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

Antiplatelet therapy is recommended in patients with peripheral arterial disease to reduce cardiovascular risk and improve outcomes. However, issues including the drug of choice and use of dual antiplatelet therapy (DAPT) vs monotherapy remain unclear. This study aims to compare the impact of aspirin (ASA) monotherapy, P2Y12 monotherapy, and DAPT on limb salvage (LS), amputation-free survival (AFS), and overall survival (OS) in patients undergoing lower extremity peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI).The Vascular Quality Initiative PVI registry was used to identify index procedures completed for CLTI between March 1, 2010 and September 30, 2017. Patients were categorized by antiplatelet use at the time of last follow-up. Patients not on antiplatelet therapy were compared with ASA, P2Y12 monotherapy, and DAPT. Propensity score-matched samples were created for direct ASA vs P2Y12 and P2Y12 vs DAPT comparisons; veracity was confirmed by χA total of 12,433 index PVI were completed for CLTI in 11,503 subjects in the pre-matched sample. Antiplatelet use at follow-up was: 12% none, 31% ASA, 14% P2Y12, and 43% DAPT. Median follow-up was 1389 days. P2Y12 monotherapy was associated with improved outcomes as compared with ASA monotherapy, OS (87.8% vs 85.5%l P = .026; Cox hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.68-0.98; P = .03), AFS (79.6% vs 74.8%; P .001; Cox HR, 0.75; 95% CI, 0.65-0.86; P .001) and LS (89.5% vs 86.8%; P = .013; Cox HR, 0.74; 95% CI, 0.60-0.91; P = .004). P2Y12 monotherapy and DAPT had comparable OS (87.8% vs 88.9%; P = .62; Cox HR, 0.94; 95% CI, 0.77-1.14; P = .50), AFS (79.6% vs 81.5%; P = .33; Cox HR, 0.92; 95% CI, 0.78-1.07; P = .28), and LS (91.7% vs 89.4; P = .03; Cox HR, 0.80; 95% CI, 0.64-1.00; P = .06).P2Y12 monotherapy was associated with superior OS, AFS, and LS as compared with ASA monotherapy, and comparable OS, LS, and AFS with DAPT in patients undergoing PVI for CLTI. P2Y12 monotherapy may be considered over ASA monotherapy and DAPT in patients with CLTI, especially in patients with high bleeding risk.

Evaluate outcomes following urinary catheter (UC) versus no urinary catheter (NUC) insertion in elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA).Retrospective record review of all elective EVAR at a university affiliated medical center over a 5-year period. Statistical analysis included Chi Sq, Independent Student t Test.Six surgeons performed 272 elective EVAR. Three surgeons preferred selective insertion of indwelling UC, such that 86 (32%) EVAR were completed without indwelling urinary catheters (NUC). Differences between NUC versus UC included; male: (86% vs. 70%; P = 0.004), CAD: (45% vs. 33%; p = 0.046), conscious sedation: (36% vs. 8%; P0.001), bilateral percutaneous EVAR (PEVAR): (100% vs. 90%; P = 0.01), within ProglideSelective preoperative UC insertion should be considered for EVAR, with particular consideration to no preoperative catheterization in men meeting Proglide IFU. Adverse urinary events occurred less frequently among NUC and were identified/ treated earlier. Moreover, AUEs were the most common reason for potential SDD ineligibility among UC patients. Selective policies may facilitate SDD.

Objectives To identify candidates undergoing elective endovascular aneurysm repair (EVAR) of asymptomatic infrarenal abdominal aortic aneurysm who are eligible for early (≤6 hours) hospital discharge or to have EVAR performed in free-standing ambulatory surgery centers. Methods A retrospective medical record review of all elective EVAR performed at a university medical center over 5 years was undertaken. Potential candidates for early discharge or to have EVAR performed in a free-standing ambulatory surgery setting were defined as those who used routine monitoring services only or had self-limited minor adverse events (AE) that were identified, treated, and resolved within 6 hours of surgery. Risk factors for ineligibility were determined by logistic regression. Sensitivity, specificity, negative and positive predictive values were measured to determine the veracity of the risk factor profile. Results There were 272 elective EVARs; the mean patient age was 74 years (range, 52-94 years), and 75% were male. Twenty-five operative major AEs (MAE) occurred in 21 patients (7.7%): bleeding (5.9%), thrombosis (1.8%), and arterial injury (1.8%). Percutaneous EVAR (PEVAR) attempted in 260 patients (96%) was successful in 238 (88%). Failed PEVAR was associated with operative MAE (P 6 hours postoperatively; EVAR, which did not require an additional aortic cuff, was associated with a lower incidence (OR, 0.17; 95% CI, 0.04-0.65; P = .01). Neither aortic nor limb IFU were independent predictors. Profiles using PEVAR IFU, PEVAR failure, and graft type demonstrated only moderate sensitivity (63%), specificity (71%), positive predictive value (70%), and negative predictive value (63%). Conclusions More than one-half of all patients who undergo EVAR are ready for discharge within 6 hours postoperatively. Failed PEVAR, aortic cuffs, and Endologix AFX graft were independent predictors of MAE or AE occurring/requiring treatment for ≥6 hours. However, sensitivity parameters of this profile were insufficient to advocate EVAR in free-standing ambulatory surgical units at this time, but hospital-based ambulatory admission with same-day discharge would be a viable option because of easy inpatient transition for those requiring continued care.

