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Subclavian artery aneurysms (SAAs) are rare, and their repair can be technically complex. We have reported the redo repair of a large, expanding, right SAA after primary repair consisting of total aortic arch replacement with bilateral subclavian artery ligation and bypass. The redo repair used claviculectomy to facilitate exposure, ligation of the right deep cervical and internal thoracic arteries from within the aneurysm sac, and revision of the previous axillary artery bypass that had thrombosed owing to the mass effect of the expanding SAA. Claviculectomy can facilitate repair of large SAAs that are poorly suited to more routine exposure approaches, with acceptable risk and functional outcomes.

Background Industry payments to physicians may influence their attitudes toward medical devices and products. Disclosure of industry compensation by authors of scientific manuscripts usually occurs at the authors' discretion and is seldom audited as part of the peer review process. The purpose of this analysis was to characterize industry compensation among highly cited research articles related to aortic aneurysm. Methods A Web of Science search for English language articles published from 2013-2017 using the search term “aortic aneurysm” identified publications for this study. The top 99 most-cited publications were abstracted by author. Physician authors with reported industry compensation from 2013-2016 were identified using the ProPublica Dollars for Docs search tool (linked to Centers for Medicare and Medicaid Services Open Payments data), based on provider name, medical specialty, and geographic location. Statistical analysis included descriptive statistics and categorical tests. Results The 99 articles had 1,264 unique authors, of whom 105 physicians (8.3%) received industry compensation during the study period. Fourteen of the 105 authors self-reported having received industry compensation. The remaining 91 authors (86.7%) did not disclose their industry-reported compensation. Industry payments during the study period totaled $6,082,574 paid through 13,489 transactions from 169 different manufacturers. In-kind items and services were the most common form of payment (65.3%). The median transaction amount was $58.32. [$138.34]. Food and beverage accounted for the largest number of transactions (N=9653), followed by travel and lodging (N=2365), consulting (N=513), and promotional speaking (N=436). Consulting accounted for the most total dollars over the study period ($1,970,606), followed by travel and lodging ($1,122,276), promotional speaking ($972,894), food and beverage ($568,251), royalty or license ($504,631), honoraria ($452,167), and education ($428,489). Royalty and license payments had the highest median transaction amount ($15,418. [$29,049]), and was the only category with a median transaction amount greater than $5,000. In contrast, several categories had median transaction amounts under $50, including food and beverage ($32. [$77]), gifts ($34. [$86]), and entertainment ($30. [$69]). No significant difference in payment amounts by medical specialty was identified (P=0.071). Conclusions Only 8.3% of physician authors of highly cited aortic aneurysm studies received industry compensation, but 86.7% of those physician authors receiving payments did not disclose industry compensation within the manuscripts. Potential bias associated with industry compensation may be underestimated and conservatively biased based on author self-reporting.

Diabetes mellitus is a major risk factor for progression to lower extremity amputation (LEA) due to progressive neuropathy and glycemia-induced vasculopathy. In this study, we evaluated risk factors for incident LEA type 2 diabetics during a randomized controlled trial and extended post-trial follow-up.The Action to Control Cardiovascular Risk in Diabetes trial randomized 10,251 type 2 diabetics to intensive glycemic control (Hemoglobin A1c (HbA1c) target6.0%) versus standard glycemic control (HbA1c target 7.0-7.9%). Using backward elimination logistic regression models, we examined relationships between neuropathy using the Michigan Neuropathy Screening Instrument (MNSI) and glycemic control and incident LEA during the clinical trial and subsequent follow-up.9,746 patients were followed for a mean of 7.9 +/-3.1 (median 8.9) years after randomization. Ninety-eight (1%) participants underwent an incident LEA during the trial or post-trial follow-up period. Baseline demographics and traditional risk factors were examined by incident amputation status. Multivariable models revealed that abnormal 10 gm filament test (HR 4.50, 95% CI 2.92-6.95, P 0.0001), presence of ulceration (HR 4.22, 95% CI 1.65-10.8, P = 0.0004), abnormal appearance on foot examination (HR 4.75, 95% CI 2.30-9.83, P 0.0001), and mean postrandomization HbA1c (HR 1.65, 95% CI 1.35-2.00, P 0.0001) were strongly predictive of LEA when accounting for other common risk factors for amputation.In this post hoc analysis of a large randomized controlled population of diabetic patients, we found that components of the MNSI score including presence of ulceration, abnormal appearance of the foot, and 10 gm filament monofilament scoring were strongly predictive of LEA. This adds a valuable clinical tool in the risk stratification of diabetic patients for LEA.

Background This qualitative research explored the lived experiences of patients who experienced postponement of elective cardiac and vascular surgery due to coronavirus disease 2019 (COVID-19). We know very little about patients during the novel coronavirus pandemic. Understanding the patient voice may play an important role in prioritization of postponed cases and triage moving forward. Methods Utilizing a hermeneutical phenomenological qualitative design, we interviewed 47 individuals who experienced a postponement of cardiac or vascular surgery due to the COVID-19 pandemic. Data were analyzed and informed by phenomenological research methods. Results Patients in our study described 3 key issues around their postponement of elective surgery. Patients described robust narratives about the meanings of their elective surgeries as the chance to "return to normal" and alleviate symptoms that impacted everyday life. Second, because of the meanings most of our patients ascribed to their surgeries, postponement often took a toll on how patients managed physical health and emotional well-being. Finally, paradoxically, many patients in our study were demonstrative that they would "rather die from a heart attack" than be exposed to the coronavirus. Conclusions We identified several components of the patient experience, encompassing quality of life and other desired benefits of surgery, the risks of COVID, and difficulty reconciling the 2. Our study provides significant qualitative evidence to inform providers of important considerations when rescheduling the backlog of patients. The emotional and psychological distress that patients experienced due to postponement may also require additional considerations in postoperative recovery.

