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Delayed-onset heparin-induced thrombocytopenia (HIT) is a rare and only recently described condition. The authors report 4 cases of delayed-onset HIT, each of which presented with thrombotic complications 8-18 days after receiving heparin for coronary artery bypass grafting. Delayed-onset HIT should be suspected in any patient presenting with arterial or venous thromboembolism after heparin therapy, even 1 to 3 weeks after heparin exposure. [ABSTRACT FROM AUTHOR]

This chapter about antithrombotic therapy for peripheral arterial occlusive disease is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004;126:179S-187S). Among the key recommendations in this chapter are the following: For patients with chronic limb ischemia, we recommend lifelong aspirin therapy in comparison to no antiplatelet therapy in patients with clinically manifest coronary or cerebrovascular disease (Grade 1A) and in those without clinically manifest coronary or cerebrovascular disease (Grade 1C+). We recommend clopidogrel over no antiplatelet therapy (Grade 1C+) but suggest that aspirin be used instead of clopidogrel (Grade 2A). For patients with disabling intermittent claudication who do not respond to conservative measures and who are not candidates for surgical or catheter-based intervention, we suggest cilostazol (Grade 2A). We suggest that clinicians not use cilostazol in patients with less-disabling claudication (Grade 2A). In these patients, we recommend against the use of pentoxifylline (Grade 1B). We suggest clinicians not use prostaglandins (Grade 2B). In patients with intermittent claudication, we recommend against the use of anticoagulants (Grade 1A). In patients with acute arterial emboli or thrombosis, we recommend treatment with immediate systemic anticoagulation with unfractionated heparin (UFH) [Grade 1C]. We also recommend systemic anticoagulation with UFH followed by long-term vitamin K antagonist (VKA) in patients with embolism [Grade 1C]). For patients undergoing major vascular reconstructive procedures, we recommend UFH at the time of application of vascular cross-clamps (Grade 1A). In patients undergoing prosthetic infrainguinal bypass, we recommend aspirin (Grade 1A). In patients undergoing infrainguinal femoropopliteal or distal vein bypass, we suggest that clinicians do not routinely use a VKA (Grade 2A). For routine patients undergoing infrainguinal bypass without special risk factors for occlusion, we recommend against VKA plus aspirin (Grade 1A). For those at high risk of bypass occlusion and limb loss, we suggest VKA plus aspirin (Grade 2B). In patients undergoing carotid endarterectomy, we recommend aspirin preoperatively and continued indefinitely (Grade 1A). In nonoperative patients with asymptomatic or recurrent carotid stenosis, we recommend lifelong aspirin (Grade 1C+). For all patients undergoing extremity balloon angioplasty, we recommend long-term aspirin (Grade 1C+). [ABSTRACT FROM AUTHOR]

Objective: Aortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein., Methods: A retrospective review of all AFBG infections from 2003 to 2015 treated at a tertiary care facility was undertaken. Patients who underwent unilateral partial graft excision with inline reconstruction using femoral vein at the distal (femoral) anastomosis were included. Complete excisions with bilateral revascularizations using any conduit or any extra-anatomic reconstructions were excluded. The primary end point was successful treatment of infection. Secondary end points were procedure-related mortality, graft patency, and perioperative complications., Results: During a 12-year period, partial graft excision with bypass using the femoral vein was performed in 21 patients (24 limbs). Mean age was 61 ± 12 years. There were 13 men and 8 women. Mean follow-up was 53 ± 27 months. Successful treatment was achieved in 19 of 21 patients. The two treatment failures were due to persistent infection. One of these patients declined complete graft excision and is receiving lifelong suppressive antibiotic therapy. The other patient underwent complete graft excision and an NAIS reconstruction. There were no perioperative or procedure-related deaths. There were no major amputations, and primary graft patency was 92% at 72 months. The most common AFBG culture isolate was Staphylococcus species. Approximately one-third of cultures did not yield any growth. Patients underwent anywhere from 1 to 12 weeks of combined intravenous and oral antibiotic therapy., Conclusions: This limited series demonstrates excellent graft patency with a low persistent infection rate. Thus, in patients with localized graft infection, partial excision with preservation of the proximal synthetic graft is an acceptable alternative when patient factors preclude complete graft excision., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

We aim to provide a thorough and current summary highlighting the use of autologous vein grafts during reconstruction of infected aortic grafts. Aortic graft infections, while rare, remain one of the most difficult problems that a vascular surgeon can encounter. Optimal management of patients with aortic graft infections requires a full understanding of all potential therapeutic interventions available. Reconstruction with autologous vein grafts is a technique that has evolved and has been refined during the past 2 decades, representing a major advance in the treatment of aortic graft infections. Thirty-day operative mortality is ≤ 10%, with 5-year mortality rates of 30% to 50%. Thirty-day major amputation rates range from 2% to 7.4%, with 5-year limb-salvage rates ranging between 89% and 96%. Early occlusion of the grafts are rare, with <4% undergoing thrombosis within the first 30 days; 5-year primary patency ranges from 75% to 91%, with secondary patency approaching 91% at 5 years. Recurrent infection is very rare, occurring in <2% of patients. Venous morbidity is similarly low, with fasciotomy rates of 12%, and only 15% of patients experiencing chronic venous insufficiency at 5 years. Aneurysmal degeneration is also exceptionally rare. Use of autologous vein grafts for in situ reconstruction of infected aortic grafts represents the standard of care in the treatment of aortic graft infections. With appropriate patient selection, centers with sufficient resources should be able to comparable outcomes., (Published by Elsevier Inc.)

Objective: Prior studies have reported improved clinical outcomes with higher surgeon volume, which is assumed to be a product of the surgeon's experience with the index operation. We hypothesized that composite surgeon volume is an important determinant of outcome. We tested this hypothesis by comparing the impact of operation-specific surgeon volume versus composite surgeon volume on surgical outcomes, using open abdominal aortic aneurysm (AAA) repair as the index operation., Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing open AAA repairs for 2000 to 2008. Surgeons were stratified into deciles based on annual volume of open AAA repairs ("operation-specific volume") and overall volume of open vascular operations ("composite volume"). Composite volume was defined by the sum of several open vascular operations: carotid endarterectomy, aortobifemoral bypass, femoral-popliteal bypass, and femoral-tibial bypass. Multiple logistic regression analyses were used to examine the relationship between surgeon volume and in-hospital mortality for open AAA repair, adjusting for both patient and hospital characteristics., Results: Between 2000 and 2008, an estimated 111,533 (95% confidence interval [CI], 102,296-121,232) elective open AAA repairs were performed nationwide by 6,857 surgeons. The crude in-hospital mortality rate over the study period was 6.1% (95% CI, 5.6%-6.5%). The mean number of open AAA repairs performed annually was 2.4 operations per surgeon. The mean composite volume was 5.3 operations annually. As expected, in-hospital mortality for open AAA repair decreased with increasing volume of open AAA repairs performed by a surgeon. Mortality rates for the lowest and highest deciles of surgeon volume were 10.2% and 4.5%, respectively (P < .0001). A similar pattern was observed for composite surgeon volume, as the mortality rates for the lowest and highest deciles of composite volume were 9.8% and 4.8%, respectively (P < .0001). After adjusting for patient and hospital characteristics, increasing composite surgeon volume remained a significant predictor of lower in-hospital mortality for open AAA repair (odds ratio, 0.994; 95% CI, .992-.996; P < .0001), whereas increasing volume of AAA repairs per surgeon did not predict in-hospital deaths., Conclusions: The current study suggests that composite surgeon volume-not operation-specific volume-is a key determinant of in-hospital mortality for open AAA repair. This finding needs to be considered for future credentialing of surgeons., (Published by Mosby, Inc.)