Objective Plateletcrit (PCT) reflects the total platelet mass in blood and can be calculated from a complete blood count. We examined the effect of PCT on outcomes of endovascular and open interventions for chronic limb ischemia. Methods Patients who underwent revascularization for chronic limb ischemia (Rutherford categories 3-6) between June 2001 and December 2014 were retrospectively identified. PCT on admission was recorded. Patients and limbs were divided into tertiles of low (0.046-0.211), medium (0.212-0.271), and high (0.272-0.842) PCT. Patency, limb salvage, major adverse limb events, major adverse cardiac events, and survival rates were calculated using Kaplan-Meier analysis and compared with log-rank test. Cox regression analysis was used for multivariate analysis. Results A total of 1431 limbs (1210 patients) were identified and divided into low PCT (477 limbs in 407 patients), medium PCT (477 limbs in 407 patients), and high PCT (477 limbs in 396 patients) groups. The patients in the high tertile were 2 years older that the patients in the other two tertiles (P = .009). Five-year primary patency was 65% ± 3% in the low-PCT group compared with 55% ± 3% and 51% ± 3% in the medium and high PCT groups, respectively (P = .004). Five-year secondary patency was 81% ± 2% in the low PCT group compared with 82% ± 2% and 72% ± 3% in the medium and high PCT groups, respectively (P = .02). Five-year limb salvage rate was 86% ± 2% in the low PCT group compared with 79% ± 3% and 74% ± 3% in the medium PCT and high PCT groups, respectively (P = .004). Multivariate regression analysis showed that low PCT was independently associated with primary patency after endovascular interventions (hazard ratio, 0.67 [0.47-0.95]; P = .02) but not after open interventions (hazard ratio, 0.72 [0.43-1.21]; P = .21). Conclusions High PCT is associated with poor patency and limb salvage rates after interventions for lower extremity chronic limb ischemia. Multivariate regression analysis confirmed association of low PCT with improved primary patency after endovascular interventions but not after open interventions. High PCT may be a marker of increased platelet reactivity and could be used to identify patients at high risk for early thrombosis and failure after interventions.

Angiotensin-converting enzyme Inhibitors and Angiotensin II Receptor Blockers (ACEI/ARB) reduce the risk of cardiovascular events and mortality in patients with peripheral arterial disease (PAD). However, their effect on limb-specific outcomes is unclear. The objective of this study is to assess the effect of ACEI/ARB on patency and limb salvage in patients undergoing interventions for critical limb ischemia (CLI).Patients undergoing infrainguinal revascularization for CLI (Rutherford 4-6) between 06/2001 and 12/2014 were retrospectively identified. Primary Patency (PP), Secondary Patency (SP), Limb Salvage (LS), major adverse cardiac events (MACE), and survival rates were calculated using Kaplan-Meier. Multivariate analysis was performed using Cox regression.A total of 755 limbs in 611 patients (311 ACEI/ARB, 300 No ACEI/ARB) were identified. Hypertension (86% vs. 70%, P 0.001), diabetes (68% vs. 55%, P = 0.001) and statin use (61% vs. 45%, P 0.001) were significantly greater in the ACEI/ARB group. Interventions were performed mostly for tissue loss (83% ACEI/ARB vs. 84% No ACEI/ARB, P = 0.73). Comparing ACEI/ARB versus No ACEI/ARB, in femoropopliteal interventions, 60-month PP (54% vs. 55%, P = 0.47), SP (76% vs. 75%, P = 0.83) and LS (84% vs. 87%, P = 0.36) were not significantly different. In infrapopliteal interventions, 60-month PP (45% vs. 46%, P = 0.66) and SP (62% vs. 75%, P = 0.96) were not significantly different. LS was significantly greater in ACEI/ARB (75%), as compared to No ACEI/ARB (61%) (P = 0.005). Cox regression identified diabetes (HR 2.4 (1.4-4.1), P = 0.002), ESRD (HR 3.5 (2.1-5.7), P 0.001), hypertension (HR 0.4 (0.2-0.6), P 0.001), and ACEI/ARB (HR 0.6 (0.4-0.9), P = 0.03), as factors independently associated with LS after infrapopliteal interventions. Freedom from MACE (ACEI/ARB 37% vs. 32%, P = 0.82) and overall survival (ACEI/ARB 42% vs. 35% No ACEI/ARB, P = 0.84) were not significantly different.ACEI/ARB is associated with improved limb salvage in CLI patients undergoing infrapopliteal interventions, but not after femoropopliteal interventions. ACEI/ARB had no impact on patency rates. They were also associated with a trend toward improved survival and freedom from MACE. Our findings suggest that the use of ACEI/ARB may improve outcomes in the high-risk CLI patient population.

Endovascular treatment of complex aortoiliac occlusive disease had been adopted widely and now rivals open reconstruction. The most important aspect of aortoiliac revascularization is to anticipate and to avoid complications via careful preoperative planning. However, despite appropriate planning, complications will occur and, in that event, timely and appropriate management can minimize adverse outcomes.

Background Surgical revascularization is the mainstay treatment in treating most traumatic arterial injuries, and autologous great saphenous vein is widely regarded as the conduit of choice. However, the use of the great saphenous vein may be limited by many factors, and there are little data to guide management in this setting. Bovine carotid artery graft (Artegraft, Inc., North Brunswick, NJ, USA) is a biologic conduit that has been used in select trauma cases at our center. The objective of this study was to review and compare our experience with autologous vein and bovine carotid artery in traumatic arterial injuries requiring bypass or interposition. Methods This is a retrospective review of all patients with a traumatic arterial injury repaired with autologous vein or bovine carotid artery graft at a single center between April 2014 and October 2016. Outcomes of interest included differences in duration of ischemia, operative times, patency, limb salvage, graft-related complications, and functional status. Results Thirty patients were included in this study. Seventeen (57%) injuries were to the lower extremity (LE) and 13 (43%) to the upper extremity. Bovine carotid artery graft was used as a conduit in 12 (40%) cases, while autologous vein was used in 18 (60%) patients. Patients were predominantly male (90%). Mean age was 31 ± 15 years. Comorbidities did not differ significantly between the groups. Mean follow-up duration was 19 ± 13 months. Overall primary patency was 82%: bovine versus autologous vein (78% vs. 85%; P = 0.68). Overall secondary patency was 91%: bovine versus autologous vein (78% vs. 100%; P = 0.16). Overall limb salvage was 90%: bovine versus autologous vein (82% vs. 94%; P = 0.28). When comparing bovine carotid artery graft to autologous vein in LE interventions, primary patency (50% vs. 71%; P = 0.40), secondary patency (75% vs. 100%; P = 0.23), and limb salvage (80% vs. 86%; P = 0.76) did not differ significantly. There were no early or late graft infections with either conduit. There were no significant differences in ambulatory status at discharge by graft type. Overall survival was 100%. Conclusions In this series, there is a trend toward improved patency and limb salvage with autologous vein. Autologous vein should be the standard of care for revascularization of traumatic arterial injuries. Bovine carotid artery graft appears be a viable alternative, especially in patients requiring urgent revascularization, that does not significantly compromise patency, limb salvage, or functional outcomes.