Patient-reported outcomes (PRO) have been increasingly emphasized for peripheral artery disease (PAD). Patient-defined treatment goals and expectations, however, are poorly understood and might not be achievable or aligned with guidelines or clinical outcomes. We evaluated the patient-reported treatment goals among patients with claudication and the associations between patient characteristics, goals, and PAD-specific PRO scores.Patients with a diagnosis of claudication were prospectively recruited. Patient-defined treatment goals and outcomes related to walking distance, duration, and speed were quantified using multiple-choice survey items. Free-text items were used to identify activities other than walking distance, duration, or speed associated with symptoms and treatment goals. The peripheral artery disease quality of life and walking impairment questionnaire instruments were included as PRO. The treatment goal categories were compared with the PRO percentile scores using 95% confidence intervals (CIs), categorical tests, and logistic regression models. Associations between the patient characteristics and PRO were evaluated using linear and ordinal logistic regression models.A total of 150 patients meeting the inclusion criteria were included in the present study. Of these 150 patients, 144 (96%) viewed the entire survey. Their mean age was 70.0 ± 11.3 years, and 32.9% were women. Most of the respondents had self-reported their race as White (n = 135), followed by Black (n = 3), Asian (n = 2), Native American (n = 2), and other/unknown (n = 2). Two participants self-reported Hispanic ethnicity. The primary treatment goals were an increased walking distance or duration without stopping (62.0%), the ability to perform a specific activity or task (23.0%), an increased walking speed (8.0%), or other/none of the above (7.0%). The specific activities associated with symptoms or goals included outdoor recreation (38.5%), labor-related tasks (30.7%), sports (26.9%), climbing stairs (23.1%), uphill walking (19.2%), and shopping (6%). Among the patients choosing an increased walking distance and duration as the primary goals, 64% had indicated that a distance of ≥0.5 mile (2640 ft) and 59% had indicated a duration of ≥30 minutes would be a minimum increase consistent with meaningful improvement. Increasing age was associated with lower odds of a distance improvement goal of ≥0.5 mile (odds ratio [OR], 0.68 per 5 years; 95% CI, 0.51-0.92; P = .012) or duration improvement goal of ≥30 minutes (OR, 0.76 per 5 years; 95% CI, 0.58-0.99; P = .047). Patient characteristics associated with PAD Quality of Life percentile scores included age, ankle brachial index, and gender. Ankle brachial index was the only patient characteristic associated with the walking impairment questionnaire percentile scores.Patients define treatment goals according to their desired activities and expectations, which may influence their goals and perceived outcomes. Patients' expectations of minimum increases in walking distance and duration consistent with meaningful improvement exceeded reported minimum important difference criteria for many patients and would not be captured using common clinic-based walking tests. Patient age was associated with both treatment goals and PRO scores, and the related floor and ceiling effects could influence sensitivity to PRO changes for younger and older patients, respectively. Heterogeneity in treatment goals supports consideration of tailored decision-making and outcomes informed by patient characteristics and perspectives.

Background Supervised exercise therapy (SET) is an inexpensive, low-risk, and effective option when compared with invasive therapies for the treatment of patients with peripheral artery disease (PAD) and intermittent claudication. Randomized, controlled trials have demonstrated the benefits of SET in improving maximum walking distance in intermittent claudication patients, and society guidelines recommend SET as first-line therapy. In 2017, the Centers for Medicare & Medicaid Services (CMS) added coverage of SET. We aimed to evaluate the availability and use of SET programs, determine the awareness of SET CMS coverage in the United States, and gauge the academic interest in SET in the vascular community. Methods An eight-question online survey regarding SET coverage, reimbursement, barriers to prescription, and SET use was sent to 900 vascular surgeons, cardiologists, and vascular medicine physicians across the United States. The most recent 2-year programs for the Vascular Annual Meeting, Midwestern Vascular Society, Eastern Vascular Society, and Western Vascular Society were reviewed to identify SET-related abstracts and gauge academic interest and awareness for SET within the vascular surgery community. Results We received 135 physician responses (15%) to the survey. All 50 states were represented. The majority of responders (54%) stated that there was no SET program at their facility, and 5% did not know if there was a SET program available. Of those who did have a SET program available, 81% were associated with cardiac rehabilitation and 19% had a PAD-specific program. A significant number of physicians (49%) had never referred a patient for SET. Twenty-six percent were not aware that CMS covered SET sessions. Of the physicians who were aware of CMS reimbursement, 36% had never referred a patient to a SET program. Of all surveyed, 98% indicated they would refer patients to a SET program if one was available. Top barriers to use of a SET program included (1) no SET center availability and (2) significant cost or travel expense to the patient. A review of major vascular surgery meeting programs for the last 2 years yielded no identification of a SET-related abstract. Conclusions There is a lack of both availability and use of SET for patients with PAD with claudication, despite guideline recommendations and CMS reimbursement for SET sessions in the United States. When SET is offered, it is typically through cardiac rehabilitation programs which is not focused on PAD. Travel distance, lack of SET program availability, and low reimbursement rates are primary areas that could be addressed to improve use.

