Management of Arterio-Venous Fistula Side Branches During Maturation: Ligation or Coil Embolization.

OBJECTIVE: Failure of maturation of arteriovenous fistulae (AVF) remains an ongoing concern for dialysis access. One etiology is the presence of side branches that divert flow from the main AVF channel. This study aims to evaluate the outcomes of endovascular and open surgical interventions for AVF side branches in the setting of maturation failure. METHODS: A retrospective review of all patients within a 10-year period with primary radio cephalic and brachiocephalic AVF was undertaken, and 380 cases of maturation failure related to branch diversion were selected for the study. Fifty-four percent and 48% of the AVF in the ENDO and OPEN groups respectively have concomitant stenosis further along in the flow path that required intervention by balloon angioplasty at the same time as a side branch intervention. All patients underwent duplex imaging or a fistulogram before intervention. Indications were low flow (<600 mL/min) or failure to increase in size (<6 mm diameter) in all cases. Interventions were divided into endovascular (coil embolization; ENDO) and surgical (branch ligation; OPEN) interventions. Outcomes of maturation (successful progression to hemodialysis (HD)), re-intervention, and functional dialysis (continuous HD for three consecutive months) were examined. RESULTS: From January 2008 to December 2018, 187 patients (49^ of all cases with side branches; 65% female, age of 57 ± 18 years; mean ± SD) with poorly maturing radiocephalic (70%) and brachiocephalic AVF (30%) underwent intervention due to the presence of accessory venous branches only. Indications were failure to mature in 54% and low flow in 46%. The average time to intervention due to failure to mature was 5 ± 4 weeks (mean ± SD) after primary access placement. Eighty-one had coil embolization and 106 had open branch ligation. Technical success was 90% in ENDO and 100% in OPEN. Technical ENDO failures had a secondary open branch ligation but were considered failures for analysis. Repeat interventions by balloon-assisted maturation were required in 45% of all the cases with no difference between ENDO and OPEN. Recannulation of the ENDO branches occurred in 10% of the cases requiring repeat intervention. Sixty one percent of isolated endovascular (n = 49) and 64% of isolated open (n = 68) matured to successful cannulation (P = 0.84). Median functional dialysis durations remained equivalent between ENDO (2.6 years) and OPEN (2.8 years) groups (P = 0.12). CONCLUSION: There is an improved maturation rate following the ENDO group compared to OPEN interventions while both ENDO and OPEN modalities demonstrated similar long-term functionality.

Predictive Accuracy of the American College of Surgeons Risk Calculator in Patients Undergoing Major Lower Extremity Amputation.

BACKGROUND: The American College of Surgeons Risk Calculator (ACS-RC) provides an assessment of a patient's risk of 30-day postoperative complications. The Surgeon Adjusted Risk (SAR) parameter of the calculator allows for ad hoc adjustment of risk based on risk factors not considered by the model. This study aims to evaluate the predictive accuracy of the ACS-RC in vascular surgery patients undergoing major lower-extremity amputation (LEA) and identify additional risk factors that warrant use of the SAR parameter. METHODS: This is a retrospective study of 298 sequential amputations at a single institution. At the population level, the mean of predicted 30-day outcomes from the ACS-RC with a SAR score of 1 (no adjustment necessary) and 2 (risk somewhat higher than estimate) were compared to the rate of observed outcomes. Predictive accuracy at the individual level was completed using receiver operating curve area under the curve (AUC). Logistic regression with respect to mortality was performed over variables not considered by the ACS-RC. Efficacy of selectively utilizing the SAR parameter in predicting mortality was analyzed with a stratified analysis in which patients with risk factors significant for mortality were assigned increased risk. RESULTS: At the population level, ACS-RC grossly underpredicted serious complications, SSI, VTE, and unplanned RTOR, while overpredicting mortality and cardiac complications. At the individual level, SAR1 was more predictive for serious complications (AUC = 0.624), SSI (AUC = 0.610), and unplanned RTOR (AUC = 0.541). Conversely, SAR2 was more predictive for mortality (AUC = 0.709), cardiac complications (AUC = 0.561), and VTE (AUC = 0.539). Logistic regression identified history of CVA with a residual deficit (OR = 4.61, P = 0.033) and ischemic rest pain without tissue loss (OR = 4.497, P = 0.047) as independent risk factors for postoperative mortality. Stratified analysis with utilization of the SAR2 based on the 2 independent risk factors improved AUC in predicting mortality (AUC 0.792 from 0.709). CONCLUSIONS: Major LEAs are associated with high perioperative morbidity and mortality. In a veteran population, the ACS-RC showed mixed predictability at the population level and fair predictability at the individual level with regards to postoperative outcomes. Rest pain without tissue loss and history of CVA with residual deficit were identified as risk factors for postoperative mortality. Although ad hoc adjustment with the subjective SAR modifier based on the presence of these 2 risk factors increased the calculator's accuracy, this study highlights some potential limitations of the ACS-RC when applied to vascular surgery patients undergoing major LEA.

