effect of metformin on limb-specific outcomes is unclear. The objective of this study was to assess the effect of metformin on outcomes after intervention for PAD., Methods: Patients who underwent revascularization for chronic limb ischemia (Rutherford 3-6) between June 2001 and December 2014 were retrospectively identified. Primary patency (PP), secondary patency (SP), limb salvage (LS), major adverse limb events (MALE), major adverse cardiac events (MACE), and survival rates were compared using Kaplan-Meier and Cox regression., Results: One thousand sixty-four limbs in 1204 patients were identified (147 metformin, 196 other hypoglycemics [OH], 216 insulin, and 645 nondiabetics (nondiabetes mellitus [DM]). Non-DM had significantly lower incidence of CAD (46%) than insulin (65%), metformin (56%), and OH groups (63%) (P < 0.001). Insulin patients (17%) had significantly higher incidence of end-stage renal disease (ESRD) than non-DM (3%), metformin (1.4%), and OH groups (8%) (P < 0.001). Ninety four percent of patients in the metformin group were on aspirin, which was significantly higher than non-DM (86%), OH (83%), and insulin groups (86%) (P = 0.02). Similarly, statin use was significantly higher in the metformin group (71%) than in OH (64%), insulin (61%), and non-DM groups (55%) (P = 0.002). Majority of patients in the insulin group presented with critical limb ischemia (CLI) (93%), which was significantly greater than the metformin (59%), OH (72%), and non-DM groups (50%) (P < 0.001). Sixty-month PP was significantly greater in non-DM group (62%) (P = 0.005) in overall comparison with no significant difference between metformin (56%), OH (60%), and insulin (51%) groups (P = 0.06). Sixty-month SP was similar in metformin (76%), OH (85%), insulin (76%), and non-DM (80%) groups (P = 0.27). LS was significantly worse in insulin group (62%) (P < 0.001) with no significant difference between metformin (84%), OH (83%), and non-DM (87%) groups (P = 0.45). Freedom from MALE at 60 months was 53% in the insulin group, which was significantly worse as compared with metformin (71%), OH (70%), and non-DM (67%) groups (P = 0.001). Sixty-month survival was significantly improved in metformin (60%) and non-DM (60%) groups as compared with that in OH (41%) and insulin groups (30%) (P < 0.001). Freedom from MACE was significantly greater in metformin (44%) and non-DM (52%) groups than that in OH (37%) and insulin groups (25%) (P < 0.001). Metformin use (HR, 0.7 [0.5-0.9]; P = 0.008) was an independent factor associated with freedom from mortality., Conclusions: Metformin is associated with improved survival and decreased incidence of adverse cardiac events in PAD patients. However, it did not have an impact on patency or LS rates after open and endovascular interventions. LS was worse in diabetic patients primarily treated with insulin., (Published by Elsevier Inc.)

Background: To evaluate outcomes after lower extremity revascularization for critical limb ischemia with tissue loss in patients with chronic immune-mediated inflammatory disease., Methods: A retrospective medical record review of all lower extremity revascularization for critical limb ischemia with tissue loss at a university-affiliated hospital over a 3-year period was completed for demographics, comorbidities, lower extremity revascularization indication, angiogram results, complications, mortality, limb salvage, and reintervention. Chronic immune-mediated inflammatory disease (CIID) and control (no autoimmune disease) were compared by chi-squared test, Student's t-test, Kaplan-Meier, and Cox Regression., Results: There were 349 procedures performed (297 patients): (1) 44 (13%) primary amputations and (2) 305 (87%) lower extremity revascularizations, in which 83% were endovascular interventions; 12% was bypass; and 5% was hybrid, in which 40% was infrainguinal and 60% was infrageniculate, 72% Wounds Ischemia Infection Score System (WIFi) tissue loss class 2-3, 35% CIID. No differences were noted between CIID and control for primary amputation (P = 0.11), lower extremity revascularization type (P = 0.50), or lower extremity revascularization anatomic level (P = 0.43). Mean age was 71 + 13 years, and 56% of the patients were of male gender. Those with CIID were of similar age as controls (71 ± 14 vs. 71 ± 13; P = 0.87) and presented with comparable runoff: (1) ≤1 vessel (52% vs. 47%; P = 0.67), (2) WIFi tissue loss classification class 2-3 (66% vs. 76%; P = 0.09), and (3) WIFi infection classification class 2-3 (29% vs. 30%; P = 0.9). They were also less likely to be male (47% vs. 61%; P = 0.022) or current smokers (13% vs. 27%; P = 0.008). Postoperative mortality (P = 0.70) morbidity and reoperation (0.31) were comparable. Twenty-four-month survival was similar for CIID and control (83% ± 5% vs. 86% + 3%; P = 0.78), as was the amputation-free interval (69% ± 5% vs. 61% ± 4%; P = 0.18) and need for target extremity revascularization (40% vs. 53%; P = 0.04). Use of steroids and other anti-inflammatory medications was associated with improved 24-month amputation-free interval (87% ± 9% vs. 63% ± 3%; P = 0. 05). Dialysis (odds ratio: 2.6; 1.5-4.7; P = 0.001), WIFi infection class 2-3 (odds ratio: 2.8; 1.6-4.9; P < 0.001), prerunoff vessel (0-1 vs. 2-3) to the foot (odds ratio: 0.52; 0.37-0.73; P < 0.001), steroids/other anti-inflammatory agents (0.29; 0.06-0.96; P = 0.04), and statins (0.44; 0.25-0.77; P = 0.005) were independent predictors of 24-month amputation-free interval (Cox proportional hazard ratio)., Conclusions: Patients with critical limb ischemia, tissue loss, and concomitant CIID can be successfully treated with lower extremity revascularization with similar limb salvage and need for reintervention. Steroid/anti-inflammatory use appears beneficial., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia., Methods: The National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications., Results: The Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35-3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06-1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08-1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39-2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09-1.61; P < .01)., Conclusions: CKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to analyse outcomes over 2 decades using cryopreserved vascular allografts to treat vascular infection., Methods: We conducted a retrospective study of patients identified from our institutional database who were treated for primary or secondary vascular infection using implanted allografts., Results: Between October 1992 and May 2014, 54 patients underwent surgery for vascular infection out of 118 patients implanted with cryopreserved vascular allografts. The 52 patients for whom we had full information form the basis of the study with a 96% follow-up. The average age was 64 ± 11 years; 87% were men; 65% had previous vascular surgery; 19% had emergency operations. A total of 75% of the patients had aortoiliofemoral infections. Five patients underwent surgery with cardiopulmonary bypass. Fifty percent required more than 1 allograft and 15% had concomitant procedures. Seventy-three percent (38/52) of specimen cultures yielded positive results with polymicrobial flora in 29%. Surgical specimens most frequently grew coagulase-negative staphylococci. The early postoperative reoperation rate was 15% for allograft-related complications. There were 20 (38%) early deaths, including deaths of acute myocardial infarction, anastomosis rupture and persistent sepsis and shock. Uncontrolled infection leading to septic shock and multiple organ failure was the cause of death in 50% of the cases. The mean duration of freedom from allograft reintervention was 12.2 years. The mean duration of freedom from allograft occlusion or limb loss was 12.1 years [95% confidence interval (CI) 9.9-14.4]. Of the 32 surviving patients, we had patency information for 66% obtained by angiography or computed tomography. The mean survival for the cohort was 5.9 years (95% CI 3.9-7.8). Mean freedom from cardiovascular infection-related death was 9.3 years (95% CI 7.2-11.4)., Conclusions: Allografts can be indicated for treatment of primary/secondary infection and have remarkable results in multimorbid patients. Patients with vascular infection have a high-risk profile, around 40% mortality during the first 6 months, with reduction in overall mortality thereafter. We believe that allografts may play a role in the surgical treatment of vascular infection.