Macrophage plasticity is critical for normal tissue repair following injury. In pathologic states such as diabetes, macrophage plasticity is impaired, and macrophages remain in a persistent proinflammatory state; however, the reasons for this are unknown. Here, using single-cell RNA sequencing of human diabetic wounds, we identified increased JMJD3 in diabetic wound macrophages, resulting in increased inflammatory gene expression. Mechanistically, we report that in wound healing, JMJD3 directs early macrophage-mediated inflammation via JAK1,3/STAT3 signaling. However, in the diabetic state, we found that IL-6, a cytokine increased in diabetic wound tissue at later time points post-injury, regulates JMJD3 expression in diabetic wound macrophages via the JAK1,3/STAT3 pathway and that this late increase in JMJD3 induces NFκB-mediated inflammatory gene transcription in wound macrophages via an H3K27me3 mechanism. Interestingly, RNA sequencing of wound macrophages isolated from mice with JMJD3-deficient myeloid cells (Jmjd3f/fLyz2Cre+) identified that the STING gene (Tmem173) is regulated by JMJD3 in wound macrophages. STING limits inflammatory cytokine production by wound macrophages during healing. However, in diabetic mice, its role changes to limit wound repair and enhance inflammation. This finding is important since STING is associated with chronic inflammation, and we found STING to be elevated in human and murine diabetic wound macrophages at late time points. Finally, we demonstrate that macrophage-specific, nanoparticle inhibition of JMJD3 in diabetic wounds significantly improves diabetic wound repair by decreasing inflammatory cytokines and STING. Taken together, this work highlights the central role of JMJD3 in tissue repair and identifies cell-specific targeting as a viable therapeutic strategy for nonhealing diabetic wounds.

Introduction: Religion is an important aspect of personal identity, which is linked to education and wealth. Religion is changing in prevalence, notoriously difficult to obtain from surveys, and seldom accounted for in clinical research. We characterized religious affiliation among patients with common diagnoses treated by vascular surgeons and explored associations with patient-level factors and health risk behaviors. Hypothesis: We hypothesize health risk behaviors will be more common among vascular patients that are unaffiliated with a particular religion. Methods: Patients treated from 2019-2021 at a single center with vascular disease (abdominal aortic aneurysm; carotid, renal, or mesenteric stenosis; or peripheral artery disease) were identified. Self-reported religious affiliation was obtained from the medical record. Patients self-reporting any religion (regardless of religion name or denomination) were categorized as religion-affiliated (RA); self-reporting as atheist, agnostic, or no religion were categorized as unaffiliated (UA). Health risk behaviors were evaluated as individual outcomes and in aggregate based on heavy drinking (per CDC recommendations), tobacco, or illegal drug use. Statistical comparisons used chi-square and Wilcoxon scores. Results: Among 3,568 patients identified, 3,247 (91%) had self-reported religion and form the basis of analysis. 2198 (67.7%) reported RA, and over 40 denominations were identified. RA was more common among women [70.3% (1041 of 1480) vs. 65.5% (1157 of 1767); P=0.003] and married patients [71.1% (1162 of 1635) vs. 65.5% (598 of 913): P=0.003]. RA by race was most common among African American patients [70.9% (158 of 223)] and least common among Asians [48.2% (26 of 54)] (P=0.002). Self-reported health risk behaviors were more common among UA patients [33.2% (348 of 1049) versus 27.2% (598 of 2198); P Conclusions: Self-reported RA is associated with demographics and health risk behaviors among vascular patients. Interventions leveraging religious organizations and leaders may not reach nearly one third of patients who are UA. Future work will explore associations with socioeconomic factors and surgical outcomes.

Introduction: Patients with hypertensive disorders of pregnancy (HDoP) have increased prevalence of renal artery stenosis due to fibromuscular dysplasia (FMD) that is usually diagnosed years post-partum. Because renal artery FMD is a treatable cause of hypertension, earlier diagnosis has potential to decrease maternal risk and improve pregnancy outcomes. We sought to characterize utilization of renal artery duplex screening among women with HDoP and associations with pregnancy outcomes. Hypothesis: We hypothesize that renal artery duplex screening for renal artery stenosis among women with HDoP will be low. Methods: Women diagnosed with HDoP treated at a single academic medical center from 2016-2021 were identified using ICD-9&10 codes for hypertension of pregnancy, pre-eclampsia, eclampsia, and HELLP syndrome. Screening for renal artery FMD was categorized based on performance of at least one renal duplex ultrasounds during the study period. Associations with maternal demographic factors and pregnancy outcomes based on screening status were explored using descriptive statistics and categorical tests. Results: 11,564 women diagnosed with HDoP were identified. Mean age was 37.1±8.5 years. Race was categorized as 17% African American, 5% Asian, and 73% white; 4% of women had Hispanic or Latino ethnicity. 33% of patients were current or former smokers. Renal artery stenosis screening was performed on 72 women (0.6%). No significant differences in age, race, or ethnicity were identified between screened versus unscreened patients. Renal artery duplex results were abnormal in 14/72 (19%) of women screened, and an additional 3 women were diagnosed with FMD at a non-renal anatomic location based on imaging studies other than renal artery duplex. Women screened for renal artery stenosis for 44/8386 pregnancies (0.5%) associated with HDoP during the study period and had higher rates of preterm delivery (53% versus 20%; P Conclusions: Renal artery stenosis screening is uncommon among women with HDoP, but identified abnormal findings in a significant proportion of studies. Associations between screening and preterm delivery may reflect selection bias based on severity of HDoP symptoms and related risks. Renal artery stenosis screening may be under-utilized among women with HDoP, and expanded screening has potential to reduce both short- and long-term maternal risk and improve pregnancy outcomes.