Hepatic artery aneurysm (HAA) is a rare form of visceral artery aneurysm. Historically, most HAAs were ruptured at presentation, but advances in imaging have led to an increase in the diagnosis of asymptomatic HAAs. Description of the natural history of patent HAAs has been difficult because of their rarity, even more so for less common thrombosed HAAs. We report the case of a 74-year-old man who experienced the rupture of a previously thrombosed HAA. He was successfully surgically treated with ligation of the aneurysm. Our case provides insight into the progression and management of thrombosed HAAs.

Fibromuscular dysplasia is rarely reported in the infra-inguinal arteries. We report a case of an 86-year-old woman who presented with a ruptured profunda femoris artery aneurysm who was found to have angiographic findings of fibromuscular dysplasia in the bilateral deep femoral arteries and bilateral renal arteries. The rupture was treated successfully with a balloon-expandable covered stent. Keywords: Fibromuscular dysplasia, Aneurysm, Profunda femoris, Rupture, Endovascular

To evaluate outcomes after lower extremity revascularization for critical limb ischemia with tissue loss in patients with chronic immune-mediated inflammatory disease.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.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).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.

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.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.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.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.

The high quality adjusted case series by Saratzis et al. 1 puts another strong counter argument to the paclitaxel increases mortality debate started by the meta-analysis from Katsanos et al. in 2018. 2 The reaction to that meta-analysis was unprecedented in recent times, halting international practice despite widespread adoption of the technology and derailing randomised trials.

Infrainguinal revascularization for disabling claudication (DC) is frequently performed, but long-term results are still unknown. In this study, we compared clinical outcomes of infrainguinal endovascular (EV) and open interventions for DC after the failure of medical management.One hundred ninety-four patients with DC (Rutherford category 3) who had open (n = 53) or EV (n = 141) interventions were grouped as open-great saphenous vein (GSV) (n = 21), open-prosthetic (n = 32), EV-Trans-Atlantic Inter-Society Consensus II (TASC II) A and B (AB) (n = 48), and EV-TASC II C and D (CD) (n = 93). Patency, primary clinical success (PCS; sustained improvement in symptoms without reintervention), and secondary clinical success (SCS; sustained improvement in symptoms with reintervention) rates were compared.Mean follow-up was 57 ± 33 months. Five-year primary patency was 58% in open-GSV, 40% in open-prosthetic, 72% in EV-AB, and 38% in EV-CD (P 0.001). Five-year secondary patency was 77% in open-GSV, 50% in open-prosthetic, 96% in EV-AB, and 61% in EV-CD (P 0.001). Freedom from major adverse limb events was 73% in open-GSV, 77% in EV-AB, 70% in EV-CD, and 67% in open-prosthetic (P = 0.279). Five-year PCS was 46% in open-GSV, 40% in open-prosthetic, 57% in EV-AB, and 44% in EV-CD (P = 0.02). Five-year SCS was 78% in open-GSV, 78% in open-prosthetic, 85% in EV-AB, and 84% in EV-CD (P = 0.732). A total of 116 reinterventions were performed, 10 in 6 limbs (27%) in open-GSV, 18 in 12 limbs (36%) in open-prosthetic, 26 in 15 limbs (24%) in EV-AB, and 62 in 39 limbs (36%) in EV-CD. Reinterventions included 71 (61%) EV and 45 (39%) open procedures.Durability of infrainguinal interventions in claudicants depends mainly on anatomic complexity of disease. Good long-term clinical success can be achieved with both open and EV interventions, albeit with high reintervention rates, especially in patients with TASC II C and D disease. A considerable subset of EV patients will eventually require surgical revascularization to maintain clinical benefit. In this study, almost 20% of patients undergoing EV for TASC II C and D disease eventually required surgical bypass.

