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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.

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.

We evaluated limb salvage (LS), amputation-free survival (AFS), and target extremity reintervention (TER) after plain old balloon angioplasty (POBA), stenting, and atherectomy for treatment of infrapopliteal disease (IPD) with chronic limb-threatening ischemia (CLTI).All index peripheral vascular interventions for IPD and CLTI were identified from the Vascular Quality Initiative registry. Of the multilevel procedures, the peripheral vascular intervention type was indexed to the infrapopliteal segment. Propensity score matching was used to control for baseline differences between groups. Kaplan-Meier and Cox regression were used to calculate and compare LS and AFS.The 3-year LS for stenting vs POBA was 87.6% vs 81.9% (P = .006) but was not significant on Cox regression analysis (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.56-0.76; P = .08). AFS was superior for stenting vs POBA (78.1% vs 69.5%; P = .001; HR, 0.73; 95% CI, 0.60-0.90; P = .003). LS was similar for POBA and atherectomy (81.9% vs 84.8%; P = .11) and for stenting and atherectomy (87.6% vs 84.8%; P = .23). The LS rate after propensity score matching for POBA vs stenting was 83.4% vs 88.2% (P = .07; HR, 0.71; 95% CI, 0.50-1.017; P = .062). The AFS rate for stenting vs POBA was 78.8% vs 69.4% (P = .005; HR, 0.69; 95% CI, 0.54-0.89; P = .005). No significant differences were found between stenting and atherectomy (P = .21 for atherectomy; and P = .34 for POBA). The need for TER did not differ across the groups but the interval to TER was significantly longer for stenting than for POBA or atherectomy (stenting vs POBA, 12.8 months vs 7.7 months; P = .001; stenting vs atherectomy, 13.5 months vs 6.8 months; P .001).Stenting and atherectomy had comparable LS and AFS for patients with IPD and CLTI. However, stenting conferred significant benefits for AFS compared with POBA but atherectomy did not. Furthermore, the interval to TER was nearly double for stenting compared with POBA or atherectomy. These factors should be considered when determining the treatment strategy for this challenging anatomic segment.

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.

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.

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.

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.

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 The short- and mid-term outcomes of endovascular aortic aneurysm repair have made it a standard treatment of abdominal aortic aneurysms. However, newer generation devices have yet to demonstrate improved long-term rates for complications, reinterventions, and survival. The TREO stent graft is a latest generation device and was evaluated for approval in the United States. Methods In a multicenter, nonrandomized, investigational device exemption clinical trial, we assessed the safety and effectiveness of the TREO device, with core laboratory assessment of the imaging studies and an independent adjudication of safety. The primary effectiveness endpoint was successful aneurysm treatment at 1 year. The primary safety endpoint was the incidence of major adverse events (MAE) at 30 days. Results A total of 150 patients (132 men; 88.0%) with infrarenal abdominal aortic (87.3%) or aortoiliac (12.7%) aneurysms were enrolled. The data were normally distributed. The mean age was 71.7 ± 7.4 years. The MAE incidence at 30 days was 0.7%. One subject experienced two MAE: myocardial infarction and procedural blood loss of 1000 mL. The proportion of successful aneurysm treatment at 1 year was 93.1%. Longer term follow-up continues, with no aneurysm-related mortality at the latest follow-up. At 3 years, the cumulative all-cause mortality and incidence of type I and type III endoleaks was 10.7% (n = 16), 2.7% (n = 4), and 0% (n = 0), respectively. In addition, aneurysm sac shrinkage >5 mm at 3 years had occurred in 54.3% of patients, and 9.3% had required a secondary intervention (n = 14). Conclusions The safety and effectiveness of endovascular repair of abdominal aneurysms with TREO were demonstrated, with 93.1% successful aneurysm treatment at 1 year and aneurysm sac shrinkage >5 mm at 3 years in 54.3% of patients. Long-term follow-up continues to determine whether these favorable outcomes will be sustained.

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.

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.