Objective: The effect of stent design on cerebral embolization has not been established. The purpose of this trial was to contrast the incidence of subclinical cerebral embolization in high-risk patients undergoing carotid artery stenting (CAS) with open-cell vs closed-cell stents., Methods: During an 18-month period, 40 patients were randomized (1:1) to undergo CAS with open-cell (Acculink, n = 20) or closed-cell stents (Xact, n = 20). A single filter device for embolic protection (Accunet filter) was used. Transcranial Doppler (TCD)-detected microembolic signals (MES) during CAS and preprocedural and 24-hour postprocedural diffusion-weighted magnetic resonance imaging (DW-MRI) were used to determine cerebral embolization. Univariate and nonparametric analyses were used to assess associations between stent design and cerebral embolization., Results: CAS was performed in 17 symptomatic patients (43%) and 23 asymptomatic patients (57%) with a similar number of open-cell and closed-cell stents (9/8 and 11/12, respectively). The total and poststenting median ipsilateral MES counts detected by TCD were 264 (interquartile range [IQR], 222-343) and 48 (IQR, 41-66) for open-cell stents and 339 (IQR, 163-408) and 53 (IQR, 23-88) for closed-cell stents, respectively (P > .56). New acute cerebral emboli detected with DW-MRI occurred in 53% and 47% of patients undergoing CAS with open-cell and closed-cell stents, respectively (P = 1.0). The total and ipsilateral median numbers of DW-MRI lesions between groups were not statistically significantly different (ie, 2 [IQR, 0-4] and 1 [IQR, 0-3] for open-cell stents and 1 [IQR, 0-3] and 1 [IQR, 0-2] for closed cell-stents, respectively; P > .4). One asymptomatic patient undergoing CAS with an open-cell stent sustained a minor stroke; the 30-day stroke-death rate in this series was 2.5%., Conclusion: Cerebral embolization, as detected by TCD and DW-MRI, occurs with similar frequency after CAS with open-cell and closed-cell stents. This randomized trial does not support the superiority of any stent design with respect to cerebral embolization., (Published by Mosby, Inc.)

Objective: To identify preoperative clinical features that predict a durable improvement in renal function with renal artery stenting (RAS)., Methods: Sixty-one patients with renal insufficiency (serum creatinine ≥ 1.5 mg/dL) underwent RAS for renal salvage. Patients were categorized as "responders" if estimated glomerular filtration rate (eGFR) at last follow-up was improved 20% or more over baseline. Patients with stable or worse renal function after RAS were labeled "non-responders." For the purpose of calculating changes in eGFR, patients on dialysis were represented by an eGFR of 10 ml/min/1.73 m(2). Renal volume was estimated as kidney length × width × depth/2., Results: The median age of the cohort was 66 years (interquartile range [IQR], 60-73 years). Median preoperative serum creatinine was 1.8 mg/dL (IQR, 1.6-2.3), and median estimated glomerular filtration rate (eGFR) was 34 mL/min/1.73 m(2) (IQR, 24-45). With stenting, 17 of 61 patients (27.9%) derived a durable improvement in renal function at a median follow-up of 24 months (IQR, 16-33 months). The largest proportion of stented patients (44.3%) had no improvement in renal function after stenting, while a subset (27.9%) experienced a decline in renal function. Responders enjoyed a 47% improvement in renal function from baseline, while non-responders had a 13% decrement in renal function (P < .0001). Responders had a higher baseline serum creatinine, lower eGFR, and a steeper decline in renal function prior to RAS, compared with non-responders. Kidney length, width, depth, and volume were not significantly different between responders and non-responders. Logistic regression analysis identified the rate of decline of renal function prior to stenting as the only independent preoperative predictor of improved renal function after RAS (odds ratio, 3.4; 95% confidence interval, 1.6 to 7.5; P = .0019). The rate of decline in eGFR per week was more than 20-fold greater for responders than non-responders (2.1% vs 0% decline in eGFR per week; P < .0001). No predictors of renal function deterioration after stenting were identified., Conclusions: The current study found that a steep decline in preoperative renal function portends a higher likelihood of renal salvage from RAS among patients with renal insufficiency. Incorporating this finding into patient selection may improve outcomes for RAS., (Published by Mosby, Inc.)

Objectives: Previous observational studies suggest that children with hand ischemia following elbow trauma can be safely observed if Doppler signals are present in the wrist arteries (pink pulseless hand, PPH). Nonoperative management of PPH is predicated on the assumption that PPH results from local arterial spasm, but the mechanism of arterial compromise has not been investigated. We hypothesized that PPH signifies a brachial artery injury that requires surgical repair., Methods: Retrospective review of operations performed on children with hand ischemia following elbow trauma at a level I trauma center pediatric hospital., Results: Between 2003 and 2010, 12 children (seven males, mean age 7.4 years) underwent brachial artery exploration for hand ischemia following elbow trauma (11 supracondylar fractures, one elbow dislocation) due to falls (n = 10) or motor vehicle crashes (n = 2). At presentation, three subjects had normal radial pulses, eight subjects had Doppler signals but no palpable pulses, and one had weak Doppler flow with advanced hand ischemia. Six of the nine subjects without palpable pulses also had neurosensory changes. All 12 subjects underwent brachial artery exploration either initially (n = 2) or following orthopedic fixation (n = 10) due to persistent pulselessness. At operation, eight of 12 patients (67%) had focal brachial artery thrombosis due to intimal flaps, and four had brachial artery and median nerve entrapment within the pinned fracture site. At discharge, all 12 subjects had palpable radial pulses, but three with entrapment had dense median nerve deficits. One of the three subjects with dense neurologic deficit had complete recovery of neurologic function at ten months. The other two subjects had residual median nerve deficits with partial recovery at 5 and 6 months follow-up, respectively. No patient developed Volkman's contracture., Conclusions: Brachial artery injuries should be anticipated in children with hand ischemia associated with elbow trauma. Neurovascular entrapment at the fracture site is a possible complication of orthopedic fixation. Absence of palpable wrist pulses after orthopedic fixation should prompt immediate brachial artery exploration. PPH should not be considered a consequence of arterial spasm in these patients., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The purpose of the current study was to identify clinical and kidney morphologic features that predict a favorable blood pressure (BP) response to renal artery stenting (RAS)., Methods: The study cohort consisted of 149 patients who underwent primary RAS over 9 years. Patients were categorized as "responders" based on modified American Heart Association guidelines: BP <160/90 mm Hg on fewer antihypertensive medications or diastolic BP <90 mm Hg on the same medications. All other patients were deemed "nonresponders." Renal volume was estimated as kidney length × width × depth/2 based on preoperative computed tomography or magnetic resonance scans. Median follow-up was 19 months (interquartile range [IQR] 10.0-29.5 months)., Results: The median age of the cohort was 68 years (IQR, 60-74 years). A favorable BP response was observed in 50 of 149 patients (34%). Multivariate analysis identified three independent predictors of a positive BP response: (1) requirement for four or more medications (odds ratio, 29.9; P = .0001), (2) preoperative diastolic BP >90 mm Hg (OR, 31.4; P = .0011), and (3) preoperative clonidine use (OR, 7.3; P = .029). The BP response rate varied significantly based on the number of predictors present per patient (P < .0001). Among patients with three-drug hypertension, a larger ipsilateral kidney (volume ≥150 cm(3)) increased the BP response rate more than threefold compared with patients with smaller kidneys (63% vs 18% BP response rate; P = .018)., Conclusions: The current study demonstrated that three clinical predictors (≥4 antihypertensive medications, diastolic BP ≥90 mm Hg, and clonidine use) are preoperative predictors of BP response to RAS. Kidney volume may help in discriminating responders from nonresponders among those patients with three-drug hypertension. These parameters may assist clinicians in patient selection and provide more concrete data with which to counsel patients on the likely outcomes for RAS., (Published by Mosby, Inc.)