Analysis of Early Lower Extremity Re-amputation.

BACKGROUND: Data is scarce regarding the need for early re-amputation to a higher anatomic level. This study seeks to define outcomes and risk factors for re-amputation. METHODS: Patients undergoing primary major lower extremity amputation were identified within the 2012-2016 ACS-NSQIP database. Demographics, outcomes, and peri-operative characteristics were compared, and multivariable logistic regression model was used to determine association with early re-amputation. RESULTS: Over a 4-year period, 8306 below knee amputations and 6367 above knee amputations were identified. Thirty-day re-amputation occurred in 262 patients (1.8%) and was associated with increased length of stay (12.9 vs. 7.3 days, P < 0.001), higher rates of readmission (64.9% vs. 13.6%, P < 0.001), and overall complications (69.5% vs. 39.3%, P < 0.01). On multivariable analysis, advanced age (OR 1.02, CI 1.01-1.03), smoking (OR 1.75, CI 1.32-2.33), dialysis dependence (OR 1.67, CI 1.23-2.26), preoperative septic shock (OR 2.53, CI 1.29-4.97), and bleeding disorders (OR 1.72, CI 1.34-2.22) were associated with early re-amputation. CONCLUSIONS: Thirty-day re-amputation rates are low, but are associated with significant morbidity, prolonged hospitalization, and frequent readmissions.

Present-day analysis of early failure after forefoot amputation.

BACKGROUND: Forefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation. METHODS: We queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation. RESULTS: In the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2-3.6) were independent predictors of more proximal amputation. CONCLUSION: Early below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.

Thirty-day outcomes after fenestrated endovascular repair are superior to open repair of abdominal aortic aneurysms involving visceral vessels.

OBJECTIVE: Although few studies have reported outcomes after branched or fenestrated endovascular aortic aneurysm repair (FEVAR) of abdominal aortic aneurysms involving visceral vessels (AAA-Vs), no multi-institutional study has compared FEVAR with open surgery (OS) for AAA-Vs. Our objective was to compare 30-day outcomes after FEVAR vs OS for AAA-Vs. METHODS: Patients who underwent FEVAR (n = 535) and OS (n = 1207) for elective AAA-Vs were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) 2008 to 2013 database. Thoracoabdominal aneurysms were excluded. Univariable and multivariable logistic regression analyses were performed. RESULTS: There were more men (82% vs 72%; P < .0001), diabetic patients (16% vs 11%; P = .005), patients with dependent functional status (4% vs 2%; P = .002), and nonsmokers (70% vs 56%; P < .0001) in the FEVAR group vs OS. There was no difference in rates of chronic obstructive pulmonary disease, cardiac history, peripheral artery disease, hypertension, and dialysis (P > .05). FEVAR had fewer major postoperative pulmonary complications (3.0% vs 19.0%; P < .0001), less renal failure requiring dialysis (1.9% vs 6.4%; P < .0001), less frequent cardiac arrest or myocardial infarction (2.2% vs 5.8%; P = .001), less bleeding with major transfusion (17.4% vs 50.2%; P < .0001), and decreased incidence of return to the operating room (4.5% vs 9.6%; P < .0001) and death (2.4% vs 4.7%; P = .02). The median length of stay was also significantly shorter for FEVAR (2 days vs 7 days; P < .0001). On multivariable analyses, OS was associated with higher risk than FEVAR for 30-day death (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.3-5.0), pulmonary complications (OR, 8.8; 95% CI, 5.1-15.0), cardiac complications (OR, 3.4; 95% CI, 1.8-6.6), renal failure needing dialysis (OR, 3.8; 95% CI, 1.9-7.7), and return to the operating room (OR 2.5; 95% CI, 1.6-4.0). CONCLUSIONS: FEVAR is associated with a lower risk for 30-day mortality and adverse events compared with OS for AAA-Vs.

