Bypass and embolization for a vertebral artery aneurysm in a patient with Marfan syndrome.

Extracranial vertebral artery aneurysms represent an uncommon presentation of collagen vascular disease. We performed staged proximal embolization of large left vertebral artery aneurysm after distal common carotid-to-vertebral bypass at C2 in a young adult patient with Marfan syndrome and a hypoplastic contralateral vertebral artery. Dilation of the autogenous saphenous vein graft occurred at 1 year with proximal graft stenosis requiring operative revision. Subsequent dilation of the basilar artery led to symptoms of pontine compression at 18 months that have resolved at 31 months of follow-up.

Conflict of interest and the Society for Vascular Surgery.

Specialty medical societies such as Society for Vascular Surgery (SVS) are instrumental in the development and dissemination of medical knowledge through scientific presentations, publication of rigorously peer-reviewed writings, awarding competitive research and training grants, and the provision of high-quality continuing medical education (CME). It is vital that in these roles the SVS remain in fact and in perception completely free of all influence and bias from industry. While independence from bias has always been necessary, the increasing focus by governmental agencies, industry organizations, and society has made it important for the SVS to address this issue in a formal way. In June 2010, the SVS Board of Directors approved a set of guidelines specifically designed to address management of conflict of interest among its members and its leaders. These guidelines, included in this article, were based on currently available information and policies put forth by legislative bodies, academic medical centers, industry groups, and other professional medical societies, and were designed to safeguard against abuse while maintaining valuable collaboration between vascular surgeons and their industry partners. The guidelines are included in this article.

Combined carotid endarterectomy and coronary artery bypass grafting versus coronary artery bypass grafting alone: a retrospective review of outcomes at our institution.

BACKGROUND: It remains controversial whether patients with concomitant carotid and coronary disease should undergo operative repair separately or in combination. METHODS: Patients with documented cerebrovascular disease undergoing coronary artery bypass grafting (CABG) alone were matched by propensity scoring with patients undergoing combined carotid endarterectomy (CEA)/CABG procedures and compared for the occurrence of stroke, myocardial infarction (MI), and mortality. RESULTS: Of the 4943 patients undergoing CABG, 908 had known cerebrovascular disease. Among these, 134 underwent concomitant CEA, and these were propensity matched with 134 patients undergoing CABG only. No differences were observed in the perioperative risks of stroke (4% vs 3%, odds ratio [OR] 1.5, 95% confidence interval [CI] 0.4-5.5), MI (0.7% vs 0.7%, not significant [NS]), or combined cardiovascular events (6% vs 10%, OR 0.5, 95% CI [0.2-1.3]), although mortality (1% vs 8%, OR 0.2, 95% CI [0.04-0.8] was higher with CABG only. DISCUSSION: Addition of CEA to CABG did not significantly alter the risk of perioperative stroke relative to propensity-matched patients undergoing CABG alone.

Increasing the proportion of autologous arteriovenous fistulas does not diminish fistula patency.

OBJECTIVE: Arteriovenous fistulas (AVF) constructed before and after initiating the kidney disease outcomes and quality initiative (KDOQI) guidelines were reviewed at a single academic center to identify decreased patency with use of potentially inferior vein conduits. METHODS: Primary access procedures performed pre- and post-adoption of KDOQI guidelines were compared for the primary outcomes of maturation rate and primary patency and the secondary outcome of access utilization. RESULTS: The proportion of autologous AVFs created was higher post-KDOQI (73% vs 35%, P < .001), and an increased use of the basilic vein was observed (20% vs 2%, P < .05). The failure rate of fistula maturation was reduced post-KDOQI (24% vs 38%, P < .05); however, access utilization was also decreased (59% vs 75%, P < .001). CONCLUSIONS: Adherence to KDOQI guidelines for AVFs does not compromise fistula patency and increased use of the basilic vein may lead to superior fistula maturation rates. Early referral may result in lower fistula utilization rates, however.

Predictors of prosthetic graft infection after infrainguinal bypass.