This study evaluated the effect of indication for use (IFU), additional graft components, and percutaneous closure of endovascular aortic repair (PEVAR) on clinical outcomes and cost of endovascular aortic repair (EVAR).Clinical and financial data were obtained for all elective EVARs completed at a university-affiliated medical center between January 2012 and June 2013. Data were analyzed by χThere were 67 elective EVARs. Additional cuffs/extensions were used in 37%, increasing the baseline graft cost by 36% (P .001), total costs by 20% (P .001), and negatively affecting the contribution margin. Aortic neck IFU (P = .02), failure of the index graft to seal the neck (P = .02), and need for an additional cuff (P = .008) were related to the need for reintervention for type Ia endoleak for graft B (Excluder; W. L. Gore and Associates, Flagstaff, Ariz), whereas limb IFU was related to the need for additional limb extension for graft A (Powerlink; Endologix, Irvine, Calif; P .001). Limb extension (P = .06) and failure of the index graft to provide an adequate seal (P .001) were associated with reintervention for type Ib endoleak. Reintervention-free rates at 24 months were 96% for graft A and 94% for graft B (P =.54), but different patterns in reintervention emerged: graft A required reoperation early (2 months) then stabilized; graft B did not require reintervention until 24 months, but rates increased substantially by 25 months. PEVAR was attempted in 61 (91%): 49 (73%) bilaterally, 7 (10%) unilaterally, and 5 (8%) failed. The mean number of closure devices was four (range, 1-9): $1000 (3.5% of total cost). Bilateral PEVAR was associated with shorter operating time than unilateral PEVAR/failed PEVAR (P .001) and lower operating room use costs (P = .005) and total hospital costs (P = .003) than failed PEVAR. The contribution margin was higher for bilateral PEVAR than unilateral PEVAR/failed PEVAR (P = .005). Patients with bilateral PEVAR and unilateral PEVAR were more often discharged on postoperative day 1 than those with failed PEVAR (P = .002). Hospital length of stay (P = .49), operating room duration (P = .31), and total costs (P = .72) were similar for unsuccessful PEVAR and EVAR completed with cutdown.Higher rates of reintervention occurred when EVAR was performed outside of IFU guidelines or when additional components were needed. Additions raised graft costs significantly above baseline. Notable differences in graft performance in complex anatomy and varied patterns of reoperation could be useful in the graft selection process to improve outcome and contain costs. Bilateral PEVAR was associated with lower costs and postoperative day 1 discharge. Attempting PEVAR may be reasonable unless there is serious concern for failure.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) reduce the risk of cardiovascular events in patients with peripheral artery disease. However, their effect on limb-specific outcomes is unclear. The objective of this study was to assess the effect of ACE inhibitors/ARBs on limb salvage (LS) and survival in patients undergoing peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI).The Vascular Quality Initiative registry was used to identify patients undergoing PVI for CLTI between April 1, 2010, and June 1, 2017. Patients with complete comorbidity, procedural, and follow-up limb and survival data were included. Propensity score matching was performed to control for baseline differences between the groups. LS, amputation-free survival (AFS), and overall survival (OS) were calculated in matched samples using Kaplan-Meier analysis.A total of 12,433 limbs (11,331 patients) were included. The ACE inhibitors/ARBs group of patients had significantly higher prevalence of coronary artery disease (31% vs 27%; P .001), diabetes (67% vs 57%; P .001), and hypertension (94% vs 84%; P .001) and lower incidence of end-stage renal disease (7% vs 12%; P .001). Indication for intervention was tissue loss in 64% of the ACE inhibitors/ARBs group vs 66% in the no ACE inhibitors/ARBs group (P = .005). Postmatching survival analysis at 5 years showed improved OS (81.8% vs 79.9%; P = .01) and AFS (73% vs 71.5%; P = .04) with ACE inhibitors/ARBs but no difference in LS (ACE inhibitors/ARBs, 88.3%; no ACE inhibitors/ARBs, 88.1%; P = .56). After adjustment for multiple variables in a Cox regression model, ACE inhibitors/ARBs were associated with improved OS (hazard ratio, 0.89; 95% confidence interval, 0.80-0.99; P = .03) and AFS (hazard ratio, 0.92; 95% confidence interval, 0.84-0.99; P = .04).ACE inhibitors/ARBs are independently associated with improved survival and AFS in patients undergoing PVI for CLTI. LS rates remained unaffected. Further research is required to investigate the use of ACE inhibitors/ARBs in this population of patients, especially CLTI patients with other indications for therapy with ACE inhibitors/ARBs.

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

Although endoscopic vein harvest (EVH) has been reported to reduce the morbidity and length of stay compared with open vein harvest (OVH) for infrainguinal bypass procedures, there have been concerns about decreased graft patency and increased rates of reinterventions with EVH compared with OVH. We started using EVH in 2008, and currently it is our preferred approach. The goal of this study was to see if EVH is comparable to OVH in terms of graft patency and limb salvage and associated with fewer wound complications.The study included 153 patients undergoing 171 elective lower extremity bypass procedures with single-piece autologous great saphenous vein from June 1, 2001, to December 31, 2014. Patients were observed postoperatively clinically and with duplex ultrasound evaluation. Patency, limb salvage rates, and postoperative complications were compared between OVH and EVH.There were 78 patients who had 88 EVH conduits and 75 patients who had 83 OVH conduits; 78.2% of the EVH group and 80% of the OVH group had critical limb ischemia (P = .237). Comorbidities were similar, but the EVH group had a significantly higher number of patients receiving antiplatelet drugs, enteric-coated acetylsalicylic acid (94.9% vs 70.7%; P .001), and clopidogrel (62.8% vs 44%; P = .02), whereas the OVH group had more patients receiving warfarin anticoagulation (33.3% vs 20.5%; P = .073). Mean vein diameter was not signifciantly different (EVH, 3.2 ± 0.7 mm; OVH, 3.2 ± 0.8 mm; P = .598). Wound complication rates were significantly higher in the OVH group (EVH, 13.6%; OVH, 43.4%; P .001), with 4.5% of patients in the EVH group and 18.1% of patients in the OVH group requiring débridement for wound complications (P = .005). Mean length of stay was shorter in the EVH group (EVH, 7.5 ± 6.4 days; OVH, 9.6 ± 11.0 days; P = .126). Early and late patency rates (EVH vs OVH 12- and 60-month primary patency, 73% ± 5% and 64% ± 6% vs 72% ± 5% and 56% ± 7 [P = .785]; assisted primary patency, 81% ± 5% and 77% ± 5% vs 81% ± 5% and 70% ± 6% [P = .731]; secondary patency, 87% ± 4% and 85% ± 4% vs 82% ± 4% and 73% ± 6% [P = .193]) and limb salvage rates (critical limb ischemia only, 12 and 60 months, 94% ± 3% and 81% ± 7% vs 83% ± 5% and 81% ± 5% [P = .400]) were similar between the groups.In experienced hands, EVH is associated with a significant decrease in wound complications with similar graft patency, reintervention rates, and limb salvage.