Background: Survival prediction models are clinical tools that help professionals make the best treatment decisions. In the treatment of critical limb ischemia, several scoring methods have emerged; however, many are limited because they are not reproducible in different populations. This study analyze the Bypass versus Angioplasty in Severe Ischemia of the Leg survival prediction model (BASIL SPM), exclusively in patients who underwent infrapopliteal (InfraPo) revascularization for the treatment of critical limb ischemia., Methods: In this retrospective cohort, patients who underwent InfraPo interventions during a 4-year period (2009-2013) were consecutively included, according to the primary intervention (endovascular or open repair), irrespective of combined treatment in the femoropopliteal and InfraPo segments. Performance of the BASIL SPM was determined using the area under the curve of the receiver-operating characteristic curve. Additionally, secondary patency, limb salvage, and overall survival were analyzed by the Kaplan-Meier method., Results: The mean follow-up duration was 32.7 ± 23.8 months. In the total patient group (n = 134), the mean age was 72 ± 8.6 years (range, 46-91 years), and the main associated comorbidities were hypertension (85.8%) and diabetes mellitus (76.8%). Regarding differences between the groups, patients in the endovascular group (n = 100) were older (73 vs. 69.5; P = 0.033) and more frequently stratified as high risk (61% vs. 38.2%; P = 0.030) than the open repair group (n = 34). The area under the curve (95% confidence interval [CI]) using the BASIL SPM at 6, 12, and 24 months was 0.499 (95% CI: 0.344-0.657), 0.508 (95% CI: 0.353-0.629), and 0.549 (95% CI: 0.420-0.678), respectively. In the total patient group, the 36-month secondary patency, limb salvage, and overall survival were 31.5%, 81.1%, and 65.9%, respectively., Conclusions: The BASIL SPM was a poor predictor of life expectancy in this patient cohort., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Stenosis is a known complication in bypass vein grafts for peripheral arterial disease. The aim of this study was to evaluate the effect of drug-coated balloons (DCBs) in the treatment of vein graft stenoses. DCBs may prevent restenosis in arterial lesions. One small prospective and larger retrospective and registry studies have failed to show benefit from DCBs in vein grafts. Prospective data are scarce., Methods: Sixty patients treated for primary or recurrent stenosis in venous bypass grafts were randomized to DCB (n = 30) or standard balloon angioplasty (BA) (n = 30). Follow-up was 1 year. The primary outcome measure was target lesion revascularization (TLR). Secondary outcome measures were assisted primary patency and secondary patency and graft occlusion., Results: Fifty-seven patients were analyzed. Three patients were excluded due to primary technical failure (2 DCB, 1 BA). Overall TLR rate was 34.5% and 46.4% in the DCB and BA groups, respectively (P = 0.33). Five (8.8%) grafts occluded during follow-up (1 DCB, 4 BA). Assisted primary patency was 93.1% (DCB) versus 85.7% (BA) (P = 0.362) and secondary patency was 100% (DCB) versus 89.3% (BA) (P = 0.076). Subgroup analysis showed a significant benefit from DCB in the treatment of primary stenosis (TLR rate 15.0% vs. 18.9%, P = 0.03)., Conclusion: There was no significant benefit from DCBs for treatment of vein graft stenosis compared to BA, although a trend in favor of DCBs could be seen., Trial Registration: ClinicalTrials.govNCT03023098., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The peroneal artery is a well-established target for bypass in patients with critical limb ischemia (CLI). The objective of this study was to evaluate the outcomes of peroneal artery revascularization in terms of wound healing and limb salvage in patients with CLI., Methods: Patients presenting between 2006 and 2013 with CLI (Rutherford 4-6) and isolated peroneal runoff were included in the study. They were divided into patients who underwent bypass to the peroneal artery and those who underwent endovascular peroneal artery intervention. Demographics, comorbidities, and follow-up data were recorded. Wounds were classified by Wound, Ischemia, foot Infection (WIfI) score. The primary outcome was wound healing; secondary outcomes included mortality, major amputation, and patency., Results: There were 200 limbs with peroneal bypass and 138 limbs with endovascular peroneal intervention included, with mean follow-up of 24.0 ± 26.3 and 14.5 ± 19.1 months, respectively (P = .0001). The two groups were comparable in comorbidities, with the exception of the endovascular group's having more patients with cardiac and renal disease and diabetes mellitus but fewer patients with smoking history. Based on WIfI criteria, ischemia scores were worse in bypass patients, but wound and foot infection scores were worse in endovascular patients. Perioperatively, bypass patients had higher rates of myocardial infarction (4.5% vs 0%; P = .012) and incisional complications (13.0% vs 4.4%; P = .008). At 12 months, the bypass group compared with the endovascular group had better primary patency (47.9% vs 23.4%; P = .002) and primary assisted patency (63.6% vs 42.2%; P = .003) and a trend toward better secondary patency (74.2% vs 63.5%; P = .11). There were no differences in the rate of wound healing (52.6% vs 37.7% at 1 year; P = .09) or freedom from major amputation (81.5% vs 74.7% at 1 year; P = .37). In a multivariate analysis, neuropathy was associated with improved wound healing, whereas WIfI wound score, cancer, chronic renal insufficiency, and smoking were associated with decreased wound healing. Treatment modality was not a significant predictor (P = .15)., Conclusions: Endovascular peroneal artery intervention results in poorer primary and primary assisted patency rates than surgical bypass to the peroneal artery but provides similar wound healing and limb salvage rates with a lower rate of complications. In appropriately selected patients, endovascular intervention to treat the peroneal artery is a low-risk intervention that may be sufficient to heal ischemic foot wounds., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients with critical limb ischemia (CLI) utilize hospital resources at high rates. One major driver for resource utilization is emergency department (ED) visits. Our goal was to assess perioperative ED visits after lower extremity bypass (LEB) for CLI., Methods: All patients undergoing LEB for CLI from 2008 to 2017 at our institution were analyzed. ED visits and details of the visit within 30 and 90 days of discharge from index admission were recorded. Multivariable analysis was performed to identify risk factors for any ED presentation and ED presentation without hospital admission., Results: There were 317 patients identified who underwent infrainguinal LEB for CLI. Average age was 66 years, and 60.6% of patients were male. Within 30 and 90 days, 24.3% and 36.3% presented to the ED overall, and 16.7% and 26.5% of all postoperative patients had an ED presentation without hospital admission, respectively. Most common reasons for any ED visits and for ED visits without admission within 30 days were wound complications (22.1% and 20.8%), cardiac complications (16.9% and 17%), and ipsilateral leg pain (10.4% and 11.3%), respectively. Cryopreserved vein bypass (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.02-8.84, P = 0.046) and index length of stay (LOS) (OR 1.09, 95% CI 1.04-1.15, P < 0.001) predicted any 30-day ED visit. Active leg infection at the time of bypass (OR 2.35, 95% CI 1.21-4.58, P = 0.012) and index LOS (OR 1.05, 95% CI 1.004-1.09, P = 0.033) predicted 30-day ED presentation without hospital admission. Most common reasons for any ED visit and for ED visits without admission within 90 days were surgical wound complications (15.8% and 14.3%), cardiac complications (14.9% and 14.3%), and nonsurgical wounds (9.6% and 9.5%), respectively. Chronic renal insufficiency (CRI) (OR 2.73, 95% CI 1.52-4.93, P = 0.001) and index LOS (OR 1.07, 95% CI 1.01-1.12, P = 0.017) predicted any 90-day ED visit. CRI (OR 3.34, 95% CI 1.81-6.17, P = 0.001) predicted 90-day ED presentation without hospital admission. For multiple ED visits within 90 days, there were 5 patients each with 5 ED visits, 12 each with 4 ED visits, 26 each with 3 ED visits, and 47 each with 2 ED visits., Conclusions: There is a high rate of ED utilization in CLI