BACKGROUND: Some patients require major leg amputation after lower-extremity prosthetic bypass for graft occlusion or failure of wound healing, despite a patent graft. Amputation above or below the knee was hypothesized to increase susceptibility to prosthetic graft infection in the ipsilateral extremity. STUDY DESIGN: All patients undergoing implantation of prosthetic infrainguinal arterial bypass grafts identified from a vascular surgical registry during a 12-year period were reviewed. Patient demographic data, comorbid conditions, and operative details were evaluated as risk factors, with graft infection among the primary outcomes of interest. RESULTS: Prosthetic graft infection occurred in 25 of 141 (18%) infrainguinal grafts and occurred most frequently after major amputation (41% versus 6%; odds ratio [OR] = 12; 95% CI, 4.1 to 34) or early reoperation after initial grafting (70% versus 16%; OR = 11; 95% CI, 1.9 to 63). Risk was highest after amputation within 4 weeks of bypass (70% versus 32%; OR = 5.0; 95% CI, 1.1 to 23). Graft thrombosis (84% versus 39%; OR = 8.3; 95% CI, 2.7 to 26) and presence of gangrene (52% versus 23%; OR = 3.6; 95% CI, 1.5 to 8.7) also increased infection risk. Independent predictors for development of graft infection were identified by stepwise regression analysis to be amputation (p < 0.001), early reoperation (p = 0.002), and absence of renal failure (p = 0.038) but not gangrene (p = 0.090). Amputations performed within 6 months of the initial bypass operation were more likely to be associated with prosthetic graft infection than those performed later than 6 months (52% versus 17%; OR = 5.3; 95% CI, 1.3 to 22). CONCLUSIONS: Amputation increases risk of prosthetic graft infection, especially when performed early or after failed revascularization. Consideration should be given to partial or complete removal of a prosthetic graft above the level of the amputation under these conditions.

Prospective decision analysis for peripheral vascular disease predicts future quality of life.

OBJECTIVE: Decision making for peripheral vascular disease can be quite complex as a result of pre-existing compromise of patient functional status, anatomic considerations, uncertainty of favorable outcome, medical comorbidities, and limitations in life expectancy. The ability of prospective decision-analysis models to predict individual quality of life in patients with lower extremity arterial occlusive disease was tested. METHODS: This was a prospective cohort study. The settings were university and Veterans Administration vascular surgery practices. All 214 patients referred with symptomatic lower extremity arterial disease of any severity over a 2-year period were screened, and 206 were enrolled. A Markov model was compared with standard clinical decision-making. Utility assessment and generalized (Short Form-36; SF-36) and disease-specific (Walking Impairment Questionnaire; WIQ) quality of life were derived before treatment. Estimates of treatment outcome probabilities and intended and actual treatment plans were provided by attending vascular surgeons. The main outcome measures were generalized (SF-36) and disease-specific (WIQ) variables at study entry and at 4 and 12 months. RESULTS: Primary intervention consisted of amputation for 9, bypass for 42, angioplasty for 8, and medical treatment for 147 patients. Considering all patients, no improvement in mean overall patient quality of life measured by the SF-36 Physical Component Score (27 +/- 8 vs 28 +/- 8; P = .87) or WIQ (39 +/- 22 vs 39 +/- 23; P = .13) was noted 12 months after counseling and treatment by the vascular surgeons. Individually considered SF-36 categories were improved only for Bodily Pain (40 +/- 23 vs 49 +/- 25; P = .03), with the most significant improvement observed among patients with the most severe pain (68 +/- 25 vs 37 +/- 23; P = .02) and among those undergoing bypass (60 +/- 29 vs 31 +/- 22; P = .02). It is noteworthy that when the treatment chosen was incongruent with the Markov model, patients were more likely to report a poorer quality of life at 1 year (Physical Component Score, 25 +/- 8 vs 29 +/- 8; P < .001). The quality of life predicted at baseline by the Markov model correlated positively with the Physical Component Score (r = 0.23), Bodily Pain (r = 0.33), and Fatigue (r = 0.44) and negatively with WIQ (r = -0.08) observed 1 year later. CONCLUSIONS: Prospective application of an individualized decision Markov model in patients with vascular disease was predictive of patient quality of life at 1 year. The patient's outcome was worse when the treatment received did not follow the model's recommendation. This decision analysis model may be useful to identify patients at risk for poor outcomes with standard clinical decision making.

Compromised bypass graft outcomes after minimal-incision vein harvest.