Outcomes After Use of Aortouniiliac Endoprosthesis Versus Modular or Unibody Bifurcated Endoprostheses for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

OBJECTIVES: Outcomes after endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAAs) have been widely published. There is, however, controversy on the role of the use of aortouniiliac endoprosthesis (AUI) versus modular or unibody bifurcated endoprosthesis (MUB) for repair of rAAAs. We study and compare 30-day outcomes after use of AUI and MUB for all rAAAs focusing specifically on patients with instability. MATERIALS AND METHODS: Patients who underwent EVAR for rAAA (n = 425) using AUI (n = 55; 12.9%) and MUB (n = 370; 87.1%) were identified from the American College of Surgeons' National Surgical Quality Improvement Program (2005-2010) database. Univariable and multivariable logistic regression analyses were performed. RESULTS: No significant difference ( P > .5) was seen in comorbidities between patients who underwent EVAR with AUI or MUB; there was also no change in endoprosthesis use from 2005 to 2010 ( P = .7). Patients who underwent EVAR with AUI more commonly had a history of peripheral arterial procedure (10.9% vs 4.6%; P = .053) and preoperative transfusion of >4 U packed red blood cells (18.2% vs 6.8%; P = .004). Use of AUI versus MUB was associated with more 30-day wound complications (16.4% vs 6.2%; P = .01), return to operating room (38.2% vs 20.0%; P = .003), and mortality (34.5% vs 21.4%; P = .03). On multivariable analysis, use of AUI was associated with an increased risk of 30-day mortality (odds ratio: 2.4; 95% confidence interval: 1.1-5.3). On subanalysis of the cohort for only the patients with unstable rAAA (n = 159; AUI = 29 and MUB = 130), 30-day mortality for AUI versus MUB was still higher but not statistically significant (44.8% vs 32.3%; P = .2). CONCLUSION: Endovascular repair for ruptured AAA using aortouniliac endoprosthesis is associated with higher 30-day mortality than using modular or unibody bifurcated endoprosthesis.

Preoperative Frailty Increases Risk of Nonhome Discharge after Elective Vascular Surgery in Home-Dwelling Patients.

BACKGROUND: Patient-centered quality outcomes such as disposition after surgery are increasingly being scrutinized. Preoperative factors predictive of nonhome discharge (DC) may identify at-risk patients for targeted interventions. This study examines the association among preoperative risk factors, frailty, and nonhome DC after elective vascular surgery procedures in patients living at home. METHODS: The 2011-2012 National Surgical Quality Improvement Project database was queried to identify all home-dwelling patients who underwent elective vascular procedures (endovascular and open aortic aneurysm repair, suprainguinal and infrainguinal bypasses, peripheral endovascular interventions, carotid endarterectomy, and stent). Preoperative frailty was measured using the modified frailty index (mFI; derived from Canadian Study of Health and Aging). Univariate and multivariate logistic regression analysis was performed to examine the association of frailty and nonhome DC. RESULTS: Of 15,843 home-dwelling patients, 1,177 patients (7.4%) did not return home postoperatively. Frailty (mFI > 0.25) conferred a significantly increased 2-fold risk of nonhome DC disposition for each procedure type. Frailty, female gender, open procedures, increasing age, end-stage renal disease, and occurrence of any postoperative complication were associated with increased risk of nonhome DC. On multivariate logistic regression analysis, frailty increased the odds of nonhome DC by 60% (odds ratio 1.6, 95% confidence interval 1.4-1.8) after adjusting for other covariates. In the presence of complications, the risk of nonhome DC was 27.5% in frail versus 16.5% in nonfrail patients (P < 0.001). In the absence of complications, although absolute risk was lower, frail patients were nearly twice as likely to not return home (frail 5.5% vs. nonfrail 2.75%, P < 0.001). CONCLUSIONS: Frail home-dwelling patients undergoing elective vascular procedures are at high risk of not returning home after surgery. Preoperative frailty assessment appears to hold potential for counseling regarding postsurgery disposition and DC planning.