Objectives: Patient-reported outcomes (PRO) are championed for assessment of peripheral artery disease (PAD) outcomes. Both general and PAD-specific instruments are available, but associations with clinical and demographic variables are unknown. We initiated a cohort study of PRO among patients with PAD and evaluated baseline correlations between PRO, clinical, and demographic variables. Methods: Patients were recruited from a diagnostic unit based on ankle brachial index (ABI). QOL was assessed using one PAD-specific (VascuQol6) and two general instruments (PROMIS Physical Function Short Form 6b & PROMIS Pain Interference Short Form 6a). Associations between PRO were evaluated with correlation coefficients. Associations with clinical and demographic variables were evaluated with simple and multivariable models. Results: 93 patients participated. All PRO were significantly correlated; greatest correlation was between VascuQol6 and PROMIS Pain Interference (-0.84; P Conclusions: QOL scores correlate with factors related and unrelated to PAD. Different measures may be helpful for capturing specific QOL domains and clinical factors. *Normalized T-scores

The surgical treatment of claudication can be associated with significant morbidity and costs. There are growing concerns that some patients proceed to interventions without first attempting evidence-based nonoperative management. We used a direct, cross-site, blinded expert review to evaluate the appropriateness of the surgical treatment of claudication.We enlisted practicing vascular surgeons to perform retrospective clinical assessments of lower extremity bypass procedures in a statewide clinical registry. Cases were limited to elective, open, infrainguinal bypasses performed for claudication using prosthetic grafts. Reviewing surgeons were randomly assigned 10 cases from a sample of 139 anonymized bypass operations and instructed to evaluate procedural appropriateness based on their expert opinion and evidence-based guidelines for preoperative treatment, namely, antiplatelet, statin, cilostazol, exercise, and smoking cessation therapy as documented in the medical record. Ninety-day episode payments were estimated from a distinct but similar cohort of patients undergoing lower extremity bypass for claudication.Of 325 total reviews, surgeons stated they would not have recommended bypass in 134 reviews (41%) and deemed bypass inappropriate in 122 reviews (38%). The most common reason for inappropriateness was lack of preoperative medical and lifestyle therapy, which was present in 63% of reviews where bypass was deemed appropriate and 39% of reviews where bypass was deemed inappropriate (P .001). Surgeons stated they would have recommended additional preoperative therapy in 65% of reviews where bypass was deemed inappropriate and 35% of reviews where bypass was deemed appropriate (P .001). The mean total episode payments in a similar cohort of 1458 patients undergoing elective open lower extremity bypass for claudication were $31,301 ± $21,219. Extrapolating to the 325 reviews, the 134 reviews in which surgeons would not have recommended bypass were associated with potentially avoidable estimated total payments of $4,194,334, and the 122 reviews in which bypass was deemed inappropriate were associated with potentially avoidable estimated total payments of $3,818,722.In this cross-site expert peer review study, 40% of lower extremity bypasses were deemed premature and, therefore, potentially avoidable, primarily owing to a lack of medical and lifestyle management before surgery. Reviews deemed inappropriate were associated with approximately $4 million in potentially avoidable costs. This approach could inform performance feedback among surgeons to help align clinical practice with evidence-based recommendations for the treatment of claudication.

Free digital platforms are smartphone-compatible and permit self-directed curriculum development based on learners' interests and educational needs. We developed a free mobile vascular surgery handbook initiated, authored, and edited by surgical house officers and surveyed on the content and users.Using a free digital platform, house officers developed a vascular surgery handbook. Initiated by a single user for conference preparation and clinical care, the use expanded through sharing among residents. The handbook was then deployed at a second medical center, with free access granted to users after completing a survey. Handbook and content use were evaluated based on user ratings ≥4 on a Likert scale from 1 to 5, where 1 = "strongly disagree" and 5 = "completely agree." Domains assessed included handbook ease of use, content, and relevance to a variety of learning environments and goals (e.g., preparation for the operating room, rounds, clinic, teaching conferences, and examinations). Analytic methods included qualitative analysis, graphical evaluation, and categorical tests.The handbook is organized into sections, with each consisting of multiple pages and/or posts related to the section topic. Sections with the most content included lower extremity arterial disease, endovascular aneurysm repair/thoracic endovascular aortic repair, venous disease, anticoagulation, and anatomy/exposures. Fifty-four users participated in the evaluation phase, including different types of surgical residents (35%), medical students (30%), and anesthesia residents (22%). Sixty-nine percent of participants were in their position for2 years. The average age was 29.1 years, and 57% were women. Preferred learning styles among users at the time of enrollment primarily included question banks (52%), followed by slide-based lectures (15%) and "chalk talk" lectures (13%). Of the users who participated in the presurvey, 43 users participated in the postsurvey with a general agreement on the handbook being an easy-to-use resource that was useful for gaining overall knowledge and contained accurate information. Users generally agreed they would recommend the handbook to a colleague.References customized to user needs can be developed through crowdsourcing and published with free digital resources. These approaches allow mobile access to useful information during conferences and clinical care. House officers' self-perceived educational needs can be targeted for tailored educational initiatives.