Objective African Americans (AAs) with symptomatic peripheral arterial disease (PAD) have been reported to have fewer revascularization attempts and poorer patency and limb salvage (LS) rates than Caucasians (CAUs). This study compared the outcomes between AA and CAU men with chronic limb ischemia. Methods All AA and CAU men who underwent treatment for symptomatic PAD between November 1, 2003, and May 31, 2012, were included. Patency rates, LS, major adverse cardiovascular and limb events, amputation-free survival, and survival were compared before and after propensity score matching and with multivariate (Cox regression) analysis. Results Of the 834 men (1062 limbs), 107 were AA (137 limbs) and 727 were CAU (925 limbs). AAs were more likely to have insulin-dependent diabetes mellitus, hypertension, dialysis dependence, lower albumin levels, and critical limb ischemia (73% vs 61%; P = .006), whereas CAUs had more coronary artery disease, dyslipidemia, and chronic obstructive pulmonary disease. In patients with critical limb ischemia, primary amputation rates (10.9% vs 7.2%; P = .209) were similar between groups; however, infrapopliteal interventions were more frequent in AAs (62.6% vs 44.3%; P = .004). Perioperative morbidity and mortality rates were similar. Mean follow-up was 38.5 ± 28.9 months (range, 0-119 months). Patency rates, major adverse limb and cardiovascular events, amputation-free survival, and survival were similar in AAs and CAUs; however, the LS rate was significantly lower in AA (73% ± 6% vs 83% ± 2%; P = .048), mainly due to the difference in the endovascular-treated group (5-year LS, 69% ± 7% in AAs vs 84% ± 2% in CAUs; P = .025). All outcomes were similar in propensity score-matched cohorts. In multivariate analysis, insulin-dependent diabetes mellitus, gangrene, poor functional capacity, dialysis-dependence, and need for infrapopliteal revascularization were independently associated with limb loss, whereas race was not. Conclusions AA men with symptomatic PAD were found to have lower LS rates than CAUs. However, this was likely due to presenting with advanced ischemia or with poor prognostic factors that are independently associated with limb loss.

The neutrophil–lymphocyte ratio (NLR), as a marker of inflammation, is associated with the severity of peripheral artery disease (PAD). The role of the NLR on predicting future complications after elective revascularization for patients with PAD remains unknown. We aimed to examine the role of the NLR in the development of major adverse limb events (MALE) and the long-term mortality of these patients. We evaluated 1708 revascularization procedures from May 2001 to December 2015 at the Veterans Affairs Western New York Healthcare System from a prospectively maintained vascular database that included demographics, comorbidities and pre-procedural medications. Peri-procedural laboratory findings including complete blood cell count and metabolic panel were further retrieved from the electronic health record. The NLR was calculated, and the patients were categorized into tertiles according to NLR cut-off points. Multivariate Cox regression analysis was performed to determine MALE and 10-year mortality. The primary endpoint of the study was MALE, and the secondary endpoint included 10-year mortality. A total of 1228 patients were included for final analyses. Patients in the third NLR tertile were more likely to experience MALE during the follow-up period ( p

Pre-emptive selective embolization of inferior mesenteric artery (IMA), lumbar arteries (LAs), and perigraft sac for prevention of type II endoleak (T2EL) has not been widely adopted. We perform pre-emptive nonselective perigraft aortic sac embolization with coils (PNPASEC) in patients at high risk for development of T2EL (four or more patent LAs, patent IMA ≥3 mm, and ≥30-mm aortic flow lumen). The goal of this study was to see whether PNPASEC decreases T2ELs requiring reinterventions.All 266 patients undergoing elective endovascular aneurysm repair between September 1, 2007, and October 31, 2015, were retrospectively evaluated from a prospectively maintained database. Patients (N = 212; 211 men) with preoperative and postoperative contrast-enhanced computed tomography scans were included. Our PNPASEC technique involves leaving a wire in the sac after cannulation of the contralateral gate and inserting large (0.035-inch) coils into the sac after bifurcated graft deployment. T2EL and reintervention rates were compared between patients who underwent PNPASEC (group I) and those who met the criteria but did not have PNPASEC (group II) and those who did not meet the criteria (Group III).Forty-seven (22.2%) patients were PNPASEC candidates and 165 (77.8%) patients (group III) were not. Among PNPASEC candidates, 16 (7.5%) underwent PNPASEC (group I) and 31 (14.6%) did not (group II). There were no significant differences between groups in terms of comorbidities, aneurysm size, and anatomic and neck characteristics. Mean number of patent LAs was similar between group I (4.5 ± 0.8) and group II (4.5 ± 0.9), which was significantly greater than in group III (1.9 ± 1.3; P .001); 43.6% of group III patients had patent IMA. Mean follow-up was 44 ± 25 months. T2EL at 6 months was observed in 48.4% in group II, 3.0% in group III, and 6.3% in group I (P .001). Sac diameter increase was seen in 38.7% in group II vs 6.1% in group III and 6.3% in group I (P .001), with complete sac shrinkage in 23.3% in group II vs 23.8% in group III and 50.0% in group I (P = .09). T2EL-related interventions were performed in 29.0% in group II vs 1.2% in group III and 6.3% in group I (P .001). Any endoleak at last follow-up was seen in 25.8% in group II vs 2.4% in group III and none in group I (P .001).Nonselective perigraft sac coil embolization in patients at high risk for T2EL (20% of patients undergoing endovascular aneurysm repair) is effective in preventing development of T2EL and is associated with decrease in sac size and reintervention rates.

To identify factors associated with acute kidney injury (AKI) and its progression to chronic kidney disease (CKD) in a non-cardiac/non-vascular surgery setting.This study examined the Veterans Affairs Surgical Quality database for surgical entries between 2000-2014. Demographics, comorbidities, laboratory findings and hospital outcomes were assessed. The primary end-point was the occurrence of AKI, defined as an increase of ≥0.3 mg/dL, 48 h post-operatively. Major adverse cardiac event (MACE) was defined as the composite first occurrence of myocardial infarction, cardiac arrest, and death in 30 days (secondary end-point) and was compared between two groups. Rates of progression to CKD in 1 year and long-term survival were examined.Occurrence of AKI 48 h post-operatively.AKI was documented in 8.5% of patients. Age, diabetes, and chronic obstructive pulmonary disease, chronic kidney disease, platelet count, serum albumin level, and duration of surgery were identified as independent predictors of AKI. In total, 6.4% patients developed MACE, which was more frequent in patients with AKI (p .001). Age and pre-operative hematocrit30% were independent predictors of progression to CKD. Pre-operative hematocrit with a cut-off value of 30% was the only modifiable factor to predict the long-term survival.Development of AKI is associated with increased odds of various post-operative complications and long-term renal insufficiency and mortality.