Background: Thoracoabdominal aortic aneurysm (TAAA) repairs are technically challenging. The advent of endovascular aneurysm repair in combination with visceral/renal artery bypasses has allowed for hybrid endovascular repair of these aneurysms. The purpose of this study was to evaluate whether outcomes were affected by the number of visceral/renal artery reconstructions, conduit, or gender., Methods: All patients who underwent visceral/renal bypass associated with an endovascular aortic aneurysm repair were prospectively studied in a vascular registry and retrospectively reviewed between the years 2004 and 2009. Patients undergoing standard open TAAA repair and those with aortic arch branch vessel reconstructions associated with thoracic endovascular repair were excluded from this analysis. Patients were segregated into two groups on the basis of number of vessels bypassed. Group 1 (n = 9) consisted of patients who required one or two bypasses, whereas group 2 (n = 15) consisted of patients who required three or four bypasses., Results: A total of 64 TAAA repairs were performed. In all, 22 patients with hybrid repair and aortic arch vessel reconstructions and 18 patients with open TAAA repair were excluded from this analysis. A total of 24 (38%) patients with hybrid endovascular repair were evaluated in this study. The 30-day mortality was found to be 12.5% (3/24) and the incidence of spinal cord ischemia was 8.3% (2/24). Preoperative comorbidities and American Society of Anesthesia (ASA) scores were reported to be similar between the two groups. As compared with group 2, patients in group 1 were reported to be younger (69.7 ± 10.6 vs. 76.0 ± 5.7 years [p = 0.074]), had less blood loss (1,200 ± 1,088 mL vs. 3,119 ± 2,188 mL, [p = 0.06]), required fewer blood transfusions (5.33 ± 2.31 vs. 9.09 ± 7.06 units packed red blood cells (PRBC) [p = 0.39]), and had a shorter length of stay (11.4 ± 5.6 vs. 21.9 ± 15.1 days, [p = 0.090]). There was no difference in 30-day mortality rates between the two groups. The incidence of perioperative morbidity, including bowel ischemia (11%[1/9] vs. 27% [4/15], [p = 0.39]), myocardial infarction (11% [1/9] vs. 13% [2/15], [p = 0.88]), wound infection (0% vs. 27% [4/15], [p = 0.09]), and pneumonia (11% [1/9] vs. 40% [6/15], [p = 0.14]) was found to be less in group 1 than group 2, but this difference was not significant. Patients with three or four bypasses had a significantly greater requirement for a skilled nursing facility or a rehabilitation facility after discharge (79% [11/14] vs. 29% [2/7], p = 0.026). There were no statistically significant differences in postoperative outcomes when comparing choice of conduit (autogenous or prosthetic) or gender. Results from the Cox-proportional hazards regression showed that bowel ischemia was the only postoperative complication associated with decreased survival (p = 0.037, confidence interval [0.1328-4.3075])., Conclusions: Hybrid aortic aneurysm repair carries a significant risk of patient morbidity with an acceptable mortality for patients considered to be at a high risk for standard thoracoabdominal repair. In patients requiring fewer visceral/renal reconstructions, there is a trend toward fewer postoperative complications and a significantly shorter length of stay. Moreover, there is a significantly lower need for skilled nursing facility requirements after discharge from the hospital. Bowel ischemia is associated with significantly worse outcome and better attempts at avoiding this complication and aggressive management is indicated., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Previous studies have investigated the predictive value of clinical and morphologic parameters for distal embolization during carotid interventions. The composition of the atherosclerotic plaque, using virtual histology intravascular ultrasound (VH-IVUS) imaging obtained with an IVUS catheter that is advanced through the lesion after a filter has been placed distally, has not been evaluated as a marker for cerebral embolization. The purpose of this study was to assess the relationship between atherosclerotic plaque composition determined with VH-IVUS and the occurrence of cerebral embolization after carotid artery stenting (CAS)., Methods: During a 10-month period, 24 patients undergoing CAS procedures using a filter device for embolic protection were prospectively evaluated. All patients underwent VH-IVUS exams at the time of the intervention, transcranial Doppler (TCD) monitoring during CAS, and pre- and 24-hour postprocedural diffusion-weighted magnetic resonance imaging (DW-MRI) exams. Using VH-IVUS, plaque components were characterized as fibrotic, fibrofatty, dense calcium, and necrotic core. The frequency of Doppler-detected microembolic signals (MES) during CAS and the incidence and location of acute postprocedural embolic lesions detected with DW-MRI were assessed to determine cerebral embolization. Univariate and correlation analyses were used to assess the association between plaque composition and frequency of cerebral embolization., Results: No periprocedural transient ischemic attacks, strokes, or deaths occurred within 30 days. Seventeen patients (71%) demonstrated new acute cerebral emboli in DW-MRI. Of these, all revealed ipsilateral lesions and 12 (50%) had contralateral lesions. For the entire study group, the median number of ipsilateral DW-MRI lesions was 1 (range, 0 to 3), and TCD MES counts were 227 (interquartile range, 143-315). Volumetric VH-IVUS analysis revealed that there was a trend for larger median dense calcium volume in patients with ipsilateral subclinical cerebral embolism detected with DW-MRI (33.2±24.5 mm3 vs 11.4±6.1 mm3; P=.08). Scatter plots of plaque components revealed statistically significant correlation between fibrofatty plaque volume (Spearman r=0.49; P=.016) and number of new ipsilateral lesions in DW-MRI. Degree of cerebral embolization during CAS measured with TCD correlated with plaque burden, necrotic core, fibrofatty, and fibrous volumes., Conclusions: Plaque composition, as determined by VH-IVUS, only weakly correlates with the degree of cerebral embolization after carotid stenting. Specifically, there is a trend for larger dense calcium volume in patients with distal embolization. Of note, the proportion of necrotic core, which has traditionally been considered the main component of a vulnerable or unstable plaque, is not definitely associated with subclinical cerebral embolization after CAS when a filter device for embolic protection is used. The role of VH-IVUS in evaluating plaque composition during CAS remains unestablished and warrants further investigation., (Published by Mosby, Inc.)