Background Frailty is associated with adverse surgical outcomes including post-operative complications, needs for post-acute care, and mortality. While multiple frailty screening tools exist, most are time and resource intensive. Here we examine the association of an automated electronic frailty index (eFI), derived from routine data in the Electronic Health Record (EHR), with outcomes in vascular surgery patients undergoing open, lower extremity revascularization. Methods A retrospective analysis at a single academic medical center from 2015 to 2019 was completed. Information extracted from the EHR included demographics, eFI, comorbidity, and procedure type. Frailty status was defined as fit (eFI≤0.10), pre-frail (0.100.21). Outcomes included length of stay (LOS), 30-day readmission, and non-home discharge. Results We included 295 patients (mean age 65.9 years; 31% female), with the majority classified as pre-frail (57%) or frail (32%). Frail patients exhibited a higher degree of comorbidity and were more likely to be classified as American Society of Anesthesiologist class IV (frail: 46%, pre-frail: 27%, and fit: 18%, P = 0.0012). There were no statistically significant differences in procedure type, LOS, or 30-day readmissions based on eFI. Frail patients were more likely to expire in the hospital or be discharged to an acute care facility (31%) compared to pre-frail (14%) and fit patients (15%, P = 0.002). Adjusting for comorbidity, risk of non-home discharge was higher comparing frail to pre-frail patients (OR 3.01, 95% CI 1.40-6.48). Discussion Frail patients, based on eFI, undergoing elective, open, lower extremity revascularization were twice as likely to not be discharged home.

Background The quality of perioperative patient education impacts surgical outcomes, patient experiences, and resources needed to address patient concerns and unplanned visits. We examined patient inquiries and education materials to assess the quality of perioperative education and identify areas of targeted improvement for postbariatric surgery body-contouring procedures. Methods We examined 100 consecutive postbariatric procedures at an academic center. Themes of patient-generated calls, e-mails, and electronic medical record portal messages during the perioperative period were identified via qualitative analysis. Understandability and actionability of perioperative educational resources were assessed using the Patient Education Materials Assessment Tool (PEMAT). Results Among 212 communications identified, 167 (79%) were postoperative. Common themes were concerns regarding the surgical site (38%), medications (10%), and activity restrictions (10%). One hundred thirty inquiries were resolved through patient re-education (57%), but 36 (16%) required in-person evaluation including 4 unplanned emergency department visits and 3 readmissions for surgical-site concerns. The PEMAT scores for institutional materials were fair for understandability (69%) and actionability (60%). American Society of Plastic Surgeons materials were more understandable (84%) but less actionable (40%). Conclusions Patient queries can be leveraged as a source of qualitative data to identify gaps in perioperative education. High-yield topics, such as education regarding the surgical site and medications, can be targeted for quality improvement through better communication and potentially reduce the number of unnecessary visits. Using the PEMAT, we also identified how directly the education materials can be revised. Improving perioperative education can promote mutual understanding between patients and surgeons, better outcomes, and efficient resource utilization.

Introduction: Objective screening for frailty is seldom performed because existing tools are time consuming and usually applied post-hoc. Implementation of efficient and feasible frailty screening approaches within clinic is needed. Purpose and hypothesis: We implemented grip strength measurement as a frailty screening tool in a cardiovascular clinic setting and compared this to existing frailty assessment tools, including the modified frailty index-5 (mFI-5) and -11 (mFI-11). We hypothesized that grip strength would be comparable to the mFI-5 and -11, associated with common adverse events including urinary incontinence (UI) and falls, and increased diagnosis of frailty would occur as a result implementation. Methods: Grip strength measurement was integrated into clinic intake to screen for weakness, a frailty component. Measurements were performed routinely for cardiovascular clinic visits and entered into the EMR data field. Categorical frailty was assessed based on 20 th percentile for grip strength (kg) adjusted for gender and BMI. A “dotphrase” statement was built to streamline clinical documentation, and quarterly newsletters were used to disseminate coding and other related information. Categorical tests were used to evaluate associations between grip, weakness, and other measures of frailty. Results: A total of 4,447 unique patients had grip strength measured. Mean age was 63.3±15.6, BMI 29.6±7.0, 47.6% (n=2,115) were female, and 86.5% were Caucasian/White. Based on grip strength, 34.6% (n=1,538) were weak, and 22.0% (n=980) and 16.9% (n=754) were frail based on mFI-5 and mFI-11, respectively. Less than 10% (n=408, 9.25%) had a history of falls and 39 (0.88%) had UI. Falls were associated with weakness (P Conclusions: Grip strength is both feasible and practical for frailty screening in clinical environments. Mismatch between screening-based and coding-based frailty prevalence suggests an opportunity to improve risk screening through routine grip strength assessment.

Introduction: Frailty is associated with increased risk of adverse health events among cardiovascular patients. Phenotype-based approaches to frailty assessment typically rely upon sex and body mass index as co-variables. Hypothesis: We hypothesized that race, ethnicity, disadvantaged community index (DCI), and health insurance coverage are associated with frailty. To test this hypothesis, we prospectively measured grip strength in a cohort of cardiovascular patients and evaluated the relationships of frailty with disparity measures. Methods: Patients treated in outpatient cardiovascular center clinics were evaluated for frailty using dominant hand grip strength. Grip strength, adjusted by gender and BMI, were used to determine frailty. Insurance status was categorized as Private, Medicaid, or Medicare based on primary coverage. Frailty was then evaluated stratified by DCI and health insurance status. Associations were evaluated using multivariable models. Results: Over 10 months, 3,986 patient grips were measured. Of these, 34.9% (n=1,392) were considered frail. Mean age was 63.5±15.6 years and 47.3% (n=1,885) were female. African American/black made up 7.73% (n=308) of the cohort and Asians/Pacific Islander 2.13% (n=85). A third of patients (32.7%) had private insurance, 2,187 (54.9%) had Medicare, and 291 (7.3%) had Medicaid. The average DCI score was 35.3±27.6. Patients with Medicare had the highest prevalence of frailty (47.4% versus 17.0% for Private Insurance and 26.5% for Medicaid; P Conclusions: When assessing insurance status related to frailty, frailty incidence was highest among patients with Medicaid insurance status. Further, age, race, insurance status, and distressed community index are associated with frailty defined by grip strength among cardiovascular patients. There may be a large segment of at-risk individuals who are missed because they do not fit the well characterized variables associated with frailty, including older age, female gender, both high and low BMI, and functional decline.