This study examined the effect of perioperative acute kidney injury (AKI) on long-term kidney dysfunction and death after lower extremity revascularization. Perioperative AKI is commonly seen in the form of mild rises of serum creatinine after major cardiovascular surgeries. Its effect on long-term survival and development of chronic kidney disease (CKD) is well established in cardiac surgery patients. However, there are no data on the effect of AKI on long-term outcomes after revascularization for lower limb ischemia.We retrospectively reviewed the patients with peripheral arterial occlusive diseases who underwent endovascular or surgical revascularization of the lower extremities from 2001 through 2010. All demographic and clinical information have been maintained prospectively by the surgeon and followed up by the research team. Perioperative AKI was defined as rises of ≥0.3 mg/dL in serum creatinine from the values measured preoperatively. The primary end points were development of CKD (estimated glomerular filtration rate60 mL/min) and all-cause mortality. Univariate and multivariate analyses were performed to examine relevant associations.Within the study period, 717 patients underwent 875 procedures. Mean follow-up was 42 ± 14 months. AKI developed in 86 patients after the index procedure. Overall prevalence of CKD diagnosed postoperatively was 14.9%. Overall mortality reported within the follow-up period was 55.9%. Perioperative AKI was a significant predictor of CKD (area under the curve, 0.84 ± 0.13) and all cause mortality (area under the curve, 0.82 ± 0.12).Perioperative AKI is associated with an increased occurrence of CKD and a higher mortality rate after revascularization procedures of the lower extremities.

BACKGROUND: To examine the validity of Veterans Affair–VA risk assessment tool in predicting the perioperative and overall mortality among octogenarians. METHODS: This is a single-institution retrospective observational study, in which the clinical information of 1,618 octogenarians were extracted from the VA Surgical Quality Improvement Program database. VA risk assessment tool and ASA classification were used to predict the probability of postoperative mortality and morbidity. Multiple risk groups were compared for mortality using multiple logistic regressions. RESULTS: There were 570 survivors and 1,048 nonsurvivors. VA risk tool strongly predicted perioperative 30-day mortality in receiver operator characteristic curve analysis (area under the curve: .82 6 .02). The power of this tool, while acceptable, was less in predicting overall mortality (area under the curve: .68 6 .01). Age, dialysis, a history of congestive heart failure, functional status, transfusion, and weight loss were also associated with increased rate of death within 30 days. CONCLUSIONS: VA risk toolpredicted both perioperative and overallmortality. Relatively strong power of this tool in predicting overall mortality may be unique to this age group because of their advanced age. Published by Elsevier Inc.

OBJECTIVE To examine the influence of perioperative blood transfusions on perioperative outcomes and late survival. BACKGROUND Perioperative blood transfusion has been reported to have a negative impact on perioperative morbidity but its long-term effect on survival is unknown. The purpose of this study was to evaluate the effects of perioperative transfusion on perioperative outcomes and survival. METHODS We studied 12,345 surgical procedures from Veteran Administration Surgical Quality Improvement Program database from July 1998 through 2010. Patients with transfusion were compared with a severity-matched control group. We performed the Fisher exact test for comparison of categorical values and Wilcoxon rank sum test for continuous values. Multivariate regression was used to eliminate other confounding factors. The predictive value of multivariate risk model was tested with receiver-operator curves. Patients were matched using an optimal 1:1 digit-matching algorithm. All analyses were performed with NCSS-2007 version 1-12. P < 0.05 was considered statistically significant. RESULTS The 848 patients who received perioperative transfusions had higher unadjusted rates of mortality and decreased long-term survival. The odds ratio (OR) for 10 years mortality in transfused group was 2.92 and after adjusting for preoperative risk factors decreased to 1.40 (P < 0.01). However, after data were filtered for any perioperative complications, such an association was seen before, OR = 2.05 (P = 0.006), and was lost after propensity matching, OR = 1.19 (P = 0.35). CONCLUSIONS After filtering out perioperative complications and adjusting for preoperative morbidity, our final analysis did not reveal an increased long-term mortality. We conclude that transfusion may reduce long-term survival through its effects on perioperative complications.

The American Society of Anesthesiology's (ASA) 6-point physical status classification remains one of the most significant predictors of perioperative morbidity and mortality and is the most widely used risk stratification tool worldwide. Its utility is significantly limited for octogenarians, however, as the majority of these patients are classified as ASA-III. Thus, for patients aged 80 or older, we hypothesized that incorporating patients' functional status, defined by the ability to perform activities of daily living independently, would improve perioperative risk stratification.All data were extracted from the Veterans Affairs Surgical Quality Improvement Program, a perioperative prospectively maintained computerized database. ASA-III patients were reclassified into subgroups IIIA or IIIB, with IIIA representing functionally independent patients and IIIB representing partially or fully dependent patients. Functional status was self-reported during preoperative assessments. In this database, mortality data (primary outcome) was reliably available for all patients for the duration of the 96-month follow-up period, as were other perioperative patient data.Seven hundred and fifty-nine (72.4%) patients were classified as ASA-IIIA, and 290 (27.6%) patients were ASA-IIIB. Thirty-day and long-term survival was significantly better in the ASA-IIIA group, irrespective of type of surgery (hazard ratio 1.87, confidence interval 1.55-2.25, p.001). ASA-IIIB hazard ratios for mortality were greatest for orthopedic and vascular surgery patients, but a significant divergence in survival between ASA-IIIA and IIIB patients was observed in all surgical specialties.As evidenced by Kaplan-Meier and multivariate analyses, functional capacity was a significant independent predictor of mortality for ASA-III patients older than 80 years of age.