Gender and frailty predict poor outcomes in infrainguinal vascular surgery.

BACKGROUND: Women have poorer outcomes after vascular surgery as compared to men as shown by studies recently. Frailty is also an independent risk factor for postoperative morbidity and mortality. This study examines the interplay of gender and frailty on outcomes after infrainguinal vascular procedures. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent infrainguinal vascular procedures from 2005-2012. Frailty was measured using a modified frailty index (mFI; derived from the Canadian Study of Health and Aging). Univariate and multivariate analysis were performed to investigate the association of preoperative frailty and gender, on postoperative outcomes. RESULTS: Of 24,645 patients (92% open, 8% endovascular), there were 533 deaths (2.2%) and 6198 (25.1%) major complications within 30 d postoperatively. Women were more frail (mean mFI = 0.269) than men (mean mFI = 0.259; P < 0.001). Women and frail patients (mFI>0.25) were more likely to have a major morbidity (P < 0.001) or mortality (P < 0.001) with the highest risk in frail women. On multivariate logistic regression analysis, female gender and increasing mFI were independently significantly associated with mortality (P < 0.05) as well as major complications. The interaction of gender and frailty in multivariate analysis showed the highest adjusted 30-d mortality and morbidity in frail females at 2.8% and 30.1%, respectively and that was significantly higher (P < 0.001) than nonfrail males, nonfrail females and frail males. CONCLUSIONS: Female gender and frailty are both associated with increased risk of complications and death following infrainguinal vascular procedures with the highest risk in frail females. Further studies are needed to explore the mechanisms of interaction of gender and frailty and its effect on long-term outcomes for peripheral vascular disease.

Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm repair.

BACKGROUND: Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm (AAA) repair. Emergency AAA repair carries a high risk of morbidity and mortality. This study seeks to examine morbidity and mortality trends from the National Surgical Quality Improvement Program (NSQIP) database, and identify potential risk factors. METHODS: All emergency AAA repairs were identified using the NSQIP database from 2005 to 2011. Univariate analysis (using the Student t, χ(2), and Fisher's exact tests) and multivariate logistic regression was performed to examine trends in mortality and morbidity. RESULTS: Out of 2761 patients who underwent emergency AAA repair, 321 (11.6%) died within 24 hours of surgery. Of the remaining 2440 patients, 1133 (46.4%) experienced major complications and 459 (18.8%) died during the postoperative period. From 2005 to 2011, there was a significant decrease in patient mortality, particularly in patients who survived the perioperative period (P = .002). Total complications increased overall (P < .0001); however, major complications decreased from 58.7% in 2005 to 42.6% in 2011 (P < .0001) among patients who survived beyond 24 hours. The use of endovascular aortic repair (EVAR) increased over the study period (P < .0001). On multivariate analysis of patients who survived past the initial 24-hour period, advancing age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.7-4.1), dependent functional status (OR, 2.0; 95% CI, 1.2-3.2), and presence of a major complication (OR, 3.1; 95% CI, 2.0-5.0) were significantly associated with death, whereas presence of a senior resident (OR, 0.4; 95% CI, 0.3-0.6) or fellow (OR 0.3; 95% CI, 0.2-0.6) was inversely associated with death. EVAR was not associated with death, but was associated with 30-day complications (OR, 0.5; 95% CI, 0.3-0.6). CONCLUSIONS: Patient survival has increased from 2005 to 2011 after emergency AAA repair, with a significant improvement particularly in patients who survive past the first 24 hours. EVAR was not associated with mortality, but was protective of 30-day complications. Although the total number of complications increased, the number of major complications decreased over the study period, suggesting that newer techniques and patient care protocols may be improving outcomes.