OBJECTIVE: To characterize the relationship between office-based laboratory utilization and Medicare payments for peripheral vascular interventions. METHODS: Using Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty (PTA), stent placement (stent), and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level. RESULTS: Between 2014 and 2017, 2,641 providers performed 308,247 procedures. Mean payment for OBL stent in 2017 was $4383.39, while mean payment for OBL atherectomy was $13079.63. Change in mean payment varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. Change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R(2)=0.40, p

Introduction: Some approaches to frailty screening use diagnostic or laboratory data that may be incomplete. Grip strength can identify weakness, a component of phenotype-based frailty assessment. We compared grip strength as a reductionist, phenotype-based approach to frailty screening with comorbidity and laboratory-based alternatives. Hypothesis: Grip strength and categorical weakness are correlated with the modified frailty index-5 (mFI-5) and lab values associated with frailty. Methods: Weakness based on grip, BMI, and gender was compared with mFI-5 comorbidities and lab values. Patients with at least 3/5 mFI-5 comorbidities were considered frail. Lab data collected within 6 months of grip measurement was assessed. Associations were evaluated using multivariable models and kappa. Methods: 2,597 patients had grip strength measured over 5 months. Mean age was 64.4±14.6, mean BMI was 29.5±6.9;46% were women, and 87% white. Prevalent comorbidities included hypertension (28%), CHF (22%), diabetes (29%), and COPD (26%); 9% were functionally dependent. 34% were weak, but only 13% were frail based on mFI-5. Hemoglobin, creatinine, and CRP differed significantly based on weakness ( Table ). Laboratory data were missing for 36%- 95% of patients. Multivariable models identified significant associations between weakness, hemoglobin, and all MFI-5 comorbidities. Categorical agreement between weakness and frailty was limited (kappa =0.09; 95% CL 0.0641-0.1232). Conclusion: Weakness based on grip strength provides a practical, inexpensive approach to risk assessment, especially when incomplete data excludes other approaches. Comorbidity-based assessment categorizes many weak patients as non-frail. Table. Demographic, laboratory values, and comorbidities by categorical weakness based on grip 20 th percentile. Mean values for continuous variables by weakness adjusted for gender and BMI, p-value for T-test; frequency and total percent for categorical variables, p-value represents chi-square test.

Objective Frailty is associated with adverse events, length of stay, and nonhome discharge after vascular surgery. Frailty measures based on walking-based tests may be impractical or invalid for patients with walking impairment from symptoms or sequelae of vascular disease. We hypothesized that grip strength is associated with frailty, comorbidity, and cardiac risk among patients with vascular disease. Methods Dominant hand grip strength was measured during ambulatory clinic visits among patients with vascular disease (abdominal aortic aneurysm [AAA], carotid stenosis, and peripheral artery disease [PAD]). Frailty prevalence was defined on the basis of the 20th percentile of community-dwelling population estimates adjusted for age, gender, and body mass index. Associations between grip strength, Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI), and sarcopenia (based on total psoas area for patients with cross-sectional abdominal imaging) were evaluated using linear and logistic regression. Results Grip strength was measured in 311 participants; all had sufficient data for CCI calculation, 217 (69.8%) had sufficient data for RCRI, and 88 (28.3%) had cross-sectional imaging permitting psoas measurement. Eighty-six participants (27.7%) were categorized as frail on the basis of grip strength. Frailty was associated with CCI (odds ratio, 1.86; 95% confidence interval, 1.34-2.57; P = .0002) in the multivariable model. Frail participants also had a higher average number of RCRI components vs nonfrail patients (mean ± standard deviation, 1.8 ± 0.8 for frail vs 1.5 ± 0.7 for nonfrail; P = .018); frailty was also associated with RCRI in the adjusted multivariable model (odds ratio, 1.75; 95% confidence interval, 1.16-2.64; P = .008). Total psoas area was lower among patients categorized as frail vs nonfrail on the basis of grip strength (21.0 ± 6.6 vs 25.4 ± 7.4; P = .010). Each 10 cm2 increase in psoas area was associated with a 5.7 kg increase in grip strength in a multivariable model adjusting for age and gender (P Conclusions Grip strength is useful for identifying frailty among patients with vascular disease. Frail status based on grip strength is associated with comorbidity, cardiac risk, and sarcopenia in this population. These findings suggest that grip strength may have utility as a simple and inexpensive risk screening tool that is easily implemented in ambulatory clinics, avoids the need for imaging, and overcomes possible limitations of walking-based measures. Lower mean psoas diameters among patients with PAD vs other diagnoses may warrant consideration of specific approaches to morphomic analysis.