Background: Thoracic endovascular aortic repair (TEVAR) is accepted treatment for blunt aortic injury (BAI). We hypothesized that immediate TEVAR would reduce deaths from aortic rupture in patients with BAI., Methods: Review of 81 patients with BAI who arrived alive at a level I trauma center over a 10-year period., Results: Twenty-three patients (28%) died within 4 hours of admission, including 12 who died of aortic rupture. Fifty-eight patients (72%) survived beyond 4 hours, and 8 (14%) ultimately died of associated injuries. Forty patients (69%) underwent aortic repair (30 open repair, 10 TEVAR), and 2 died of multisystem organ failure (MSOF). Comparing open repair to TEVAR, there were no differences in the length of hospital stay (33 +/- 27 vs 33 +/- 31 days), operative complications (77% vs 70%), or mortality (7% vs 0). Ten patients (17%) with minimal BAI were treated with beta blockade and observation; 4 have not healed their aortic injuries and 6 have been lost to follow-up. Thirty-three of the original 81 study patients (41%) ultimately died. Compared with the patients who died, the survivors were younger (37 vs 48 years; P = .01) and less likely to develop aortic rupture (0 vs 12; P < .001), require intubation in the field (27% vs 49%; P < .05), require cardiopulmonary resuscitation (CPR; 2% vs 30%; P < .001), or arrive hypotensive (17% vs 67%; P < .001). Survivors also had a lower mean injury severity score (34 +/- 12 vs 44 +/- 12; P < .001), fewer associated injuries (3 +/- 1 vs 4 +/- 3; P = .02), and a higher prevalence of aortic repair (79% vs 6%; P < .001). Multivariate analysis selected no attempt at aortic repair (odds ratio [OR], 90.9; 95% confidence interval [CI], 10.6-1000) and hypotension on arrival (OR, 6.1; 95% CI, 1.4-27) as the only independent variables associated with death., Conclusion: Mortality remains high for patients with BAI, but most patients who arrive alive at the hospital do not experience aortic rupture. Rupture occurs within the first 4 hours of admission, often before the injury is recognized in time for salvage with immediate TEVAR. The decision to repair BAI was based on the extent of associated injuries and on the individual surgeon's judgment. Survival was not influenced by the timing of repair, but further studies are needed to compare the outcome of open repair vs TEVAR in patients who survive beyond 4 hours., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Thoracic endoluminal aortic aneurysm repair (TEVAR) is associated with improved outcomes compared with open thoracic aortic aneurysm repair. This study was designed to better characterize TEVAR outcomes in a large population, and to determine if outcomes are independently influenced by patient ethnicity and insurance status., Methods: Using the Nationwide Inpatient Sample (NIS) database, we selected patients who underwent TEVAR between 2001 and 2005. Ethnicity and insurance type were independently evaluated against the outcome variables of mortality and postoperative complications. Age, gender, hospital region, hospital location, hospital size, and comorbidities were controlled as cofounders., Results: Between 2001 and 2005, 875 patients underwent TEVAR. There was a significantly greater proportion of Caucasians (n = 650) compared with African Americans (n = 104) or Hispanics (n = 49). Patients had a male preponderance, and most procedures were elective. The overall mortality was 13.3% (n = 117), and spinal cord ischemia was 0.8% (n = 7), with no differences between patients of varied ethnicity or payer status. Significant differences were noted among the races including gender (P = .003), income (P < .0001), hospital region (P < .001), hospital bed size (P = .013), and insurance type (P < .001). Significant variations in demographics characteristics were also present between patients with different insurance classifications including gender (P < .001), surgery type (P = .009), income (P = .003), race (P < .0001), and comorbidity index (P < .0001). After adjustment for cofounders and multiple comparisons, there were no differences in rates of complications among patients with varying race or insurance status., Conclusions: Mortality after TEVAR remains high in the US, although this may be associated with its early introduction during the study period. Nonetheless, the incidence of spinal cord ischemia is very low. Ethnicity and insurance type do not appear to influence TEVAR outcomes., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Peripheral arterial disease (PAD) is a highly prevalent public health problem associated with major detrimental effects on quality of life and functional status, and it is also the main cause of limb amputation. More importantly, PAD has been classified as a coronary artery disease equivalent, meaning that patients with a diagnosis of PAD carry a risk for major coronary events equal to that of established coronary artery disease. PAD is also a potent predictor of stroke and death. Despite its frequent occurrence (8 to 10 million Americans are affected), little is known about the natural history of PAD in racial/ethnic minorities, particularly in Hispanics, who represent 12.5% of the United States population. Furthermore, the disease is commonly underdiagnosed and undertreated in this minority group, and outcomes are poorer in Hispanics as compared with whites. Limited access to health care, difficulties for recruitment in population-based studies, and limitations of the noninvasive screening tests are well-established barriers to determine the prevalence and natural history of PAD in Hispanics. Although the most widely used test for assessment of patients at risk for PAD is the ankle-brachial index (ABI), the test has substantial limitations in individuals with diabetes and arterial calcification, which are highly prevalent in Hispanics. The ABI should, therefore, be supplemented by the use of other noninvasive tests, such as the pulse volume recordings (PVR) and toe-brachial index. Besides the use of a combination of diagnostic techniques, the implementation of a research methodology that improves recruitment of Hispanics in population-based studies is necessary to obtain better knowledge of the epidemiology of the disease in this group. Community-based participatory research may be the most appropriate approach to study this ethnic minority because it overcomes barriers for limited access to health care and increases the possibility of overcoming distrust of research on the part of communities. Understanding the epidemiology of PAD to improve its detection and treatment among Hispanics is relevant to reduce disparities in the health status of this group, the most rapidly growing ethnic minority in the United States., (Published by Mosby, Inc.)

Previous reports suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (P-EVAR) is as safe as open access (O-EVAR) in patients with favorable femoral anatomy. Severe femoral artery calcification and obesity have been considered relative contraindications to P-EVAR, but these criteria have not been evaluated. The purpose of this study was to assess the postoperative anatomic changes associated with P-EVAR versus O-EVAR using three-dimensional (3-D) computed tomographic (CT) reconstruction and to evaluate the overall results of the two procedures in a group of patients with suboptimal femoral anatomy. During a recent 26-month period, 173 patients underwent EVAR at our institutions, including 35 P-EVARs. Of these, 22 (63%) had complete pre- and postoperative CT imaging of the femoral arteries. These subjects were compared to 22 matched controls who underwent O-EVAR during the same period. Automated 3-D reconstructions were used to measure the following anatomic femoral artery parameters before and after EVAR: arterial depth, calcification score, minimum diameter and area, and maximum diameter and area. Of the 88 study arteries, 50 underwent open access and 38 percutaneous access (Proglide, n=11; Prostar XL, n=27). Both groups were similar regarding sheath size, number of components, operative time, blood loss, and length of stay. Significantly more O-EVAR subjects suffered groin complications (p=0.02), including five hematomas, two wound infections, two femoral thromboses, and one vessel which required patch repair. In the P-EVAR group there was only one hematoma, which was managed conservatively. There was no difference between the P-EVAR and O-EVAR groups with respect to femoral artery calcification (Agatston scores 667+/-719 vs. 945+/-1,248, p=0.37). Obesity (body mass index >30) was documented in six (27%) of both the P-EVAR and O-EVAR groups (p=nonsignificant). Pre- and postoperative CT-derived anatomic data showed a significant decrease in the minimal vessel area with O-EVAR compared to P-EVAR (p=0.02). This study demonstrates that patients with obesity or severely calcified femoral arteries can be successfully treated percutaneously with fewer minor groin complications.

Background: A recent report determined that the nationwide mortality for renal artery bypass (RAB) is surprisingly high-10%. We hypothesized that operative mortality for RAB is related to the volume of such operations performed in each center., Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing RAB for the years 2000-2005. In-hospital mortality for RAB was compared between hospitals., Results: During the study period, RAB was performed on 7413 patients with an overall in-hospital mortality of 9.6%. The multivariate logistic regression analyses revealed that after adjusting for surgical risk, increasing hospital volume was significantly associated with decreased in-hospital mortality for RAB (odds ratio 0.98; 95% confidence interval, 0.96-0.99; P=.015)., Conclusions: Patient risk profile and hospital volume are critical determinants of in-hospital mortality for RAB, which should be factored into decision making for patients requiring intervention for renovascular disease.