patients after LEB. Targeting these patients with closer follow-up and improved outpatient ambulatory access could assist in decreasing the frequency of postoperative ED visits. Particular areas of targeted improvement are those patients who presented to the ED and were not admitted., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Acute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Few contemporary reports focus specifically on patients undergoing open mesenteric bypass (OMB) or delineate outcome differences based on bypass configuration. This is notable, because there is a subset of patients who are poor candidates for endovascular intervention including those with flush mesenteric vessel occlusion, long segment occlusive disease, and a thrombosed mesenteric stent and/or bypass. This analysis reviewed our experience with OMB in the treatment of AMI and compared outcomes between patients undergoing either antegrade or retrograde bypass., Methods: A single-center, retrospective review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. A preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in-hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan-Meier estimation and Cox proportional hazards regression were used to analyze all end points., Results: Eighty-two patients (female 54%; age 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. A history of prior stent/bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass and the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were more likely to be male (53% vs 25%; P = .02), have coronary artery disease (48% vs 25%; P = .06), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Concurrent bowel resection was evenly distributed (antegrade, 45%; retrograde, 45%; P = .9) and 37% (n = 30) underwent subsequent resection during second look operations. The median duration of stay was 16 days (interquartile range, 9-35 days) and 78% (n = 64) experienced at least one major complication with no difference in rates between antegrade/retrograde configurations. In-hospital mortality was 37% (n = 30; multiple organ dysfunction, 22; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia, 1; stroke, 1; 30-day mortality, 26%). The median follow-up was 8 months (interquartile range, 1-26 months). The 1- and 3-year primary patency rates were both 82% ± 6% (95% confidence interval, 71%-95%), with 10 patients requiring reintervention. Estimated survival at 1 and 5 years was 57% ± 6% and 50% ± 6%, respectively. Bypass configuration was not associated with complication rates (P > .10), in-hospital mortality (log-rank, P = .3), or overall survival (log-rank, P = .9). However, a higher risk of reintervention was observed in patients undergoing retrograde bypass (hazard ratio, 3.0; 95% confidence interval, 0.9-11.0; P = .08)., Conclusions: OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with comparable outcomes as retrograde OMB. The bypass configuration choice should be predicated on patient presentation, anatomy, physiology, and surgeon preference; however, an antegrade configuration may provide a lower risk of reintervention., (Copyright © 2018 Society for Vascular Surgery. All rights reserved.)

Background: Chronic limb-threatening ischemia (CLTI), defined as ischemic rest pain or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease with frequent, severe infrageniculate disease. The rise in CLTI is in part the result of increasing worldwide prevalence of diabetes, renal insufficiency, and advanced aging of the population. The aim of this study was to compare a bypass-first with an endovascular-first revascularization strategy in patients with CLTI due to infrageniculate arterial disease., Methods: We reviewed the American College of Surgeons National Surgical Quality Improvement Program targeted lower extremity revascularization database from 2012 to 2015 to identify patients with CLTI and isolated infrageniculate arterial disease who underwent primary infrageniculate bypass or endovascular intervention. We excluded patients with a history of ipsilateral revascularization and proximal interventions. The end points were major adverse limb event (MALE), major adverse cardiovascular event (MACE), amputation at 30 days, reintervention, patency, and mortality. Multivariable logistic regression was used to determine the association of a bypass-first or an endovascular-first intervention with outcomes., Results: There were 1355 CLTI patients undergoing first-time revascularization to the infrageniculate arteries (821 endovascular-first revascularizations and 534 bypass-first revascularizations) identified. There was no significant difference in adjusted rate of 30-day MALE in the bypass-first vs endovascular-first revascularization cohort (9% vs 11.2%; odds ratio [OR], 0.73; 95% confidence interval [CI], 0.50-1.08). However, the incidence of transtibial or proximal amputation was lower in the bypass-first cohort (4.3% vs 7.4%; OR, 0.60; CI, 0.36-0.98). Patients with bypass-first revascularization had higher wound complication rates (9.7% vs 3.7%; OR, 2.75; CI, 1.71-4.42) compared with patients in the endovascular-first cohort. Compared with the endovascular-first cohort, the incidence of 30-day MACE was significantly higher in bypass-first patients (6.9% vs 2.6%; adjusted OR, 3.88; CI, 2.18-6.88), and 30-day mortality rates were 3.23% vs 1.8% (adjusted OR, 2.77; CI, 1.26-6.11). There was no difference in 30-day untreated loss of patency, reintervention of treated arterial segment, readmissions, and reoperations between the two cohorts. In subgroup analysis after exclusion of dialysis patients, there was also no significant difference in MALE or amputation between the bypass-first and endovascular-first cohorts., Conclusions: CLTI patients with isolated infrageniculate arterial disease treated by a bypass-first approach have a significantly lower 30-day amputation. However, this benefit was not observed when dialysis patients were excluded. The bypass-first cohort had a higher incidence of MACE compared with an endovascular-first strategy. These results reaffirm the need for randomized controlled trials, such as the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL-2) trial and Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI), to provide level 1 evidence for the role of endovascular-first vs bypass-first revascularization strategies in the treatment of this population of challenging patients., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite national vascular access guidelines promoting the use of arteriovenous fistulas (AVF) over arteriovenous grafts (AVGs) for dialysis, AVF use is substantially lower in females. We assessed clinically relevant AVF and AVG surgical outcomes in elderly male and female patients initiating hemodialysis with a central venous catheter (CVC)., Methods: Using the United States Renal Data System standard analytic files linked with Medicare claims, we assessed incident hemodialysis patients in the United States, 9,458 elderly patients (≥67 years; 4,927 males and 4,531 females) initiating hemodialysis from July 2010 to June 2011 with a catheter and had an AVF or AVG placed within 6 months. We evaluated vascular access placement, successful use for dialysis, assisted use (requiring an intervention before successful use), abandonment after successful use, and rate of interventions after successful use., Results: Females were less likely than males to receive an AVF (adjusted likelihood 0.57, 95% CI 0.52-0.63). Among patients receiving an AVF, females had higher adjusted likelihoods of unsuccessful AVF use (hazard ratio [HR] 1.46, 95% CI 1.36-1.56), assisted AVF use (OR 1.34, 95% CI 1.17-1.54), and AVF abandonment (HR 1.28, 95% CI 1.10-1.50), but similar relative rate of AVF interventions after successful use (relative risk [RR] 1.01, 95% CI 0.94-1.08). Among patients receiving an AVG, females had a lower likelihood of unsuccessful AVG use (HR 0.83, 95% CI 0.73-0.94), similar rates of assisted AVG use (OR 1.05, 95% CI 0.78-1.40) and AVG abandonment, and greater relative rate of interventions after successful AVG use (RR 1.16, 95% CI 1.01-1.33)., Conclusions: While AVFs should be considered the preferred vascular access in most circumstances, clinical AVF surgical outcomes are uniformly worse in females. Clinicians should also consider AVGs as a viable alternative in elderly female patients initiating hemodialysis with a CVC to avoid extended CVC dependence., (© 2018 S. Karger AG, Basel.)