Developed in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation, Inter-Society Consensus for the Management of Peripheral Arterial Disease, Society for Cardiovascular Angiography and Interventions, Society for Clinical Vascular Surgery, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Nursing, Society for Vascular Surgery, and Vascular and Endovascular Surgery Society

Jonathan L. Halperin, MD, FACC, FAHA, Chair Glenn N. Levine, MD, FACC, FAHA, Chair-Elect Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD, MPH, MACC Joaquin E. Cigarroa, MD, FACC Lesley H. Curtis, PhD, FAHA

Background Endovascular intervention is considered the first-line treatment for chronic mesenteric ischemia (CMI) when feasible. Two-vessel revascularization is most definitive when celiac (CA) and superior mesenteric arteries (SMA) are diseased, but single-vessel intervention may be performed in patients with 2-vessel disease due to anatomic/technical factors. We evaluated anatomic predictors of clinical outcomes associated with endovascular treatment of CMI among patients with occlusive SMA lesions. Methods Patients with CMI treated with endovascular revascularization over 10 years were identified. Patients with SMA occlusions were selected for analysis. Between-group comparisons based on inclusion of an SMA revascularization were evaluated using t -test and chi-squared test. Freedom from symptomatic recurrence or repeat intervention was analyzed using proportional hazards regression. Results Fifty-four patients with CMI were analyzed. Sixteen (29.6%) patients had CA-only intervention, and 38 (70.4%) patients had SMA revascularization with or without CA intervention. No significant differences in demographics or comorbidity were identified between groups. In the CA-only intervention group, 8 of the 16 (50%) patients developed symptomatic recurrence compared with 8 of the 31 (21.1%) patients whose intervention included the SMA. Patients treated without SMA intervention also had decreased freedom from both symptomatic recurrence (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.2–8.6, P = 0.016) and repeat intervention (HR 5.5, 95% CI 1.8–16.3, P = 0.001). Conclusions Among patients with CMI and occlusive SMA lesions, SMA revascularization appears to be the key determinant for symptomatic outcomes and repeat intervention. Patient counseling should include potential future need for surgical revascularization if endovascular SMA treatment cannot be accomplished.

Objective Industry compensation to authors may influence the interpretation of study results. Scientific journals often require author disclosure of a relevant financial conflict of interest (FCOI) but seldom quantify compensation and leave reporting up to the author's discretion. Professional and public concerns related to potential bias introduced into medical research by FCOI have arisen, especially when physician compensation from manufacturers is not disclosed. Little is known, however, about the prevalence of industry compensation to authors of related publications, payment amounts, or how this information compares with self-reported FCOI. The objective of this study was to compare industry compensation and disclosed FCOI among highly referenced publications related to treatment of peripheral artery disease, a disease that affects approximately 8.5 million Americans and is often treated with medications and devices. Methods “Peripheral artery disease” was used as a Web of Science search term to identify publications from 2013 to 2016, excluding review articles, conference proceedings, book chapters, abstract publications, and non-English language publications. The top 99 most cited publications were abstracted for self-reported FCOI by author. Industry compensation to authors was queried using a ProPublica Dollars for Docs custom data set based on Centers for Medicare and Medicaid Services Open Payments data. Providers practicing in the United States in any of the following specialties were included: cardiology, cardiothoracic surgery, vascular and interventional radiology, or vascular surgery. Payment transactions were matched to physician authors on the basis of provider name, specialty, and geographic location. Statistical analysis included descriptive statistics and categorical tests. Descriptive statistics are reported as frequency (percentage) or median (interquartile range). Results Among 1008 vascular specialist authors identified, 218 (22%) self-reported FCOI. Fifty-six physician authors had compensation reported to the Centers for Medicare and Medicaid Services by industry during the study period. Among those identified as recipients of industry compensation, 28 (50%) self-reported FCOI. Industry payments to the 56 authors totaled $11,139,987, with a median total payment of $18,827 (interquartile range, $152,084) per author. Food and beverage was the most frequently identified nature of payment (n = 8981 [74%]), promotional speaking involved the largest total amount of payments ($3,256,431), and royalty or license was the highest median payment ($51,431 [$72,215]). Physicians reporting FCOI received a total of $9,435,340 during the study period vs $1,706,647 for those who did not report any FCOI. Median total payments were higher among authors reporting FCOI vs not ($81,224 [$324,171] vs $9494 [$43,448]; P Conclusions Nondisclosed author compensation from industry is relatively uncommon among highly cited peripheral artery disease research studies but may be associated with substantial payments. These results suggest that self-reported FCOI does not provide a comprehensive overview of industry compensation. Reporting all payments rather than only those deemed relevant by the author might provide a more complete and transparent report of potential FCOI, allowing independent assessment of relevance in interpreting study findings.

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

Background The availability of electronic health (eHealth) information and disease-related community forums has grown over the last decade. Although patients and families frequently use these resources, their content has not been characterized in terms users, content, or reliability of information. eHealth communities therefore represent a potentially valuable but uncharted source of information about key patient issues, communication terminology, and unmet needs. We hypothesized that eHealth forums would contain terminology, themes, and advice inconsistent with resources from medical providers and references. To test this hypothesis, we performed a qualitative analysis of posts and responses from an open-access peripheral artery disease (PAD) eHealth community forum to characterize the discussion, participants, and the information being exchanged. Methods Posts were collected from an online PAD Medical Support Community forum (MedHelp), which is open access, does not require participants to identify themselves, and is based in the United States. Posts were selected from threads in which the main topic was PAD, including diagnosis, symptoms, and treatment. Original posts and related responses were analyzed for thematic content, common vernacular, and self-reported characteristics of the participants using a qualitative analysis software program. Disease-specific comments and advice were evaluated for congruence with contemporary PAD treatment guidelines. Results A total of 103 posts were collected and analyzed, including 40 original posts and 63 responses. Forty-five percent of the original posts and 19% of the responses were authored by participants who self-identified as patients with PAD. The remaining posts were authored by people with undeclared relationships to patients with PAD, followed by children, spouses, and other relatives. The most common themes among original posts included PAD diagnosis (and differential) (25%), treatment (23%), epidemiology and pathophysiology (21%), disease symptoms and impacts on activities of daily living (15%), and health-care provider recommendations (13%). Themes of responses included medical advice (40.5%), personal experiences with PAD (32.8%), and social support (12.6%). Negative attitudes were identified in 10 of 18 (55.6%) posts related to experiences with health-care providers. Of all medical advice, 15.1% was inconsistent with clinical treatment guidelines. Conclusion eHealth communities are a rich source of information related to the experiences of patients with PAD, their treatment preferences, questions they consider important, and terminology that they use. This information can be used to understand unmet patient needs, develop educational resources, and improve communication.