Objective: Graft excision and neo-aortoiliac system (NAIS) reconstruction with large caliber, femoral popliteal vein (FPV) grafts have been reported as successful treatment of aortic graft infection (AGI) in several small series with limited follow-up. The goal of this study was to evaluate long-term outcomes in large cohort of consecutive patients treated with NAIS for AGI., Methods: From 1990 to 2006, 187 patients (age: 63 +/- 10 years) with AGI were treated with in situ reconstructions using 336 FPV grafts. Data from a prospectively maintained data base were analyzed., Results: NAIS reconstruction was performed for 144 infected aortofemoral bypasses, 21 infected aortic-iliac grafts, and 22 infected axillofemoral bypasses that had been placed to treat AGI. Polymicrobial cultures were present in 37% while 17% showed no growth. There were 55% gram positive, 32% gram negative, 13% anaerobic, and 18% fungal infections. The mean Society for Vascular Surgery run-off resistance score was 4.5 +/- 2.3. Concomitant infrainguinal bypass was necessary in 27 (14%) patients (32 limbs). Major amputations were performed in 14 (7.4%) patients. Out of 14 amputations, five patients had irreversible ischemia and in four, there was no conduit available. Graft disruption from reinfection occurred in 10 patients (5%). While 30-day mortality was 10%, procedure-related mortality was 14%. Independent risk factors for perioperative death on multivariate analysis were: preoperative sepsis (odds ratio [OR] 3.5) ASA class 4 (OR 2.9), Candida species (OR 3.4), Candida glabrata (OR 7.6), Klebsiella pneumoniae (OR 3.5), and Bacteroides fragilis (OR 4.1). Perioperative factors included use of platelets (OR 2.4), blood loss >3.0 liters (OR 9.5). Cumulative primary patency at 72 months was 81%; secondary/assisted primary patency was 91%. Limb salvage at 72 months was 89%. Five-year survival was 52%., Conclusions: These results compare favorably with other methods of treating AGI, especially in patients with multilevel occlusive disease. Principle advantages include acceptable perioperative mortality, low amputation rate, superior durability with excellent long-term patency, and freedom from secondary interventions and recurrent infections.

Background: U.S. black and Hispanic populations are growing at a steady pace. In contrast, the medical profession lacks the same minority growth and representation. Women are also under-represented in many surgical disciplines. The purpose of this study was to assess trends in the proportion of women, blacks, and Hispanics admitted to vascular surgery (VS) and related specialties, and to compare them with each other and with a surgical specialty, orthopedic surgery (OS), with a formal diversity initiative., Methods: Data on the fellowship pool of VS, interventional radiology (IR), and interventional cardiology (IC), as well as the resident pools of general surgery (GS) and orthopedic surgery (OS), were obtained from U.S. graduate medical education reports for 1999 through 2005. Cochrane-Armitage trend tests were used to assess trends in the proportion of females, blacks, and Hispanics in relation to the total physician workforce for each subspecialty., Results: No significant trends in the proportion of females, blacks, or Hispanics accepted into VS and IC fellowship programs occurred during the study period. In contrast, IR, GS, and OS programs revealed significant trends for increasing proportions of at least one of the underrepresented study groups. In particular, OS, which has implemented a diversity awareness program, showed a positive trend in female and Hispanic trainees (P < .04 and P < .02, respectively). Blacks showed a significant increasing trend only in IR (P = .05). Conversely, a positive trend toward continued growth in the Hispanic group was seen in GS (P < .001), IR, and OS (P = .04 and P = .02, respectively)., Conclusions: The racial/ethnic and gender composition of the physician trainee pool in vascular specialties, particularly VS, has not matched the increasing growth of underrepresented groups in the US population of patients with vascular disease. Formal programs to recruit qualified women and minorities appear successful in increasing workforce diversity.

Objectives: To compare hybrid repair (HR) (aortic debranching and TEVAR) with conventional open thoracoabdominal and aortic arch repairs (OR), including a cost analysis., Design: Retrospective cohort., Setting: University hospital., Patients: Thirty patients with thoracoabdominal aneurysms were evaluated between November 1, 2005, and December 31, 2006., Interventions: There were 18 HRs and 12 ORs. Aortic abnormalities included the arch, visceral aorta, and arch/visceral aorta combined. Aortic debranching with TEVAR (HR) was performed at a single setting. Dacron grafts were used for OR, and branch vessels were bypassed. Hospital costs and reimbursements were obtained from the finance department., Main Outcome Measures: Perioperative morbidity, mortality, and cost., Results: Patients were significantly older in the HR group (mean [SD], 72 [8.9] vs 58 [17.4] years, P = .2). The HR group had significantly less blood loss (mean [SD], 1.7 [2.3] vs 4.8 [3.1] L, P = .004), transfusions (5.1 [5.9] vs 14.7 [7.8] units, P = .001), renal failure (0% vs 42.0%, P = .002), and pulmonary morbidity (17% vs 67%, P < .001); shorter intensive care unit stays (5.2 [4.8] vs 16.4 [12.9] days, P = .005); and shorter hospital length of stay (mean [SD], 11.6 [6.2] vs 20.8 [10.8] days, P = .01). There were no differences in mortality or spinal cord ischemia. There was no difference in mean direct hospital costs (HR: $59,435.70 vs OR: $49,341; P = .35). However, the mean cost margin per case was -34% for HR and +6.2% for OR (P = .04)., Conclusions: Improved clinical outcomes are seen after HR despite treatment of an older, sicker patient population. However, HR ultimately comes at a significant cost to the hospital, with a 34% loss in revenue per case.

Purpose: To assess the agreement between three methods of calculation of mean aortic wall thickness (MAWT) using magnetic resonance imaging (MRI)., Materials and Methods: High-resolution MRI of the infrarenal abdominal aorta was performed on 70 subjects with a history of coronary artery disease who were part of a multi-ethnic population-based sample. MAWT was calculated as the mean distance between the adventitial and luminal aortic boundaries using three different methods: average distance at four standard positions (AWT-4P), average distance at 100 automated positions (AWT-100P), and using a mathematical computation derived from the total vessel and luminal areas (AWT-VA). Bland-Altman plots and Passing-Bablok regression analyses were used to assess agreement between methods., Results: Bland-Altman analyses demonstrated a positive bias of 3.02+/-7.31% between the AWT-VA and the AWT-4P methods, and of 1.76+/-6.82% between the AWT-100P and the AWT-4P methods. Passing-Bablok regression analyses demonstrated constant bias between the AWT-4P method and the other two methods. Proportional bias was, however, not evident among the three methods., Conclusion: MRI methods of measurement of MAWT using a limited number of positions of the aortic wall systematically underestimate the MAWT value compared with the method that calculates MAWT from the vessel areas., (Copyright (c) 2009 Wiley-Liss, Inc.)

Objective: The differential effect of open-cell vs closed-cell stent design configuration on carotid velocities detected by duplex ultrasound (DUS) imaging has not been established. To identify possible stent design differences in carotid velocities, we analyzed DUS studies obtained before and immediately after carotid artery stenting (CAS)., Methods: In a series of 141 CAS procedures performed during a 3-year period, data from the first postinterventional DUS images and carotid angiograms were evaluated for each patient. Peak systolic velocities (PSV), end-diastolic velocities (EDV), and internal carotid artery/common carotid artery (ICA/CCA) PSV ratios were compared according to stent design. Differences in carotid velocities were analyzed using nonparametric statistical tests., Results: Completion angiograms revealed successful revascularization and <30% residual stenosis in each case. The 30-day stroke-death rate in this series was 1.6% and was unrelated to stent type. Postintervention DUS images were obtained a median of 5 days (interquartile range [IQR], 1-25 days) after CAS. Closed-cell stents were used in 41 procedures (29%) and open-cell stents in 100 (71%). The median PSV was 95.9 cm/s (IQR, 77-123 cm/s) for open-cell stents and 122 cm/s (IQR, 89-143 cm/s) for closed-cell stents, which was significantly higher (P = .007). Closed-cell stents also had significantly higher median EDVs (36 vs 29 cm/s; P =.006) and ICA/CCA PSV ratios (1.6 vs 1.1; P =.017). By DUS criteria, the carotid velocities in 45% of closed-cell stents exceeded the threshold of 50% stenosis for a nonstented artery compared with 26% of open-cell stents (P =.04). Closed-cell stents had a 2.2-fold increased risk of yielding abnormally elevated carotid velocities after CAS compared with open-cell stents (odds ratio, 2.2; 95% confidence interval, 1.02-4.9)., Conclusions: Carotid velocities are disproportionately elevated after CAS with closed-cell stents compared with open-cell stents. This suggests that the velocity criteria for quantifying stenosis may require modification according to stent design. The importance of these differences in carotid velocities related to stent design and the potential relationship with recurrent stenosis remains to be established.