Objective: Autologous vein is the preferred conduit for lower extremity bypass. However, it is often unavailable because of prior harvest or inadequate for bypass owing to insufficient caliber. Cryopreserved cadaveric vessels can be used as conduits for lower extremity revascularization when autogenous vein is not available and the use of prosthetic grafts is not appropriate. Many studies have shown that donor characteristics influence clinical outcomes in solid organ transplantation, but little is known regarding their impact in vascular surgery. The purpose of this study was to examine the effects donor variables have on patients undergoing lower extremity bypass with cryopreserved vessels., Methods: The tissue processing organization was queried for donor blood type, warm ischemia times (WITs), and serial numbers of cryopreserved vessels implanted at a single center from 2010 to 2016. The serial numbers were then matched with their respective patients using the institutional Clinical Data Repository and patient data were obtained from the Clinical Data Repository and chart review. Primary outcomes were primary patency of the bypass conduits and limb salvage. Time to loss of patency was evaluated using Kaplan-Meier methods and a Cox proportional hazards model determined risk-adjusted predictors of patency and limb salvage., Results: Sixty patients underwent lower extremity bypass with 65 cryopreserved vessels (23 superficial femoral arteries, 41 saphenous veins, 1 femoral vein). Thirty-eight procedures were reoperations. There were 21 inflow, 44 outflow, and 44 infrainguinal procedures. Preexisting comorbidities did not differ significantly between those who lost patency and those who did not. The mean WIT among the entire cohort was 892.3 ± 389.1 minutes (range, 158.0-1434.0 minutes). The median follow-up was 394 days. Kaplan-Meier analysis demonstrated an overall 1-year primary patency rate of 51%. Primary patency at 1 year was 67% and 41% for inflow and outflow procedures, respectively, and did not differ significantly between the two groups (P = .15). Donor-to-recipient ABO incompatibility was not associated with loss of primary patency. The 1-year amputation-free survival was 74%. Primary patency significantly decreased with each hourly increase in WIT on risk-adjusted analysis (hazard ratio, 1.1; P = .02)., Conclusions: Higher cryopreserved vessel WIT was associated with increased risk-adjusted loss of primary patency in this cohort. At 1 year, the overall primary patency was 51% and amputation-free survival was 74%. Vascular surgeons should be aware that WIT may affect outcomes for lower extremity bypass., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The burden of metabolic syndrome (MetS) is increasing in the United States and is pervasive among patients with peripheral arterial disease. Whereas MetS has been implicated in the development of all types of cardiovascular disease and adverse outcomes after vascular interventions, little is known about how MetS influences perioperative outcomes of lower extremity bypass surgery and whether any negative effects can be modified by use of cardiovascular risk-modifying medications., Methods: We used the National Surgical Quality Improvement Program vascular procedure-targeted database to capture patients undergoing infrainguinal bypass surgery between 2011 and 2015. We defined MetS using the modified MetS criteria: concomitant diabetes, hypertension, and body mass index >30 kg/m 2 . We used multivariable logistic regression analyses to examine the association between MetS and 30-day postoperative morbidity and mortality. We also examined whether preoperative aspirin, statin, and beta blockade modify the effects of MetS on 30-day postoperative outcomes., Results: Of 10,053 patients who underwent infrainguinal bypass, 16% (1693) met criteria for MetS. After adjusting for covariates, MetS was significantly (P ≤ .05) associated with higher odds of postoperative myocardial infarction (odds ratio [OR], 1.66), infection (OR, 1.76), renal dysfunction (OR, 2.42), and length of stay (0.34 days). Within the MetS subgroup, there were no significant associations between use of preoperative cardiovascular risk-modifying agents and postoperative outcomes, with the exception of beta blockade and an increase in length of stay (0.33 days)., Conclusions: Patients with MetS undergoing infrainguinal bypass surgery are at an increased risk of postoperative complications, including myocardial infarction. This elevated risk persists despite medical therapy with preoperative aspirin, statin, and beta blockade., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Case Presentation: A 57-year-old man was admitted for 1 month of accelerating hemoptysis and hematemesis. Two weeks earlier, he first presented with fevers and hemoptysis of 2 weeks' duration and was diagnosed with community-acquired pneumonia treated with 5 days of ceftriaxone and azithromycin. He improved and was discharged, but his hemoptysis recurred 1 day after discharge and progressed over 9 days, leading to the present admission. He endorsed an 5-kg weight loss, daily fevers up to 39.4°C, and night sweats since discharge. His medical history was significant for peptic ulcer disease complicated by a perforated gastric ulcer 30 years ago, type 2 diabetes, and Barrett esophagus with recent normal upper endoscopy. The patient had coarctation of the aorta repaired 35 years ago. The patient takes aspirin, atorvastatin, and pantoprazole. He emigrated from Mexico 10 years before presentation and lives in Texas with his family. He returns to Mexico several times per year, most recently 2 days before admission. He works at a supermarket. He does not smoke, drink, or use illicit drugs. He denied sick contacts, pets, or incarceration., (Copyright © 2018 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: When an autogenous vein is harvested and used for arterial bypass, it suffers physical and biologic injuries that may set in motion the cellular processes that lead to wall thickening, fibrosis, stenosis, and ultimately graft failure. Whereas the injurious effects of surgical preparation of the vein conduit have been extensively studied, little is known about the influence of the clinical environment of the donor leg from which the vein is obtained., Methods: We studied the cellular responses of fresh saphenous vein samples obtained before implantation in 46 patients undergoing elective lower extremity bypass surgery. Using an ex vivo model of response to injury, we quantified the outgrowth of cells from explants of the adventitial and medial layers of the vein. We correlated this cellular outgrowth with the clinical characteristics of the patients, including the Wound, Ischemia, and foot Infection classification of the donor leg for ischemia, wounds, and infection as well as smoking and diabetes., Results: Cellular outgrowth was significantly faster and more robust from the adventitial layer than from the medial layer. The factors of leg ischemia (P < .001), smoking (P = .042), and leg infection (P = .045) were associated with impaired overall outgrowth from the adventitial tissue on multivariable analysis. Only ischemia (P = .046) was associated with impaired outgrowth of smooth muscle cells (SMCs) from the medial tissue. Co-culture of adventitial cells and SMCs propagated from vein explants revealed that adventitial cells significantly inhibited the growth of SMCs, whereas SMCs promoted the growth of adventitial cells. The AA genotype of the -838C>A p27 polymorphism (previously associated with superior graft patency) enhanced these effects, whereas the factor of smoking attenuated adventitial cell inhibition of SMC growth. Comparing gene expression, the cells cultured from the media overexpress Kyoto Encyclopedia of Genes and Genomes pathways associated with inflammation and infection, whereas those from the adventitia overexpress gene families associated with development and stem/progenitor cell maintenance., Conclusions: The adverse clinical environment of the leg may influence the biologic behavior of the cells in the vein wall, especially the adventitial cells. Chronic ischemia was the most significant factor that retards adventitial cell outgrowth. The cells arising from the vein adventitia may be key players in determining a healthy adaptive or a pathologic response to the injuries associated with vein grafting., (Copyright © 2018 Society for Vascular Surgery. All rights reserved.)