Identifying risk factors for surgical site complications after laparoscopic ventral hernia repair: evaluation of the Ventral Hernia Working Group grading system.

BACKGROUND: In 2010, the Ventral Hernia Working Group (VHWG) published a grading system to assess the risk of surgical site complications in patients undergoing ventral hernia repair. This study evaluated the predictive value of the VHWG classification for the surgical outcomes of laparoscopic ventral hernia repair (LVHR) and identified independent factors associated with surgical site infection (SSI) and surgical site occurrence (SSO). METHODS: A retrospective review was performed of all patients who underwent LVHR over a 10-year period at two institutions. The U.S. Centers for Disease Control and Prevention definition of SSI and the VHWG definition of SSO were used. Univariable analysis was performed using the Student t-test, analysis of variance, chi-square test, or Fisher exact test, as appropriate. Multivariable analysis was used to identify independent factors associated with SSI and SSO. RESULTS: Differences in American Society of Anesthesiologists class, body mass index, diabetes mellitus, chronic obstructive pulmonary disease, tobacco use, hernia type, prior abdominal surgery, prior ventral hernia repair, hernia size, and total infections were identified by grade. There was no difference in SSI or SSO by grade. Multivariable analysis revealed institution and number of prior abdominal operations to be associated with SSI. Institution, prostate disease, and prior ventral hernia repair were associated with SSO. CONCLUSIONS: The VHWG classification was unable to predict SSI and SSO and may not be applicable in LVHR. This study identified independent factors associated with SSI and SSO in LVHR. Although further study is warranted to validate these results, the factors presented may be a useful tool to stratify patient risk of SSI and SSO with LVHR.

Prevalence of surgical site infection at the stoma site following four skin closure techniques: a retrospective cohort study.

BACKGROUND/AIMS: Surgical site infection (SSI) is a common complication of stoma reversal. Studies have suggested that different skin closures affect SSI rates. Our aim was to determine which skin closure technique following stoma reversal leads to the lowest rate of SSI. METHODS: We conducted a retrospective review of all adult patients undergoing stoma reversal at a single institution (2005-2011) and compared the rate of SSI following four skin closure techniques: primary closure (PC), secondary closure (SC), loose PC (LPC), and circular closure (CC). Univariate analysis included χ(2) or Fisher's exact test and ANOVA or Kruskal-Wallis H test for categorical and continuous data, respectively. A multivariate logistic regression model was created to identify predictors of SSI. RESULTS: One hundred and forty-six patients were identified: 40 (27%) PC, 68 (47%) SC, 20 (14%) LPC, and 18 (12%) CC. CC was less likely to have SSI (6%) compared to PC (43%), SC (16%), and LPC (15%; p < 0.01). Increasing body mass index was a predictor of SSI (odds ratio 1.11, 95% confidence interval 1.04-1.12, p < 0.01). CC was associated with the lowest odds of developing SSI [0.07 (0.01-0.63), p = 0.02]. CONCLUSIONS: SSI rate was the lowest for stomas that were closed with CC.

Recurrence and pseudorecurrence after laparoscopic ventral hernia repair: predictors and patient-focused outcomes.

Laparoscopic ventral hernia repair (LVHR) is gaining popularity as an option to repair abdominal wall hernias. Bulging after repair remains common after this technique. This study evaluates the incidence and factors associated with bulging after LVHR. Between 2000 and 2010, 201 patients underwent LVHR at two affiliated institutions. Patients who developed recurrence or pseudorecurrence (seroma or eventration) were analyzed with univariate and multivariate analyses to identify predictors of these complications. Of the 201 patients who underwent LVHR, 40 (19.9%) patients developed a seroma, 63 (31.3%) patients had radiographically proven eventration, and 25 (12.4%) patients had a hernia recurrence. On multivariate analysis, seromas were associated with number of prior ventral hernia repairs, surgical site infections, and prostate disease. Mesh eventration was associated with hernia size and surgical technique. Tissue eventration was associated with primary hernias and surgical technique. Hernia recurrence was associated with incisional hernias and mesh type used. Recurrence and pseudorecurrence are important complications after LVHR. Large hernia size, infections, and surgical technique are important clinical factors that affect outcomes after LVHR.