This study compares outcomes of basilic and cephalic vein fistulas for hemodialysis. A retrospective review of arteriovenous fistulas in a university hospital system was performed using charts and hemodialysis records. Patency and demographic data were assessed with life table analysis. One hundred fifty-six patients (88 males; 68 females) underwent creation of 172 autogenous fistulas (mean age 61 years; mean follow-up 78 weeks). There were 101 basilic vein transpositions and 71 cephalic vein fistulas. Primary patency did not differ significantly, while assisted primary patency was significantly better for basilic vein fistulas at one year (73% versus 53%: P = 0.024). Secondary patency was significantly better for basilic fistulas through three years (58% versus 52%; P = 0.027). Primary failure (thrombosis before access or failed maturation) was significantly higher for cephalic than basilic fistulas (28% versus 13%; P = 0.01). Maturation time, usage time and complications were not significantly significant. Thirty-three (33%) basilic vein-based fistulas and 12 (17%) cephalic vein fistulas required revision during follow-up. Basilic vein-based fistulas perform as well as or better than cephalic vein-based fistulas in terms of patency, maturation time, and usage time and complication rates, though requiring more re-interventions.

Introduction Le traitement endovasculaire (TEV) pour claudication, dont le but est d’ameliorer la qualite de vie, est en augmentation malgre son cout eleve. Nous examinions les resultats cliniques et les couts du TEV pour claudication. Methodes Les dossiers de tous les TEV realises au sein d’un centre hospitalo-universitaire sur une annee etaient revus et les donnees relatives a la capacite fonctionnelle, la classification TASC (Trans-Atlantic Inter-Society Council), la procedure, les reinterventions eventuelles, et les couts financier etaient relevees. La persistance du succes clinique (PSC, amelioration sans revascularisation de l’extremite concernee [REC]) et la persistance secondaire du succes clinique (PSSC, amelioration avec REC) etaient examines avec un suivi de 2 ans. Resultats Il y avait 77 patients (90 membres). Le suivi moyen etait de 14,8 ± 7,7 mois (1-30). Le taux de succes technique etait de 94%. Les PSC et PSSC a 2 ans etaient de 28 ± 9% et 49 ± 11%, respectivement. La PSC differait significativement de la TASC (p = 0,02), alors que ce n’etait pas le cas de la PSSC (p = 0,33). Le delai moyen a la reintervention etait de 11,7 ± 6,6 mois. Le taux d’indemnite de REC a 2 ans (65 ± 7%) ne differait pas significativement en fonction de la procedure (p = 0,26), de l’artere traitee (p = 0,24), ni de la classification TASC (p = 0,18). Le cout a 2 ans du TEV etait de 13886$, differant significativement en fonction de la TASC (p = 0,017) et de l’artere traitee (p Conclusions La REC etait necessaire sur plus d’un tiers des membres pour maintenir la PSSC a 2 ans chez 49% des patients. Le TEV etait deux fois plus cher que le cout estime de 2 ans d’exercice supervise associe a un traitement medicamenteux, et 10 fois plus couteux qu’un programme de 3 mois. L’obligation de tenter un programme de traitement conservateur avant TEV merite d’etre consideree.

Treatment of claudication with endovascular intervention (EVI), a procedure designed to enhance quality of life, is on the rise despite being expensive. We examined clinical outcomes and costs for treatment of claudication with EVI.Records of all EVI performed at a University Health Center during a single year were reviewed for functional capacity, Trans-Atlantic Inter-Society Council (TASC) classification, procedure, reintervention, and financial data. Sustained clinical success (SCS) (improvement without target extremity revascularization [TER]) and secondary sustained clinical success (SSCS) (improvement with TER) were tracked over 2 years follow-up.There were 77 patients (90 limbs). Mean follow-up was 14.8 +/- 7.7 months (1-30). Procedural success was 94%. Two-year SCS and SSCS were found to be 28 +/- 9% and 49 +/- 11%, respectively. SCS differed significantly from TASC (p = 0.02), whereas SSCS did not (p = 0.33). Mean time to reintervention was 11.7 +/- 6.6 months. Two-year TER-free rate (65 +/- 7%) did not differ significantly by procedure (p = 0.26), the artery treated (p = 0.24), or TASC (p = 0.18). Two-year costs for EVI were $13,886, differing significantly by TASC (p = 0.017) and by the artery treated (p0.001). Estimated cost for a 3-month trial of supervised exercise and pharmacotherapy was $1,376, and the maintenance cost over a 2 year follow-up period was $6,602.TER was necessary in more than one-third of limbs to maintain 2-year SSCS in 49% of patients. EVI was twice as expensive as estimated 2-year costs for supervised exercise and pharmacotherapy, and 10 times more costlier than a 3-month trial. Mandating a trial of conservative therapy before EVI merits consideration.

ObjectiveThe goal was to compare the outcomes in patients with disabling claudication (DC) or critical limb ischemia (CLI) to determine if diabetics (DM) have poorer patency, limb salvage (LS), and survival rates than nondiabetic patients and if the diabetic regimen affects these outcomes.MethodsAll patients who presented with DC or CLI between June 2001 and September 2008 were included. Non-DM patients were compared with those with DM who are currently managed by diet only or oral medications (D-OM), oral medications plus insulin (OM+INS), or insulin alone (INS).ResultsOf the 746 patients (886 limbs), there were 406 patients (464 limbs) in non-DM, 96 patients (135 limbs) in D-OM, 98 patients (118 limbs) in OM+INS, and 146 patients (185 limbs) in INS groups. There were more patients with coronary artery disease, hypertension, and renal insufficiency in the DM group than non-DM, with the INS group having the highest incidence of renal insufficiency/dialysis (46%/20%). Gangrene and foot sepsis were significantly more frequent in patients in OM+INS (45%/3%) and INS (50%/6%) than non-DM (15%/0.2%) and D-OM groups (25%/1%; P < .001). More patients in the INS group (14%) and OM+INS (9%) had primary amputation than non-DM (4%) and D-OM (4%; P < .01). Mean follow-up was 26.3 ± 20.7 months. Overall survival following revascularization was similar in D-OM and non-DM and OM+INS and INS, the latter being significantly worse (P < .001). The LS rate in D-OM and non-DM was also identical, whereas OM-INS and INS had significantly worse LS, with OM-INS marginally better than INS (P = .094). Primary patency (PP) was worse in endovascular-treated patients on insulin than non-DM and D-OM patients (P < .001), whereas PP was similar between groups in open-treated patients. Multivariate analysis showed that coronary artery disease, renal insufficiency, chronic obstructive pulmonary disease, indication for intervention, insulin use, nonambulatory status, and statin drug non-use were independently associated with decreased survival, whereas insulin use, presence of gangrene, need for infrapopliteal interventions, and nonambulatory status were independently associated with limb loss. TransAtlantic Inter-Society Consensus (TASC) classification of the treated lesions being C or D, infrapopliteal interventions, and indication of intervention (DC vs CLI) were independently associated with primary patency, whereas insulin use was not.ConclusionsDiabetic patients who present with limb ischemia can be subdivided into three distinct subgroups based on their diabetic regimen. The survival and LS rates of those controlled with diet or OM are nearly identical to nondiabetics, both of which are significantly better than OM+INS or INS. The PP rate in endovascular-treated patients is worse in patients who are on insulin. Being on insulin is independently associated with decreased survival and limb loss but not PP.