Background: Despite advances in endovascular therapy, infrainguinal bypass continues to play a major role in achieving limb salvage. In this study, we sought to compare outcomes of infrainguinal bypass in patients with limb-threatening ischemia who presented with or without foot infection., Methods: We conducted a retrospective cohort study of patients who underwent infrainguinal bypass for chronic limb-threatening ischemia at a single institution. End points of interest included long-term mortality, 45-day readmission, postoperative length of stay (LOS), major amputation, and time to wound healing. Multivariable Cox, logistic, and robust regressions were used to model time to event outcomes, readmission rates, and LOS., Results: There were 454 infrainguinal bypass procedures analyzed. Demographics and baseline characteristics were similar, except congestive heart failure and diabetes were more common in the infection group. Presence of foot infection had no impact on mortality (hazard ratio [HR], 0.78; P = .243). Significant predictors of long-term mortality included increasing age, hypoalbuminemia, and congestive heart failure; preoperative use of clopidogrel was protective. Presence of foot infection was an independent predictor of major amputation. In the multiple regression model, the presence of foot infection was independently associated with amputation rate (HR, 2.14; 95% confidence interval, 1.42-3.22; P < .001); use of venous conduit and increasing age and body mass index were protective. Foot infection was an independent predictor of prolonged LOS (mean LOS was 1.54 days longer in patients with vs those without infection; P = .001). Other independent predictors of prolonged LOS included intraoperative blood loss and reoperation; history of continuous preoperative aspirin use and normal baseline renal function and albumin levels were associated with decreased LOS. Readmission was influenced by reoperation (odds ratio [OR], 2.51; P < .001) but not by presence of foot infection (OR, 1.21; P = .349). There was a strong trend for prolonged wound healing time in patients with diabetes (HR, 1.58; P = .05) but not in those with foot infection (OR, 0.74; P = .36)., Conclusions: Among patients requiring infrainguinal bypass for limb-threatening ischemia, infection was more common in patients with diabetes and was a significant predictor of major amputation and prolonged LOS. Infection was not predictive of mortality, wound healing time, or readmission. These findings lend support to the inclusion of infection in risk stratification schemes for patients with chronic limb-threatening ischemia, as recommended in the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system, because of its adverse impacts on limb salvage., (Copyright © 2018. Published by Elsevier Inc.)

Vascular access infection is a frequent complication in hemodialysis patients. We report the second case worldwide of a prosthetic hemodialysis vascular graft infection by Coxiella burnetii, with intense hypermetabolism on PET-CT, Q fever serology consistent with persistent infection, and positive C. burnetii DNA in the blood and removed vascular graft.

Background: Transfusion of blood products commonly occur in patients undergoing repair of acute type A aortic dissection (AADA)., Materials and Methods: The medical records of 102 AADA patients were retrospectively reviewed and stratified into cohorts by packed red blood cell (PRBC) and platelet units received: PRBC ≤2 units (n = 68) versus PRBC >2 units (n = 34); platelets ≤1 unit (n = 74) versus platelets >1 unit (n = 28). Continuous and categorical variables were assessed by analysis of variance testing and chi-square or Fisher's testing as appropriate. Multivariate logistic regression was applied to derive P values for post-transfusion complications. Kaplan-Meier survival analyses were used to compare the hospital length of stay (LOS) and survival rate at 1 mo and 1 y., Results: Patients receiving >2 units of PRBC had a median LOS of 14 d versus 9 d for those receiving ≤2 units (P < 0.002). Transfusion of >2 units of PRBC was a risk factor for postoperative infection (odds ratio [OR] = 5.4, 95% confidence interval [CI]: 1.5-19.0, P = 0.009). Survival at 1 mo was 91% versus 94% (P = 0.783) and 1 y survival was 82% versus 93% (P = 0.269) between the two groups. Patients receiving >1 unit of platelets had a median LOS of 15 d versus 10 d for those receiving ≤1 unit (P = 0.005). Transfusion of >1 unit of platelets was a risk factor for postoperative atrial fibrillation and acute kidney injury (OR = 2.9, 95% CI: 1.1-7.6, P = 0.031; OR = 3.3, 95% CI: 1.2-9.4, P = 0.025, respectively). Survival at 1 mo was 93% versus 93% (P = 0.872) and 1 y survival was 81% versus 92% (P = 0.582) between the two groups., Conclusions: Transfusion of PRBC and platelets above a threshold increases the incidence of postoperative complications and hospital LOS among patients undergoing repair of AADA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) at 30 days provide standardized metrics for comparison and have been adopted by the Society for Vascular Surgery's objective performance goals for critical limb ischemia. However, MALEs and MACEs have not been widely adopted within the claudication population, and the comparative outcomes after lower extremity bypass (LEB) and infrainguinal endovascular intervention (IEI) remain unclear. The purpose of this study was to compare MALEs and MACEs after LEB and IEI in a contemporary national cohort and to determine predictors of MALEs and MACEs after revascularization for claudication., Methods: A national data set of LEB and IEI performed for claudication was obtained using National Surgical Quality Improvement Program vascular targeted Participant Use Data Files from 2011 to 2014. Patients were stratified by LEB vs IEI and compared by appropriate univariate analysis. The primary outcomes were MALE (defined as untreated loss of patency, reintervention on the index arterial segment, or amputation of the index limb) and MACE (defined as stroke, myocardial infarction, or death). Multivariable logistic regression was used to identify predictors of MALEs and MACEs., Results: A total of 3925 infrainguinal revascularization procedures (2155 LEB and 1770 IEI) were performed for claudication. There was no difference in 30-day MALEs between LEB and IEI (4.0% vs 3.2%; P = .17). On multivariable logistic regression, predictors of 30-day MALEs included tibial revascularization (odds ratio [OR], 2.2; P < .0001) and prior LEB on the same arterial segment (OR, 1.8; P = .004). LEB had significantly higher 30-day MACEs (2.0% vs 1.0%; P = .01) but similar mortality (0.5% vs 0.4%; P = .6). Predictors of MACEs included LEB vs IEI (OR, 2.1; P = .01), chronic obstructive pulmonary disease (OR, 2.2; P = .01), dialysis dependence (OR, 4.4; P = .003), and diabetes (OR, 1.9; P = .02)., Conclusions: In this large national cohort, LEB and IEI for claudication are associated with similar 30-day MALEs. Tibial revascularization and revascularization after prior failed bypass predict MALEs in claudicants and should therefore be undertaken with caution. LEB was associated with more 30-day MACEs but comparable 30-day mortality compared with IEI. Patients with end-stage renal disease, chronic obstructive pulmonary disease, and diabetes are at high risk for MACEs. The risk of 30-day MACEs after LEB should be weighed against the longer term outcomes of LEB vs IEI and conservative management, particularly in these higher risk patients. This analysis helps define contemporary 30-day outcomes after infrainguinal revascularization performed for claudication and serves as a baseline with which the short-term outcomes of future treatments can be compared., (Copyright © 2018. Published by Elsevier Inc.)