Following new trends in precision medicine, Juxatarenal Abdominal Aortic Aneurysm (JAAA) treatment has been enabled by using patient-specific fenestrated endovascular grafts. The X-ray guided procedure requires precise orientation of multiple modular endografts within the arteries confirmed via radiopaque markers. Patient-specific 3D printed phantoms could familiarize physicians with complex procedures and new devices in a risk-free simulation environment to avoid periprocedural complications and improve training. Using the Vascular Modeling Toolkit (VMTK), 3D Data from a CTA imaging of a patient scheduled for Fenestrated EndoVascular Aortic Repair (FEVAR) was segmented to isolate the aortic lumen, thrombus, and calcifications. A stereolithographic mesh (STL) was generated and then modified in Autodesk MeshMixer for fabrication via a Stratasys Eden 260 printer in a flexible photopolymer to simulate arterial compliance. Fluoroscopic guided simulation of the patient-specific FEVAR procedure was performed by interventionists using all demonstration endografts and accessory devices. Analysis compared treatment strategy between the planned procedure, the simulation procedure, and the patient procedure using a derived scoring scheme. Results: With training on the patient-specific 3D printed AAA phantom, the clinical team optimized their procedural strategy. Anatomical landmarks and all devices were visible under x-ray during the simulation mimicking the clinical environment. The actual patient procedure went without complications. Conclusions: With advances in 3D printing, fabrication of patient specific AAA phantoms is possible. Simulation with 3D printed phantoms shows potential to inform clinical interventional procedures in addition to CTA diagnostic imaging.

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

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.

Management of lower extremity arterial disease with endovascular intervention is on the rise. Current practice patterns vary widely across and within specialty practices that perform endovascular intervention. This study evaluated reimbursement and costs of different approaches for offering endovascular intervention and identified strategies to improve cost-efficiency.The medical records of all patients admitted to a university health system during 2005 for an endovascular intervention were retrospectively reviewed. Procedure type, setting, admission status, and financial data were recorded. Groups were compared using analysis of variance, Student t test for independent samples, and chi2.A total of 296 endovascular interventions were completed, and 184 (62%) met inclusion criteria. Atherectomy and stenting were significantly more costly when performed in the operating room than in the radiology suite: atherectomy, dollars 6596 vs dollars 4867 (P = .002); stent, dollars 5884 vs dollars 3292, (P.001); angioplasty, dollars 2251 vs dollars 1881 (P = .46). Reimbursement was significantly higher for inpatient vs ambulatory admissions (P.001). Costs were lowest when the endovascular intervention was done in the radiology suite on an ambulatory basis and highest when done as an inpatient in the operating room (dollars 5714 vs dollars 12,278; P.001). Contribution margins were significantly higher for inpatients. Net profit was appreciated only for interventions done as an inpatient in the radiology suite. Reimbursement, contribution margins, and net profit were significantly lower among private pay patients in both the ambulatory and inpatient setting. The 30-day hospital readmission after ambulatory procedures was seven patients (6%).Practice patterns for endovascular interventions differ considerably. Costs vary by procedure and setting, and reimbursement depends on admission status and accurate documentation; these dynamics affect affordability. Organizing vascular services within a hub will ensure that care is delivered in the most cost-efficient manner. Guidelines may include designating the radiology suite as the primary venue for endovascular interventions because it is less costly than the operating room. Selective stenting policies should be considered. Contracts with private insurers must include carve-outs for stent costs and commensurate reimbursement for ambulatory procedures, and Current Procedural Terminology (CPT; American Medical Association, Chicago, Ill) coding must be proficient to make ambulatory endovascular interventions fiscally acceptable.

Objective The new millennium has seen an increase in vascular residency vacancies. The American Board of Vascular Surgery recently proposed new training paradigms, but their impact on recruitment remains unknown. We surveyed vascular fellows regarding factors and timing of career decisions to determine an optimal strategy for recruitment. Methods Surveys were sent electronically to vascular residents for completion. Data were analyzed using SPSS software. Additional data were obtained from the National Resident Matching Program. Results Of the 90 fellows that responded, 84% committed to vascular surgery during residency. Of these, 18% decided during postgraduate year 1, 54% by year 2, 84% by year three, and 95% by year 4. Sixteen percent of all trainees decided in medical school. Seventy-three percent of residents performed a minimum of 20 to 50 cases before reaching a decision. Among the group deciding between years 2 to 4 of residency, there was a significant difference in the number of vascular rotations before career commitment ( P = .0001). In the 2004 Match, 21% of vascular residency positions were unfilled, up from 12% in 2003, 9% in 2002, and 4% in 2001. Conclusions Leaders in the field of vascular surgery have proposed focused training through the new paradigms. The incline in unmatched vascular residency positions over the past 4 years highlights the importance of a strategic plan to optimize recruitment. Few current trainees decided early in training about career choice, and volume appears critical to the decision process. Utilizing the current matching system (an 18-month process) and without any proactive change in recruitment, an integrated program after medical school would be reasonable for only 16% of applicants, or the 3+3 option for 54% of residents. For the new paradigms to be successful and to prevent more unfilled positions, increased medical student integration into vascular rotations and early active exposure to endovascular and open procedures during general surgical training will be necessary across the country.