ObjectiveThe goal of this study was to assess the frequency and predictors of major amputation with patent endovascular-treated arterial segments (PETAS) in patients with critical limb ischemia.MethodsThe study included 358 consecutive patients (412 limbs) who underwent endovascular (236 limbs) or open (176 limbs) revascularizations for critical limb ischemia from June 2001 through May 2007. Patients with limb loss despite PETAS were compared with the rest of the endovascular-treated group (EV-other, n = 212) and with those who underwent amputations with patent bypasses (APB).ResultsThe EV group underwent 30 amputations (24 in PETAS, 6 in EV-other), and 37 occurred in the open group (14 in APB, 23 in open-other). Amputations occurring despite a patent revascularized segment constituted 38% of limb loss in open and 80% in EV-treated patients (P = .001). Limb loss occurred earlier in the PETAS group (58% vs 30% ≤3 months). Primary indications for limb loss in the PETAS group were extensive tissue loss or limb dysfunction after radical débridement of infection or gangrene (37%), recurrent infection (42%), and failure to reverse ischemia (21%). There were more patients with diabetes in PETAS group (96%) than in the APB group (64%, P = .018). Diabetes, dialysis-dependence, lower albumin level, gangrene, and infrapopliteal interventions were more likely in the PETAS group than in the EV-other group. Multivariate analysis showed diabetes (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.22-8.13, P = .018), gangrene (OR, 3.33; 95% CI, 1.43-7.75; P = .005), and infrapopliteal interventions (OR, 3.09; 95% CI, 1.38-6.94; P = .006), predicted limb loss with patent open or EV-treated segments, whereas dialysis-dependence, peroneal artery-only runoff, albumin level

BACKGROUND Alpha2 adrenergic agonists have long been employed as analgesics and to sedate patients undergoing surgical procedures. In addition, their therapeutic response synergizes that elicited by opioids. Although this response is well known, the role of alpha2 agonists, such as clonidine, during various painful surgical procedures remains to be elucidated. The goal of our study was to evaluate the effects of the intrathecal administration of clonidine on postoperative pain control and time to extubation in patients undergoing coronary artery bypass grafting. METHODS Eighty-five patients undergoing coronary artery bypass grafting randomly received either an intrathecal injection of preservative free morphine 0.5 mg (MOR) or a combination of morphine 0.5 mg and clonidine 100 microg (CMC) before induction of anesthesia. Anesthesia was induced and maintained using a balanced anesthesia technique. Patients were transferred to the intensive care unit while intubated and weaned from mechanical ventilation following an established weaning protocol. Postoperative pain, opioid use within the first 24 hours, and time to extubation were used as primary outcome variables. Data were analyzed by a 2-tailed t test for continuous variables and Fisher exact test for nonparametric variables. RESULTS There were no demographic differences between the CMC and MOR groups. Postoperative pain, as assessed by a visual analog scale, was milder in the CMC group when compared with that of the MOR group (2.2+/-0.36 vs. 3.4+/-0.33, P

Objective Peroneal artery bypass is effective for limb salvage (LS), however, the efficacy of peroneal artery-only runoff (PAOR) following endovascular (EV) interventions is unknown. The goal of our article was to compare the efficacy of EV interventions with PAOR to those with other runoff vessels for LS in patients presenting with tissue loss. Methods A retrospective review of 111 consecutive patients who underwent infrainguinal EV revascularizations for nonhealing ulcers/gangrene between June 2001 and December 2006 was performed. Patients with PAOR (n = 33) were compared with those with other vessel runoff (OTHER, n=78). Fisher exact test and χ 2 test were used for comparing variables, Kaplan-Meier analyses for patency, LS, and Cox regression multivariate analysis was used for identifying factors associated with limb loss. Results The patients in PAOR were older, but other morbidities were similar between groups. The most distal level of intervention was infrapopliteal (tibioperoneal or peroneal artery) in 42% in PAOR group whereas this was 24% in OTHER group ( P = .071). Preoperative ankle-brachial index (ABI) was similar (0.49 ± 0.23 vs 0.50 ± 0.23), however, postprocedure ABI was significantly less for patients with PAOR (0.76 ± 0.21 vs 0.92 ± 0.13, P = .001). The primary patency, assisted primary patency, secondary patency and LS were not significantly different between groups. There was also no difference in time-to healing between groups (PAOR vs OTHER, 2.9 ± 2.1 mo vs 3.7 ± 3.6 mo, P = .319). We found the presence of gangrene (odds ratio [OR]: 3.5, 95% confidence interval [CI], 1.1-10.8, P = .028) and dialysis-dependence (OR: 2.9, 95% CI, 1.0-8.2, P = .046) to be associated with limb loss, when adjusted for diabetes, hypertension, hyperlipidemia, smoking, location of wound, and PAOR. Conclusion Endovascular revascularization with PAOR results in acceptable patency and limb salvage rates in patients presenting with tissue loss, and is equivalent to other vessel runoff for patency, limb salvage and wound healing rates.