Vascular graft infection is a devastating complication of vascular reconstructive surgery. The infection can occur early in the postoperative period and is largely due to intraoperative contamination or by contiguous extension from a nearby infection. It can also occur years after implantation. Staphylococci remain the most common organisms and biofilm production makes eradication difficult. Factors commonly reported to predispose to vascular graft infection are periodontal disease, nasal colonization with Staphylococcus aureus, bacteremia, certain graft characteristics, diabetes mellitus, postoperative hyperglycemia, location of the incision, wound infection, and emergency procedure. Management consists of antibiotic and surgical therapy. Preventive methods are described., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background:: Evaluation of below-the-knee open revascularization (OR) versus endovascular revascularization (EVT) in patients with end-stage renal disease and critical limb ischemia (CLI) was performed., Patients and Methods:: Seventy-seven dialysis patients with CLI and infrapopliteal involvement from 2007 to 2017 were included. Thirty-five patients received OR and 42 patients were treated with EVT. Survival, amputation-free survival (AFS) and wound-healing were evaluated. Furthermore, both groups were analyzed for differences as to anatomic (lesion length, runoff, pedal arch classification) and clinical (VSG risk score, WIfI score) characteristics., Results:: Amputation-free survival (1-year AFS: OR 54.5% vs 47.6% in EVT, 2-year AFS OR 38.3% vs 23.9% EVT, P = .201) did not significantly differ between OR and EVT nor did the wound healing rate (29% OR vs 31% EVT, P = .532). Overall survival was noticeably poor (1-year survival: 66.7% in OR and 49% in EVT, 2-year survival OR 47.4% vs EVT 27.7%; P = .088); evaluation of peripheral runoff (Rutherford score 6.9 OR vs 7.1 EVT, P = .499) and pedal arch classification as well as WIfI or VSG risk score (9.8 OR vs 9.6 EVT, P = .673) could not detect significant differences as to both the groups. Treated median lesion length was significantly increased in OR patients (OR 26 cm vs EVT 7 cm, P < .001), whereas the incidence of major adverse cardiac events was higher in EVT patients (67% in EVT vs 40% OR, P = .023)., Conclusion:: OR and EVT showed comparable outcomes as to AFS and wound healing. Poor overall survival remains the determining factor in patients with ESRD having CLI. Both groups differ in terms of anatomic features as lesion length and severity of comorbidities; considering the comparable long-term outcomes, decision-making should be based on these premises; individually applied, each method can contribute to limb salvage, although the overall survival remains limited.

A one-size-fits-all approach to vascular access for dialysis may be prejudicial. Arteriovenous fistulae (AVF) have high primary failure, failure to mature rate, and late-stage complications making them unsuitable choice for many patients. Aging of population with chronic kidney disease (CKD) coupled with venous injury during CKD stages depletes suitable superficial veins for AVF creation. The National Institutes of Health consortium demonstrated the difficulty in attaining a functional AVF in hemodialysis patients. Recognition of flaws in AVF and the quest to reduce catheter use bring to the fore the benefits of arteriovenous grafts (AVG). Advances in catheter technologies, flow, care, and antibiotic locks have resulted in significant improvement in catheter-related infections. However, widespread recognition of catheter-related complications like central vein stenosis, metastatic infections, and exhaustion of venous access sites preclude their being a viable alternative to AVF, furthering the need to explore AVG as a substitute. Placement of "early cannulation" AVG is a catheter sparing option in patients who are likely to have inadequate fistula maturation. Advances in biohybrid technology and tissue-engineered grafts are providing a robust opportunity to develop biocompatible graft materials with minimal tissue reactivity and thrombogenicity. Xenografts (bovine carotid artery grafts) are proving to be comparable and, in many cases, better than conventional polytetrafluoroethylene material. Older age, dialysis dependence, and smaller vein size are related to the appropriateness of AVG creation. An individualized approach in selecting optimal upper extremity vascular access option using patient-specific factors while incorporating the benefits of an AVG would greatly aid in achieving low catheter usage in the dialysis population., (© 2018 Wiley Periodicals, Inc.)

Background: Ankle-brachial index (ABI) is a common method of graft surveillance after infrainguinal lower extremity bypass (LEB) surgery and is recommended by the Society for Vascular Surgery. Several studies failed to show the benefit of ABI surveillance but were limited by sample size, and the practice remains variable., Methods: We identified all patients who underwent LEB for occlusive disease from the Vascular Study Group of New England Registry (VSGNE) between 2003 and 2016. Postoperative changes were defined as follows: improvement for ABI >0.15 at discharge or clinical status improved (i.e., symptoms improved from rest pain to asymptomatic, and so forth), no change if ABI was within 0.15 or no change in clinical status, or worsened if ABI decreased >0.15 or clinical status deteriorated. We determined the independent effect of these changes on rates of mortality, reintervention, patency loss, amputation, and Major Adverse Limb Events (MALE-above ankle amputation, revision, thrombectomy, or lysis). In addition, we compared the practice of perioperative ABI to follow-up without ABI using propensity scores with inverse probability weights., Results: We identified 7,994 patients undergoing their first intervention in the VSGNE, 2,251 of whom (29%) had both preoperative and discharge ABIs. Overall, 5,369 (67%) of the bypasses used vein, and 4,539 (57%) were femoropopliteal, with no difference in the rate of vein use or bypass type between those who had discharge ABIs and those who did not (P > 0.05). Most bypasses were performed for chronic limb-threatening ischemia (59% in the ABI group, 65% in those without ABI data, P < 0.01 for difference). At discharge, ABI remained stable in 22%, improved in 69%, and worsened in 9%, whereas clinical status remained stable in 12%, improved in 77%, and worsened in 12%. In univariate analysis, clinical status was associated with mortality, amputation, and MALE, but ABI change was only associated with mortality (all P < 0.01). After multivariable adjustment, ABI change was no longer associated with mortality and remained unassociated with amputation and MALE (P > 0.05), and the addition of ABI change to the models did not improve the fit of the model (likelihood ratio P > 0.05). Forgoing perioperative ABI was associated with higher rates of patency loss (P = 0.02), but not reinterventions (P = 0.57), or untreated patency loss (P = 0.17)., Conclusions: A change in clinical status, but not a change in ABI, was associated with adverse outcomes after LEB. In this group of VSGNE patients with follow-up, perioperative ABI did not add incremental value to clinical status alone as a method of graft surveillance., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The aim of the study was to evaluate the outcomes of duplex ultrasonography (DUS)-guided autologous vein bypass to paramalleolar (distal third of tibial arteries and peroneal artery) and inframalleolar arteries (dorsalis pedis, common plantar, medial, and lateral plantar arteries) in patients with critical limb ischemia (CLI) and extensive tibial artery disease Trans-Atlantic Inter-Society Consensus D., Methods: Between January 2007 and October 2016, all paramalleolar or inframalleolar bypasses performed in