Background: Intracranial hemorrhage (ICH) following carotid endarterectomy (CEA) or carotid artery stenting (CAS) is a rare but potentially devastating complication. The effect of more intense dual antiplatelet therapy required for CAS on the frequency of ICH has not been established. This study was undertaken to evaluate the nationwide occurrence of ICH associated with CAS vs CEA., Methods: The Nationwide Inpatient Sample was used to identify patients discharged after CAS and CEA during 2005. The type of revascularization and major adverse events, ie, in-hospital ICH, postprocedural stroke, and death rates, were determined by cross-tabulating specific procedural codes for CAS and CEA and diagnostic codes for carotid stenosis. Risk stratification was performed using the Charlson Comorbidity Index. Univariate and multivariate logistic regression analyses were used to assess the association between type of revascularization, comorbidities, ICH, and risk-adjusted mortality., Results: In 2005, the estimated number of carotid revascularizations was 135,903. The vast majority of patients underwent CEA (90.4%), whereas CAS was performed in 13,093 (9.6%) patients. Most patients (92.2%) underwent treatment for asymptomatic carotid stenosis. CAS patients had higher postoperative stroke rates (2.1% vs 1.1%; P < .001) and in-hospital mortality (1.1% vs 0.6%; P < .001) than CEA patients. ICH occurred in 19 patients (0.15%) after CAS and in 20 patients (0.016%) after CEA (P < .001). CAS was identified as an independent predictor for postoperative stroke (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.5-2.0; P < .001), in-hospital mortality (OR, 1.49; 95% CI, 1.2-1.8; P < .001) and ICH (OR, 5.9; 95% CI, 3.1-11.1; P < .001) after adjusting for age, gender, symptomatic status, comorbidities, admission, and hospital type using logistic regression. In-hospital mortality was 12.5% among patients developing ICH (OR, 23.2; 95% CI, 9.1-54.4; P < .001)., Conclusion: In the United States, patients undergoing CAS have not only significantly increased postoperative stroke and death rates compared with those undergoing CEA, but also a sixfold increased risk of ICH. Although ICH after CAS is extremely rare, its devastating nature and high mortality warrant further investigation to define specific risk factors, prevention, and treatment strategies.

The United States population with vascular disease has changed dramatically during the past 2 decades, with large increases in the proportion of Hispanic, African American, and other minority patients. Not only has the number of these patients increased, but the types and distribution of vascular disease in minority populations is also different from that encountered in non-Hispanic whites. Although genetic makeup accounts for some of these differences, access to vascular care is also an important determinant, with many minority patients presenting late in the course of the disease process. These factors create significant challenges for the vascular specialists caring for these patients. The vascular surgery workforce is composed of >90% white men and does not currently represent the changes in the population of patients with vascular disease. In addition, women with vascular disease comprise up to 50% of many vascular surgery practices. In many parts of the country, Hispanics and African Americans outnumber non-Hispanic whites with vascular disease. Yet, women and minority physicians are still significantly under-represented in the field of vascular surgery. This year's E. Stanley Crawford Critical Issues Forum at the Society for Vascular Surgery meeting addressed the disconnect between the vascular surgery workforce and the patients whom we serve. This article reviews the projected demographic changes in the population of the United States, which supports the need for training a vascular surgery workforce that is more diverse. This article also reviews the current status of minority and female representation in medical schools, surgical training programs, and vascular surgery programs in the United States.

Background: Direct communication between an aortic prosthesis and the gastrointestinal (GI) tract may present with GI bleeding (aortoenteric fistulas [AEF]) or be incidental to a graft infection (paraprosthetic erosions [PPE]). The purposes of this study were to compare the outcomes of AEF versus PPE and to determine predictors of mortality associated with these lesions., Study Design: Since 1992, 38 patients (23 men, 15 women; mean age 67 years) presented with AEF (n=16) or PPE (n=22)., Results: After complete graft excision, 26 patients (8 AEF, 18 PPE) underwent in situ revascularization using femoral vein (n=24) or rifampin-soaked prosthetic graft (n=2); 12 (8 AEF, 4 PPE) underwent extraanatomic bypass. There was no significant difference in mortality for AEF versus PPE (38% versus 36%). Postoperative complications developed in 25 (66%) patients, including 10 (26%) with GI complications requiring reintervention (5 colon necrosis, 5 duodenal bleed or leak). There were no differences between AEF and PPE in operative transfusions, operative times, GI complications, ICU stay, hospital stay, or final discharge status. Multivariate stepwise logistic regression analysis revealed that GI complications (odds ratio [OR], 52.5; 95% CI, 3.5 to 781; p=0.004) and age (OR, 1.2; 95% CI, 1.02 to 1.3; p=0.026) were the only independent predictors of in-hospital mortality., Conclusions: Surgical management of AEF and PPE should be tailored to patient illness and the extent of graft infection. Mortality from both lesions is dependent on patient and technical factors, not on the mode of presentation.

Background: Stents alter flow velocities after carotid artery stenting (CAS). To identify criteria for in-stent restenosis (ISR), velocities obtained by duplex ultrasonography (DU) after CAS were analyzed., Methods: Carotid angiography and DU were performed after 129 CAS procedures. The 2 x 2 table method and receiver operating characteristic curves were used to assess the ability of DU to detect ISR., Results: The median follow-up period was 21.2 months (interquartile range 14-32 months). Overall, 6 patients (4.7%) had significant ISR by angiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the validated criteria for nonstented arteries were 100%, 85%, 25%, and 100%, respectively, to determine ISR. Newly validated criteria revealed optimal detection of ISR, with 100% sensitivity, 99% specificity, PPV of 66%, and NPV of 100%. Patients with abnormal findings on initial DU revealed increased velocities by >80% when ISR occurred., Conclusions: DU can accurately detect ISR after CAS, but velocity criteria require modification and validation at each vascular laboratory. For patients with abnormal findings on initial DU, significant changes in velocities suggest ISR.