Objectives Frailty is associated with adverse outcomes among patients with vascular disease. Grip strength measurement is a comparatively simple, quick, and inexpensive screening test for weakness (a component of frailty) that is potentially applicable to clinical practice. We hypothesized that grip strength and categorical weakness are associated with clinical outcomes among patients with vascular disease. To test this hypothesis, we conducted a longitudinal cohort study evaluating associations between grip strength measured during outpatient clinic visits for vascular disease and clinical outcomes, including survival and perioperative outcomes. Methods Adult patients recruited from outpatient vascular surgery and/or vascular medicine clinics underwent dominant hand grip strength measurement using a hand dynamometer. Participants were categorized as weak based on grip strength, sex, and body mass index. Multivariable logistic models were used to evaluate perioperative outcomes. Mortality was evaluated using Cox proportional hazards models adjusted for sex, age, and operative intervention during follow-up. Results We enrolled 321 participants. The mean patients age was 69.0 ± 9.4 years, and 33% were women. Mean grip strength was 32.0 ± 12.1 kg, and 92 participants (29%) were categorized as weak. The median follow-up was 24.0 months. Adverse perioperative events occurred in 32 of 84 patients undergoing procedures. Grip strength was associated with decreased risk of perioperative adverse events (hazard ratio [HR], 0.41 per 12.7 kg increase; 95% confidence interval [CI], 0.20-0.85; P = .0171) in a model adjusted for open versus endovascular procedure (HR, 12.75 for open; 95% CI, 2.54-63.90; P = .0020) and sex (HR, 3.05 for male; 95% CI, 0.75-12.4; P = .120). Grip strength was also associated with a lower risk of nonhome discharge (HR, 0.34 per 12.7 kg increase; 95% CI, 0.14-0.82; P = .016) adjusted for sex (HR, 2.14 for male; 95% CI, 0.48-9.50; P = .31) and open versus endovascular procedure (HR, 10.36 for open; 95% CI, 1.20-89.47; P = .034). No associations between grip strength and length of stay were observed. Mortality occurred in 48 participants (14.9%) during follow-up. Grip strength was inversely associated with mortality (HR, 0.46 per 12.5 kg increase; 95% CI, 0.29-0.73; P = .0009) in a model adjusted for sex (HR, 5.08 for male; 95% CI, 2.1-12.3; P = .0003), age (HR, 1.04 per year; 95% CI, 1.01-1.08), and operative intervention during follow-up (HR, 1.23; 95% CI, 0.71-2.52). Categorical weakness was also associated with mortality (HR, 1.81 vs nonfrail; P = .048) in a model adjusted for age (HR, 1.06 per year; P = .002) and surgical intervention (HR, 1.36; 95% CI, 1.02-0.09; P = .331). Conclusions Grip strength is associated with all-cause mortality, perioperative adverse events, and nonhome discharge among patients with vascular disease. These observations support the usefulness of grip strength as a simple and inexpensive risk screening tool for patients with vascular disease.

Background: Sleep disturbance is an important determinant of both mental and physical health-related quality of life (QOL). Associations between sleep disturbance and subclinical cardiovascular disease have been described but little is known about it among patients with symptomatic PAD. We studied sleep disturbance in symptomatic PAD patients using a wearable device for 30 days. Methods: Patients with claudication confirmed by ABI Results: Twenty participants enrolled and completed the study; 35% were female; 30% were African American. Mean age was 69±9 years; mean ABI was 0.69±0.14. Over a mean study period of 34±6 days, sleep data were recorded an average of 28±6 days and walking activity on 12±10 days. Mean nights of interrupted sleep was 1.3±1.8; 8 participants (40%) had sleep interruption at least one night. No associations were observed between daily walking activity or VascuQol-6 scores and sleep disturbance. Increases in sleep disturbance were associated with higher (i.e., more severe) WIQ distance (P=0.02) and stair (P=0.03) scores at baseline, and WIQ distance (P=0.03), speed (P=0.002) and overall (P=0.009) scores at study completion. Conclusions: These observations suggest that sleep disturbance impacts walking, disability and QOL among people with symptomatic PAD. Further investigation is warranted to characterize sleep disturbance among patients with both claudication and critical limb ischemia, evaluate associations with disease severity, and explore utility as a treatment outcome.

Management of renal artery stenosis requires understanding of complex pathophysiology, familiarity with both epidemiology and anatomic characteristics for accurate diagnosis, and appreciation of both evidence and evidence gaps. Approaches, diagnosis, and treatment of renal artery stenosis have changed rapidly over the past few decades. Although renal artery stenosis is a widely accepted cause of secondary hypertension (and complications resulting from consequent target organ damage), the role of renal artery revascularization for patients with symptomatic renal artery stenosis remains controversial. Enthusiasm for renal artery revascularization has been dampened by lack of observed benefit in randomized trials, but the results are not generalizable to all patients or clinical presentations. This article will review the pathophysiology, epidemiology, clinical presentation, diagnostic evaluation, and clinical management of renal artery stenosis in adults, focusing on atherosclerosis and fibromuscular dysplasia (the most common etiologies in adults). Review of clinical trials will focus on the most recent studies, including their outcomes, inclusion and exclusion criteria, and limitations.