patients with CLI, planned only on the basis of DUS, were collected and analyzed retrospectively. DUS evaluation included arterial disease extension, inflow and outflow arteries' diameter, outflow vessels resistance, and autologous veins quality. Patient's demographics and clinical characteristics were assessed. Tissue loss was graded according to Texas University Wound Classification (TWC). Follow-up included periodic clinical and DUS examinations. Primary end points were technical success (TS) (patent bypass with distal anastomosis performed on the Duplex-selected runoff artery, without stenosis >30% and in line flow with the inframalleolar arteries at completion angiography and without hemodynamic bypass stenosis at postoperative DUS) and bypass patency (primary [PP], assisted [AP], and secondary [SP]). Secondary end points were perioperative and follow-up patient survival (PS), limb salvage (LS), and amputation-free survival (AFS). Descriptive statistics and Kaplan-Meier analysis were performed. Univariate and Multivariate Cox analyses were used to define risk factors., Results: Seventy-four bypasses in 73 patients with CLI (Rutherford 5-6 93.2%, TWC stage III in 63.5% and grade D in 48.6%) were performed in the study period (January 2007-October 2016). diabetes mellitus, coronary artery disease, and kidney disease were present in 67.6%, 60.8%, and 37.8% patients, respectively. Distal anastomosis was performed at the paramalleolar and inframalleolar arteries in 47.3% and 52.7%, respectively. Only autologous veins were used as conduit. TS was 98.6%. At 1-month, PP, AP, SP, PS, LS, and AFS were 87.8%, 91.9%, 93.2%, 95.9%, 94.6%, and 90.5%, respectively. The mean follow-up was 33.7 months; at 1-year, PP, AP, SP, PS, LS, and AFS were 54.4%, 71.4%, 75.1%, 89.9%, 84.3%, and 79.1%, respectively, and at 3-year, 42.3%, 63%, 66%, 67.5%, 80.6%, and 61%, respectively. At univariate and multivariate analyses, arterial hypertension was protective for PP (P = 0.035) while insulin-dependent diabetes was a negative predictor (P = 0.01); insulin-dependent diabetes was a negative predictor of LS (P = 0.002); TWC grade D was a negative predictor of AP (P = 0.047) and SP (P = 0.013). Age (P < 0.001) and major amputation (P = 0.014) resulted as negative predictors of PS., Conclusions: Bypass of the Duplex-selected paramalleolar and inframalleolar arteries in CLI has high TS and high rate of perioperative and late LS. Duplex evaluation and planning in CLI patients with extensive tibial arteries disease is associated with efficacy of surgical revascularization and high LS rates., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: This study aims to present early and midterm results of vascular reconstruction with saphenous vein panel graft., Methods: Between August 2014 and August 2017, 11 saphenous vein panel grafts were used for vascular reconstruction in 10 patients. Patient data including age, gender, etiology of the vascular pathology, concomitant injury, site of injury, surgical procedure, additional surgical procedure, and hemodynamic status were retrospectively collected and analyzed. The Kaplan-Meier method was used to calculate the reintervention and patency rates., Results: Mean duration of follow-up was 16.5 ± 13.2 months (ranged, 2-39 months). The freedom from reintervention for any reason was 82% at 1 and 2 years. There was no evidence of arterial claudication or venous insufficiency in all patients. The primary patency rates were 82% at 1 and 2 years. There was no mortality, deep venous thrombosis, pulmonary embolism, graft thrombosis, anastomotic stenosis, diameter discrepancy, and aneurysm formation during late follow-up., Conclusions: The autologous saphenous panel vein graft enables the surgeon to prepare suitable conduits easily with an appropriate diameter and length for vascular reconstruction. Although long-term results are unknown, this technique provides high patency rates in midterm follow-up, resistance to infection, and low reintervention rates. In conclusion, autologous saphenous vein panel grafts may well be preferred in various vascular disorders that require surgical reconstruction., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Analytic morphometry is a novel concept in perioperative risk assessment. Low core muscle mass assessed by morphometry is associated with frailty and has been demonstrated to be an independent predictor of postoperative complications and mortality in oncologic, transplant, and aneurysm surgery. We aimed to study associations between core muscle mass and complication rates, length of hospital stay, and survival after surgical lower limb revascularization., Methods: In this retrospective cohort study, 263 patients considered for surgical lower limb revascularization between January 2013 and December 2014 underwent cross-sectional imaging. Total psoas area (TPA) was measured on computed tomography angiograms at the level of the fourth lumbar vertebra by two independent observers blinded to clinical details. Clinical information was collected from patients' notes and the electronic medical record. Cox and logistic regression analyses were used to estimate the effect of clinical factors and psoas muscle area on survival, complication rates, and prolonged hospital stay after surgical lower limb revascularization., Results: Data from 263 patients were analyzed. The American Society of Anesthesiologists score (hazard ratio [HR], 3.05; confidence interval [CI], 1.69-5.50; P < .001), emergency status (HR, 2.26; CI, 1.21-4.22; P = .011), lowest TPA quartile (HR, 1.89; CI, 1.07-3.35; P = .028), and Fontaine stage (HR, 1.63; CI, 1.04-2.53; P = .031) were found to be independent predictors of survival. Low TPA was not associated with increased rate of postoperative complications or prolonged hospital stay., Conclusions: Psoas muscle area may help identify patients with a shorter life expectancy after lower limb revascularization, but its role in predicting postoperative complications or length of hospital admission seems to be limited., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Atherosclerotic disease of the lower extremity arteries (PAD) remains a significant burden on global healthcare systems with increasing prevalence. Various guidelines on the diagnosis and treatment of patients with PAD are available but they often lack a sufficient evidence base for high-grade recommendations since randomized and controlled trials (RCT) remain rare or are frequently subject to conflicts of interest. This registry trial aims to evaluate the outcomes of catheter-based endovascular revascularisations vs. open-surgical endarterectomy vs. bypass surgery for symptomatic PAD on medical and patient-reported outcomes., Methods and Design: The study is a prospective non-randomized multicentre registry trial including invasive revascularisations performed in 10 000 patients treated for symptomatic PAD at 30 to 40 German vascular centres. All patients matching the inclusion criteria are consecutively included for a recruitment period of six months (between May and December 2018) or until 10 000 patients have been included in the study registry. There are three follow-up measures at three, six, and 12 months. Automated completeness and plausibility checks as well as independent site visit monitoring will be performed to assure high internal and external validity of the study data. Study endpoints include relevant major cardiovascular and limb events and patient-reported outcomes from two Delphi studies with experts in vascular medicine and registry-based research., Discussion: It remains unclear if results from RCT can reflect daily treatment practice. Furthermore, great costs and complexity make it challenging to accomplish high quality randomized trials in PAD treatment. Prospective registry-based studies to collect real-world evidence can help to overcome these limitations.