A Baker's or popliteal cyst is a synovial cyst in the popliteal fossa arising from the knee joint. The majority of patients develop a popliteal mass that is asymptomatic, but in a small percentage of patients, complications and symptoms occur; these may not only encompass the popliteal veins and arteries but may also include cyst leakage, infection, hemorrhage, and compartment syndrome. Severe lower limb ischemia caused by a Baker's cyst is extremely rare, having been reported only six times since 1960; all patients were treated with surgical intervention. We report the case of a 29-year-old male presenting with right calf claudication caused by a Baker's cyst. The patient was managed nonoperatively with nonsteroidal anti-inflammatory agents, proper exercises, and close observation. His claudication improved progressively and had completely disappeared at 12 months of follow-up. A repeat duplex arterial study showed that increased blood flow to the right foot and the right ankle/brachial index improved to 0.97 from 0.67. Repeat ultrasonography demonstrated that the size of the cyst decreased from 4.5 × 1.5 cm to 2.8 × 0.9 cm. The patient had been followed for 20 months and remained asymptomatic in the last 8 months. We will continue to follow the patient to evaluate the long-term outcome. In summary, our own data and literature review suggest that the limb ischemia caused by Baker's cyst may be a transient condition and can be managed nonoperatively in selected patients.

Distal peripheral microembolism is caused by embolization of atherosclerotic debris into small arteries and arterioles. The recent advances in endovascular technique have been met with a gradual increase in the incidence of iatrogenic atheroembolism. This review seeks to explore the nature of distal peripheral microembolism, pathophysiology, and the management options, with a focus on iatrogenic distal peripheral microembolism.

The development of limb ischemia in patients who are dependent on an intra-aortic balloon pump (IABP) and/or extracorporeal membrane oxygenation (ECMO) is a serious problem. We used external femorofemoral bypass grafting at the bedside as a salvage procedure in two such patients with effective reversal of ischemia, although both died of cardiac complications. This procedure can be considered in patients who are severely coagulopathic and are dependent on IABP and/or ECMO, in whom the graft removal would be considered at the time of balloon removal.

Background To evaluate hospital costs and reimbursement for open (OAAA) and endovascular (EVAAA) repair of abdominal aortic aneurysm. Study design Review of all patients who underwent OAAA or EVAAA in two teaching hospitals during the period January 1, 2000, to December 31, 2000, was completed for the following: demographics, Diagnosis Related Group (DRG), resource use, length of stay, hospital costs, and reimbursement data. Results There were 130 abdominal aortic aneurysm procedures performed. Fifty-seven (44%) OAAA were completed; EVAAA was attempted in 73 (56%). Seventy EVAAA patients (96%) had endografts placed, and three (4%) required conversion to open repair. Significant differences were noted between OAAA and EVAAA in operative time (311.7 ± 107.5 minutes versus 263.4 ± 110.8 minutes, respectively, p=0.02), ICU admission and length of stay (100%, 5.0 ± 6.1 days versus 29%, 1.4 ± 7.1 days, respectively, p=0.003), and hospital length of stay (12.6 ± 14.8 days versus 4.9 ± 13.4 days, respectively, p=0.002). Total costs were $17,539.00 for EVAAA and $9,042.00 for OAAA. EVAAA was profitable ($3,072.00) for Medicare DRG 110 classification, but significant loss occurred with DRG 111 ($5,065.00). Contract renegotiation with private payers (to cover graft costs) was necessary to avoid substantial per- patient loss ($12,108.00). Overall net per-patient profit for EVAAA was $737.00. Conclusions Endovascular abdominal aortic aneurysm repair is significantly more expensive than open repair, with the major portion attributed to graft cost. Although ICU use and total length of stay decreased with EVAAA, overall costs were not substantially reduced. Hospitals must develop new financial strategies and improve the efficiency of their infrastructures in order to offer EVAAA.