Prior to approval by the U.S. Food and Drug Administration of larger endografts (main body diameters up to 36 mm), small abdominal aortic aneurysms (AAAs, <5.5 cm) were shown to be more suitable for endovascular repair (EVAR) than large AAAs (> or =5.5 cm). The purpose of this study was to assess changes in EVAR suitability with the potential use of larger endografts in unselected consecutive patients. The influence of age, aneurysm size, and patient fitness on EVAR suitability was also assessed. We studied 186 male patients referred for evaluation of nonruptured AAAs who underwent contrast-enhanced computed tomographic scans with three-dimensional reconstructions. Morphologicall AAA features and neck characteristics were measured according to Society for Vascular Surgery reporting standards to determine EVAR suitability. Patient fitness for repair was assessed using the customized probability index, a validated fitness score for vascular surgery procedures. Suitability for EVAR was determined by neck anatomy, iliac artery morphology, and total aortic aneurysm angulation and tortuosity according to the clinicians' experience and current practice. The median age of the study cohort was 72 years (interquartile range [IQR] 65-79 years). The median maximum AAA diameter was 5.4 cm (IQR 4.1-5.9). Median fitness score was +7 (IQR -7 to +14). EVAR suitability for large AAAs significantly increased with larger endografts (35-63%, p<0.001). Changes in EVAR suitability for small AAAs were not significant (69-75%, p=0.06). Maximum AAA diameter was not an independent predictor for EVAR suitability with larger endografts after adjusting for neck anatomy. Aortic neck length (odds ratio [OR]=1.2, 95% confidence interval [CI] 1.1-1.2) and diameter (OR=0.78, 95% CI 0.63-0.96) were the only independent predictors for EVAR suitability with larger endografts. Age, AAA size, and fitness did not differ between patients suitable and unsuitable for EVAR with larger endografts. In conclusion, introduction of larger endografts (up to 36 mm in main body diameter) in the United States has resulted in significantly increased anatomic suitability for EVAR for large AAAs. Conversely, suitability has not significantly changed for small AAAs. Overall, EVAR suitability is not influenced by age, aneurysm size, or patient fitness.

Objective: In this article, we discuss the neoaortoiliac system procedure, a surgical procedure that uses femoropopliteal vein segments for arterial reconstructions in patients with aortofemoral prosthetic graft infections., Conclusion: CT angiography (CTA) is a powerful imaging tool that can be used in the follow-up of patients after this complex surgery. CTA accurately detects early and late complications that may develop after the neoaortoiliac system procedure.

Background: The mortality rate for renal artery bypass grafting (RABG) is reported to be 0% to 4% for patients with renovascular hypertension and 4% to 7% for patients with ischemic nephropathy. However, these data come from high-volume referral centers known for their expertise in treating these conditions. Because of the relative infrequency of these operations in most vascular surgery practices, the nationwide outcomes for RABG are not known. The purpose of this study was to define the operative mortality rate for RABG in the United States and to identify risk factors for perioperative mortality., Methods: The National Inpatient Sample was analyzed to identify patients undergoing RABG for the years 2000 to 2004. Categoric data were analyzed using chi(2) and the Cochran-Armitage trend tests. Multivariate logistic regression analyses were performed to identify risk factors for perioperative mortality after RABG., Results: During the study period, 6608 patients underwent RABG, representing a frequency of 3.51 operations per 100,000 discharges. More than two-thirds were performed at teaching hospitals (4564 vs 2,044; P < .0001). The frequency of RABG decreased by 30.7% between 2000 and 2004 (4.28 vs 2.96 RABGs per 100,000 discharges; P for trend < .0001). The in-hospital mortality for RABG was 10.0%. On univariate analysis, in-hospital mortality after RABG varied with increasing age, race, region of the country, and a preoperative history of chronic renal failure, congestive heart failure, or chronic lung disease. Logistic regression models identified advanced age (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.44-1.72], female gender (OR, 1.20; 95% CI, 1.02-1.41), and a history of chronic renal failure (OR, 2.21; 95% CI, 1.75-2.78), congestive heart failure (OR, 1.94; 95% CI, 1.44-2.62), or chronic lung disease (OR, 1.40; 95% CI, 1.18-1.67) as independent markers of risk-adjusted, in-hospital mortality (P < .0001 for each of these five variables)., Conclusions: Nationwide in-hospital mortality after RABG is higher than predicted by prior reports from high-volume referral centers. Advanced age, female gender, and a history of chronic renal failure, congestive heart failure, or chronic lung disease were predictive of perioperative death. For the typical vascular practice, these data may provide a rationale for lower risk alternatives, such as renal artery stenting or referral to high-volume referral centers for RABG.

Background: The management of concurrent carotid and coronary artery disease is controversial. Although single-center observational studies have revealed acceptable outcomes of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG), community-based outcomes have been substantially inferior. Recently, carotid artery stenting (CAS) has been introduced for the management of high-risk patients with carotid stenosis, including those with severe coronary artery disease. This study was undertaken to evaluate the nationwide trends and outcomes of CAS before CABG vs combined CEA and CABG and to assess the risk for adverse events., Methods: The Nationwide Inpatient Sample (NIS) was used to identify patients discharged after concurrent carotid and coronary revascularization procedures. All patients that underwent CAS before CABG and combined CEA-CABG during the years 2000 to 2004 were included. The type of revascularization and major adverse events (ie, in-hospital stroke and death rates) were determined by cross-tabulating discharge diagnostic and procedural codes. Risk stratification was performed using the Charlson Comorbidity Index. Weighted exact Cochrane-Armitage trend test and multivariate logistic regression were used to assess the association between types of revascularization, comorbidities, complications, and risk-adjusted mortality., Results: During the 5-year period, 27,084 concurrent carotid revascularizations and CABG were done. Of these, 96.7% underwent CEA-CABG, whereas only 3.3% (887 patients) had CAS-CABG. From 2000 to 2004, the proportion of patients undergoing CAS-CABG vs CEA-CABG did not significantly changed (P = .27). Patients undergoing CAS-CABG had fewer major adverse events than those undergoing CEA-CABG. CAS-CABG patients had a lower incidence of postoperative stroke (2.4% vs 3.9%), and combined stroke and death (6.9% v. 8.6%) than the combined CEA-CABG group (P < .001), although in-hospital death rates were similar (5.2% vs 5.4%). After risk-stratification, CEA-CABG patients had a 62% increased risk of postoperative stroke compared with patients undergoing CAS before CABG (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.1-2.5; P = .02). However, no differences in the risk of combined stroke and death were observed (OR, 1.26; 95% CI, 0.9-1.6; P = NS)., Conclusion: Although CAS may currently be performed for high-risk patients, it is still infrequently used in patients who require concurrent carotid and coronary interventions. In the United States, patients who undergo CAS-CABG have significantly decreased in-hospital stroke rates compared with patients undergoing CEA-CABG but similar in-hospital mortality. CAS may provide a safer carotid revascularization option for patients who require CABG.

Endovascular aneurysm repair (EVAR) is the greatest technological advance in the field of vascular and endovascular surgery in the past 15 years. However, its widespread application has created potential problems, and EVAR may be overused in some circumstances. As long-term outcome data are being sought for EVAR, it is becoming apparent that complications (infection, device migration, and the development of late endoleaks, aneurysm growth, and rupture) are occurring at a higher rate than anticipated. It is also apparent that follow-up is not complete in a large proportion of patients after EVAR, and these are the patients most prone to present with late complications. Surgeons are placing devices in large numbers of patients with poor anatomy for EVAR, in part because of pressures from patients, families, and referring physicians. In patients with good anatomy, EVAR is an excellent option and will likely be durable. In those with unfavorable anatomical features, we need to better appreciate the potential for adverse long-term outcomes and advocate more strongly for open repair.