Background: Hospital readmissions are associated not only with increased mortality, morbidity, and costs but also, with current health-care reform, tied to significant financial and administrative penalties. Some studies show that patients undergoing vascular surgery may have higher than average readmission rates. The recently released Nationwide Readmission Database (NRD) is the most comprehensive national source of readmission data, gathering discharge information from 22 geographically dispersed states, accounting for 51.2% of the total U.S. resident population and 49.3% of all U.S. hospitalizations. The aim of this study is to use the power of the NRD and obtain nationally representative readmission information for patients admitted with claudication or critical limb ischemia (CLI) who underwent revascularization procedures., Methods: The NRD was queried for all patients admitted for claudication (International Classification of Diseases Ninth Revision [ICD-9] 440.21) or CLI (ICD-9 440.22-440.24) and who underwent percutaneous transluminal angioplasty, peripheral bypass, or aortofemoral bypass. Patient demographics, comorbidities, length of stay (LOS), mortality, readmission rates, and associated costs were collected. Univariable and multivariable logistic regression analysis was implemented on claudication and CLI groups on all outcomes of interest. The most common readmission diagnosis codes and diagnosis groups were also identified., Results: A total of 92,769 patients were admitted for peripheral vascular disease (33,055 with claudication and 59,714 with CLI). The 30-day readmission/any readmission rate was 8.97%/21.49% and 19.26%/40.36%, for claudication and CLI, respectively. Significant differences were found for claudication and CLI, respectively, on initial cost of admission ($18,548 vs. $29,148, P < 0.001), readmission costs ($14,726 vs. $17,681 P < 0.001), LOS (4 days vs. 9 days, P < 0.001), days to readmission (73 days vs. 59 days, P < 0.001), mortality during initial admission (256 vs. 1,363, P < 0.001), and mortality during any admission (538 vs. 3,838, P < 0.001). Univariate and multivariate logistic regression analysis found that claudication, CLI, angioplasty, peripheral bypass, aortofemoral bypass, female sex, age >65, Charlson Comorbidity Index, LOS, and primary expected payer status were all significant predictors of 30-day and overall readmissions at varying degrees. The 5 most common disease readmission groups found were other vascular procedures (12.6%), amputation of lower limb except toes (6.3%), sepsis (5.4%), heart failure (4.9%) and postoperative or other device infections (4.8%). Of the abovementioned groups, the 4 most common diagnoses included "other postoperative infections," sepsis, atherosclerosis of native arteries with gangrene, and "other complications due to other vascular device, implant, or graft.", Conclusions: Our results demonstrate that there is a significant difference in readmission rates, cost, and morbidity between patients admitted for claudication and CLI. Furthermore, based on regression analysis, there are multiple other clear risk factors associated with worse clinical and economic outcomes. Further study is needed to predict which patients will require increased vigilance during their hospital stay to prevent readmissions and worse outcomes., Level of Evidence: Care management/epidemiological, level IV., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: 18 F-FDG PET/CT (PET/CT) is a useful tool for the diagnosis of aortic graft infection (AGI), but has rarely been used to influence therapeutic decisions during follow-up. We aimed to study the role of PET/CT in the long-term monitoring of patients., Methods: Participants of the prospective Vascular Graft Infection Cohort Study (VASGRA) were included if they had microbiologically proven AGI. We quantified the metabolic activity in PET/CT by using maximum standardized uptake value (SUV max ) and further classified it as being focal or diffuse. Multivariable linear regression models were fit using generalized estimating equations to investigate factors associated with SUV max over time., Results: Sixty-eight participants with AGI contributed to 266 PET/CTs including 36 examinations performed after stop of antimicrobial therapy. Higher C-reactive protein (CRP) (adjusted coefficient per log 10 mg/L 0.05 [95% C.I. 0.02-0.08]) was associated with higher SUV max . CRP, metabolic and clinical findings informed the decision to either start (medians of SUV max 7.1 and CRP 31.5 mg/L; 100% focal uptake), escalate (SUV max 9.5; CRP 31.5; 100% focal uptake), continue (SUV max 6.0; CRP 9.95 mg/L; 90% focal uptake), or stop (SUV max 4.3; CRP 3.5 mg/L; 61% focal uptake) antibiotic treatment. Of note, decisions to escalate or continue antibiotic treatment were taken despite normal CRP values in 12.5 and 35.7% of PET/CTs, respectively., Conclusions: Consecutive PET/CTs could influence the clinical decision-making in patients with AGI in the near future. More studies on the use of PET/CT in case of aortic graft infection may offer the potential for individualized treatment approaches. CLINICALTRIALS., Gov Identifier: NCT01821664.

Background: Endovascular treatment of symptomatic peripheral artery disease has gained widespread acceptance. The efficacy and safety of drug-coated balloon (DCB) angioplasty in the setting of critical limb ischemia in comparison to conventional surgery has not been demonstrated. We have compared our results with DCB angioplasty to conventional bypass surgery in patients with critical limb ischemia (CLI)., Methods: A total of 187 patients with CLI treated over a 6-year period between 2006 and 2012 by a single operative team constituted the study population. Between 2006 and 2009, all patients underwent conventional surgery. Between 2009 and 2012, the investigators adopted endovascular approach with the use of IN.PACT Admiral (Medtronic Inc., Santa Rosa, CA, USA). Data collection was achieved prospectively., Results: A total 210 procedures (100 surgery, 110 endovascular) were performed over a 6-year period. A 72% of all bypasses were performed using saphenous vein grafts with above-the-knee bypass as the technique of choice in 80% of the cases. 6-mm DCB was used in 41% of the patients. Procedural success rates (98% vs. 99%, NS) as well as clinical success rates (99% vs. 99%, P=NS) and operative mortality (3.7% vs. 2%, NS) was similar in both groups. Primary patency for DCB vs. bypass groups 91.8% vs. 88.9%, respectively (P=0.31) at 12 months and 82.7% vs. 82.8% at 24 months, respectively (P=0.28). Freedom from clinically-driven target lesion revascularization at 12 months was similar in both groups (87.6% vs. 85%, P=0.33). Primary patency for DCB vs. bypass groups at 24 months was 82.7% vs. 82.8%, respectively (P=0.28)., Conclusions: DCB angioplasty yields comparable results to surgery in the setting of critical ischemia. The efficacy and the safety of DCBs in more complex lesions is to be investigated with randomized trials.

Background: Current surgical management of retroperitoneal masses involving major vessels now includes complete en bloc resection with in situ venous, arterial, or combined reconstruction. No studies have investigated preresection arterial bypass for continuous lower extremity perfusion during definitive resection. Here, we characterize and compare the outcomes of surgery for retroperitoneal masses with major vascular involvement by a two-stage approach (femoral-femoral bypass preceding resection) and the traditional one-stage approach (consecutive resection and in situ vascular reconstruction)., Materials and Methods: We retrospectively reviewed patients who underwent resection of retroperitoneal masses and reconstruction of major arterial or venous structures from 2004 to 2016. Outcomes were compared with unpaired t-tests, chi-squared tests, and Kaplan-Meier analysis., Results: Eight patients underwent a two-stage procedure, and seven underwent a one-stage procedure for retroperitoneal masses with vascular involvement. Mean (±SD) oncologic resection time (443 ± 215 versus 648 ± 128 min, P = 0.047) and postoperative ICU stay (0.9 ± 1.3 versus 4.4 ± 2.9 d, P = 0.018) were significantly shorter for the two-stage approach., Conclusions: To our knowledge, this is the first report of a two-stage approach for resection of retroperitoneal masses with major vessel involvement. Femoral-femoral arterial bypass before definitive resection could be a viable option for improving intraoperative vascular control and decreasing perioperative complications in these complex procedures., (Published by Elsevier Inc.)