The purpose of this study was to evaluate the potential feasibility and financial impact of same-day discharge after elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm.All elective EVARs performed between January 2012 and June 2013 were identified. Demographics, comorbidities, complications, nursing care, financial data, and length of stay were analyzed.Sixty-seven (73%) EVARs were performed electively, 73% percutaneously. Intraoperative complications were blood loss requiring transfusion (4.5%), thrombosis (3%), femoral artery injury (1.5%), postoperative urinary retention (4.5%), myocardial infarction (3%), respiratory failure (1.5%), congestive heart failure (1.5%), and hemodynamic or rhythm alterations (37%; evident in 88%6 hours; 13% required therapy). Monitoring only was needed in 28 patients (42%), intensive care in 15%. Seventy-two percent were discharged on postoperative day one; 6% were readmitted30 days. Telemetry, oxygen, intravenous hydration, and urinary catheters (routine services) were used for shorter periods in uncomplicated patients and those discharged on postoperative day 1. Total hospital costs were $29,479: operating room, 80.3%; anesthesia, 2.2%; preadmission, 1%; postanesthesia unit, 3.1%; intensive care unit, 1.9%; floor, 4.7%; laboratory and diagnostic tests, 1.2%; pharmacy, 1.4%; other, 4.2%. Total cost was similar for those discharged20 hours or ≥24 to 31 hours postoperatively (P = .51) and for monitoring only vs others ($28,146 vs $30,545; P = .12). Pharmacy ($351 vs $509; P = .05), laboratory work ($86 vs $355; P = .01), and diagnostic testing ($4 vs $254; P = .02) costs were lower for uncomplicated cases.Same-day discharge is clinically feasible in40% of elective EVARs but requires coordination for adequate postoperative monitoring. Significant savings are unlikely as most cost is operating room and device related, and further reduction of costs in uncomplicated cases is unlikely.

Purpose: To retrospectively review the long-term outcome as well as the cost effectiveness of thrombolytic therapy and balloon angioplasty (TBA) versus surgical thrombectomy and balloon angioplasty (SBA) in the treatment of prosthetic dialysis access grafts. Methods: Between February 1996 and February 1999, 63 hemodialysis patients (35 women; mean age 62.2 years) were treated for 105 thromboses in 6-mm polytetrafluoroethylene straight or loop bridge arteriovenous grafts. Choice of treatment was at the discretion of the surgeon or interventional radiologist: either Fogarty balloon thrombectomy followed by balloon dilation of the venous anastomotic stenosis or urokinase thrombolysis followed by angioplasty. Results: Forty-eight SBAs and 55 TBAs were performed in 63 patients without complications. The primary patency rates in the entire cohort were 34%, 29%, and 17% at 1, 2, and 3 months, respectively. Primary patency after TBA was 29%, 18%, and 11%, and that for SBA, 45%, 45%, and 33% over the same time intervals. The mean graft survival was 10 days for TBA versus 31 days for SBA. Repeat angioplasty performed in 23 grafts produced secondary patency rates of 52% at 1 month, 34% at 3 months, and 5% at 5 months. The Medicare reimbursement for both treatments was identical ($1638 for TBA and $1670 for SBA). Conclusions: The poor patency rate and high cost of TBA and SBA suggests that these procedures should not be routinely used for salvage of thrombosed arteriovenous grafts with outflow stenosis. Patch angioplasty or creation of simultaneous temporary and new permanent accesses may be a more cost-effective approach in these patients.

Objectives: thrombolytic therapy is frequently used to manage vascular graft thrombosis. However, long-term patency after thrombolysis remains poor. The purpose of this study was to characterise the morphological and functional response of endothelial cells (EC) exposed to a thrombus and subsequently lytic therapy. Methods: human EC were exposed to human whole blood thrombus for 2, 6, 12, and 24 h. The thrombus was lysed with urokinase. Cell morphology was studied with electron microscopy. Northern blot analyses were performed with human c-DNA probes for endothelin-1, thrombomodulin, tissue factor, tissue plasminogen activator, plasminogen activator inhibitor, and triose phosphate isomerase. Results: EC retraction occurred for each period of incubation. Thrombomodulin expression was increased 2.2-fold at 6 h and 2.4-fold at 24 h. t-PA expression was depressed proportionally to the duration of thrombus exposure. PAI and TF expression transiently increased 1.5-fold at 2 h of exposure and returned to baseline at 6 h. Endothelin expression remained unchanged. Conclusions: except for a transient increase in TF expression and reversal of the tPA/PAI ratio, EC exposed to thrombus do not appear to become actively procoagulant. The increase in TM expression may reflect enhanced thromboresistance. However, EC retraction may be responsible for an increase thrombogenicity of saphenous vein graft after thrombosis and Urokinase therapy.

Background Hemorrhage from large retroperitoneal veins is usually controlled by suturing the venous tear. Infrequently, the extent and location of the tear and amount of hemorrhage preclude successful suturing. Methods In seven patients with severe hemorrhage from large retroperitoneal veins encountered in association with resection of retroperitoneal sarcoma (6) or repair of a ruptured abdominal aortic aneurysm (1), packing of the area with sufficient amounts of Surgicel (Ethicon, Johnson & Johnson, Somerville, NJ) and pressure for one half hour was used. Results All seven patients did not show any bleeding postoperatively and no clinical sequelae developed, with the exception of one patient who developed an abscess requiring drainage. Conclusion Internal packing with Surgicel appears to be reliable in controlling venous hemorrhage not manageable by the standard methods and may be preferable to roll gauze packing.