Objective: This study analyzed device-specific aneurysm sac morphology after endovascular aneurysm repair (EVAR) with low-permeability devices., Methods: Between September 2004 and May 2006, 122 patients were treated with EVAR. Three different devices were implanted: 47 Zenith (Cook, Indianapolis, Ind), 46 AneuRx (Medtronic, Santa Rosa, Calif) with Resilient Dacron Graft Material, and 29 Excluder (W. L. Gore & Associates, Flagstaff, Ariz) with low-porosity polytetrafluoroethylene (PTFE). Patients were followed up at 1, 6, and 12 months and then biannually with computed tomography (CT) angiography. Standard axial two-dimensional CT measurements were obtained and compared with preoperative imaging. The preoperative scan served as a baseline, and the minor axis diameter, measured at the largest axial cut of the abdominal aortic aneurysm, was compared with the same measurement at follow-up., Results: Patient age, sex, and preoperative aneurysm morphology were similar among groups. Patients receiving the Zenith endograft had a significantly larger neck diameter; however, there was no difference in the neck length between groups. The rate of type II endoleaks was similar for the Zenith (17%), AneuRx (17%), and Excluder (14%). At 1, 6, 12, and 18 months, all three grafts were associated with sac shrinkage. The resulting decreases in mean aneurysm size at 18 months and corresponding shrinkage were Zenith, 11%, 6.4 +/- 1.8 mm; AneuRx, 18.9%, 12.7 +/- 2.7 mm; and the Excluder, 5.5%, 3.3 +/- 0.9 (P < .05). The sac size in the 19 patients with a type II endoleak decreased 8.06% compared with a 15.43% decrease in sac size in patients without endoleak at 6 months. No significant sac expansion > or =5 mm has been observed among any of the groups to date., Conclusions: Sac regression with all devices appears to have been favorably influenced by the new generation of graft materials and is improved compared with published reports of older generation graft materials for the AneuRx and Excluder. However, there is a trend toward greater sac regression with devices using Dacron vs PTFE. The relationship of aneurysm morphology and long-term effects on aortic stent grafts is yet to be determined.

The femoral-popliteal vein has proved to be an excellent conduit for a variety of indications. These include in situ reconstruction of infected aortic grafts, and mesenteric, brachiocephalic, and lower-extremity bypasses. This article discusses the technical details of successful deep vein harvest. Information regarding the preoperative evaluation, postoperative surveillance, reintervention, and venous morbidity is provided. The femoral-popliteal vein graft has proven to be a durable conduit with minimal late venous morbidity.

Background: Management using femoral-popliteal vein (FPV) of aortic graft infections, failing aortofemoral bypass, and aortoiliac occlusive disease in young patients with a small aorta is now an accepted therapeutic method and is performed frequently at our institution. A high reintervention rate for FPV graft stenosis has recently been reported. The purpose of this study was to determine the incidence of FPV graft failure due to stenosis after neoaortoiliac system (NAIS) reconstruction, and to identify risk factors for this complication., Methods: A review was performed of 240 patients who underwent NAIS reconstruction at our institution between January 1991 and December 2005. All patients were entered into a prospective database and were evaluated for the incidence of vein graft stenosis requiring reintervention, risk factors for stenosis, and the rate and type of reintervention required to assist patency. Patients with occlusion are evaluated and reported, but excluded from detailed analysis. Risk factors assessed included gender, operative features, FPV size (diameter), smoking history, and medical comorbidities., Results: Of the 240 NAIS procedures performed during this time period, 11 (4.6%) patients have required 12 graft revisions (one patient required a second intervention) for stenosis using open and endovascular techniques. Over the same time period, graft occlusion occurred in nine patients (3.8%). This provided a primary patency at 2 and 5 years of 87% and 82%, and an assisted primary patency rate of 96% and 94%. Mean time to revision was 23.5 months (range 5.5 to 83.5 months). Median FPV graft size in the nonrevised patients was 7.8 mm (range 4.0 to 11.4 mm), and 6.4 mm (range 4.7 to 8.7 mm) in the revised group (P = .006). Survival analysis revealed small vein graft size (<7.2 mm), coronary artery disease (CAD), and extensive smoking history as independent predictors of time to stenosis (P = .002, .02, .01, respectively), with multivariable analysis confirming these results (P = .002, .06, .012). Patients with CAD combined with small graft size were found to be at especially high risk for stenosis, with 8/36 (22.2%) requiring revision vs 3/184 (1.6%) of patients without both factors (P < .0001)., Conclusions: FPV graft stenosis requiring revision after NAIS reconstruction is uncommon. Risk factors for stenosis include small graft size, history of CAD, and smoking. All patients merit aggressive counseling for smoking cessation, and patients exhibiting multiple risk factors should undergo close postoperative surveillance for graft stenosis.

The Clinical Practice Council of the Society for Vascular Surgery (SVS) was charged with providing an updated consensus on guidelines for hospital privileges in vascular and endovascular surgery. One compelling reason to update these recommendations is that vascular surgery as a specialty has continued to evolve with a significant shift towards endovascular therapies. The Society for Vascular Surgery is making the following four recommendations concerning guidelines for hospital privileges for vascular and endovascular surgery. First, anyone applying for new hospital privileges to perform vascular surgery should have completed an Accreditation Council for Graduate Medical-accredited vascular surgery residency and should obtain American Board of Surgery certification in vascular surgery within 3 years of completion of their training. Second, we reaffirm and provide updated recommendations concerning previous established guidelines for peripheral endovascular procedures, thoracic and abdominal aortic endograft replacements, and carotid artery balloon angioplasty and stenting for trainees and already credentialed physicians who are adding these new procedures to their hospital credentials. Third, we endorse the Residency Review Committee for Surgery recommendations regarding open and endovascular cases during vascular residency training. Fourth, we endorse the Inter-societal Commission for Accreditation of Vascular Laboratories (ICAVL) recommendations for noninvasive vascular laboratory interpretations and examinations to become a registered physician in vascular interpretation (RPVI) or a registered vascular technologist (RVT).

Background: The deep veins (DV) of the thigh have proven to be versatile autogenous conduits for arterial reconstruction. Harvesting DV poses a theoretical risk of compromising venous outflow of the limb, which could predispose to chronic venous morbidity. The purpose of this study was to define the late incidence of chronic venous insufficiency (CVI) and to characterize the long-term alterations in venous physiology after DV harvest., Methods: Since 1991, 269 patients have undergone arterial reconstructions using DV at our facility. Patients with DV harvest at least 43 months prior to the study (n = 151) were eligible for inclusion. Eighty-nine patients were excluded (deceased = 70; lost to follow-up = 19). Forty-six patients who declined formal testing were queried by phone for signs and symptoms of CVI. The current study presents a case-control series of 16 patients (27 limbs) after DV harvest and six age- and gender-matched control patients (12 limbs) who underwent examination and venous testing., Results: At a mean follow-up of 70.1 +/- 5.6 months, 23 of 27 limbs (85.2%) had no significant CVI (CEAP C(0) to C(2)). Four limbs (14.8%) had significant venous morbidity (C(3) to C(6)), including edema alone (C(3); n = 2 limbs), edema with skin changes (C(4); n = 1 limb), and a healed venous ulceration (C(5); n = 1 limb). APG testing confirmed relative venous outflow obstruction after DV harvest (mean outflow fraction: harvested limbs = 38.4 +/- 3.9% vs control limbs = 51.7 +/- 4.3%; P = .04). Despite the relative outflow obstruction, the mean VFI was not significantly different between harvested and control limbs (harvested limbs = 1.08 +/- 0.15% vs control limbs = 0.77 +/- 0.16%; P = .19). DV harvest resulted in no significant changes in calf ejection fraction (harvested limbs = 67.4 +/- 6.4% vs control limbs = 86.8 +/- 9.5%; P = .09) or residual volume fraction measured (harvested limbs = 32.3 +/- 6.4% vs control limbs = 47.7 +/- 11.6%; P = .22). Of the 46 patients interviewed by phone, five (10.9%) reported bilateral amputations, seven (15.2%) reported chronic edema in their harvested limbs (C(3)), and 34 (73.9%) reported no signs of CVI in their harvested limbs (C(0))., Conclusions: Deep vein harvest produces few symptoms of chronic venous insufficiency, and venous ulceration is infrequent. Despite relative venous outflow obstruction, noninvasive indices of chronic venous insufficiency on APG are often normal, suggesting that the risk of developing venous ulceration is low in the majority of patients after DV harvest.