BACKGROUND: Minimal incision techniques for vein harvest may lessen wound complications after lower extremity revascularization, but long-term patency and limb salvage data are limited. METHODS: This retrospective case-control study used a computerized vascular registry set in an academic vascular surgical practice. All patients undergoing lower extremity revascularization using autogenous reversed great saphenous vein by a single vascular surgeon in a 10-year period were reviewed. Harvest of great saphenous vein via long single incision (SI) in 133 patients was compared with minimal incisions with endoscopy (MIE) in 85, or MI without endoscopy in 106. The main outcome measures were primary and secondary graft patency by Kaplan-Meier life-table analysis and cumulative sum failure (CUSUM). Secondary outcomes of interest were limb salvage and wound complications. RESULTS: No differences were observed between MIE, MI, and SI patients for demographic data, risk factors, or primary indications, including claudication, rest pain, ischemic ulcer, and gangrene. Endoscopic vein harvest patients were significantly more likely than MI or SI to be women and more likely to use tobacco. Primary patency at 5 years was better after SI vein harvest (59%) than with either MI (33%, P = .004) or MIE (44%, P = .045) techniques, although both MI groups had a higher proportion of bypass grafts to the popliteal artery. Similarly, cumulative secondary patency was better after SI (66%) than with MI (47%, P = .045), but not MIE (58%, P = .45). Differences in limb salvage at 5 years in SI (73%) were not statistically superior to either MI (59%, P = .24) or MIE (58%, P = .13). No learning curve for MI or MIE vein grafts was evident by CUSUM for primary patency at 12 months. No differences in wound complication rates were observed for SI (9%), MI (10%), or MIE (6%) grafts (P = .54). CONCLUSIONS: Graft patency and limb salvage deteriorated during the time when MI or MIE techniques of great saphenous vein harvest were adopted. This observation raises concern about the advisability of limiting the extent of the incision at the potential cost of compromised outcomes without an obvious advantage in limiting wound complications.

Suprarenal Clostridium septicum aortitis with rupture and simultaneous colon cancer.

We report a case of combined colon cancer and Clostridium septicum aortitis involving the suprarenal abdominal aorta with rupture. An 82-year-old male presented with fever, abdominal pain, and back pain associated with constipation. He was successfully treated by in situ aortic graft placement with polytetrafluroethylene and concomitant colon resection. Only 20 other cases of C. septicum mycotic aneurysm, aortitis, or aortic dissection have been reported. Concomitant surgical treatment for Clostridium aortitis or mycotic abdominal aortic aneurysm and colon cancer can be accomplished successfully in selected cases when the diagnosis of both conditions is made preoperatively.

Prophylactic beta-blocker use to prevent perioperative morbidity and mortality.

Cardiovascular disease continues to be a major health concern and leads to significant perioperative morbidity and mortality. Evidence for prophylactic use of beta-blockade to decrease these complications continues to grow. Not all patients benefit from perioperative beta-blockade, thus a thorough preoperative cardiac assessment should be performed with every patient undergoing surgery. Although physicians may have doubts with this new strategy, the literature overwhelmingly supports prophylactic beta-blockade use as a safe, efficacious, and cost effective new therapy in patients at risk for cardiac complications.

Prospective decision analysis modeling indicates that clinical decisions in vascular surgery often fail to maximize patient expected utility.

BACKGROUND: Applied prospectively to patients with peripheral arterial disease, individualized decision analysis has the potential to improve the surgeon's ability to optimize patient outcome. METHODS: A prospective, randomized trial comparing Markov surgical decision analysis to standard decision-making was performed in 206 patients with symptomatic lower extremity arterial disease. Utility assessment and quality of life were determined from individual patients prior to treatment. Vascular surgeons provided estimates of probability of treatment outcome, intended and actual treatment plans, and assessment of comfort with the decision (PDPI). Treatment plans and PDPI evaluations were repeated after each surgeon was made aware of model predictions for half of the patients in a randomized manner. RESULTS: Optimal treatments predicted by decision analysis differed significantly from the surgeon's initial plan and consisted of bypass for 30 versus 29%, respectively, angioplasty for 28 versus 11%, amputation for 31 versus 6%, and medical management for 34 versus 54% (agreement 50%, kappa 0.28). Surgeon awareness of the decision model results did not alter the verbalized final plan, but did trend toward less frequent use of bypass. Patients for whom the model agreed with the surgeon's initial plan were less likely to undergo bypass (13 versus 30%, P < 0.01). Greater surgeon comfort was present when the initial plan and model agreed (PDPI score 47.5 versus 45.6, P < 0.005). CONCLUSIONS: Individualized application of a decision model to patients with peripheral arterial disease suggests that arterial bypass is frequently recommended even when it may not maximize patient expected utility.

Molecular detection of micrometastatic breast cancer in histopathology-negative axillary lymph nodes correlates with traditional predictors of prognosis: an interim analysis of a prospective multi-institutional cohort study.

OBJECTIVE: We sought to establish the clinical relevance of micrometastatic disease detected by reverse transcription polymerase chain reaction (RT-PCR) in axillary lymph nodes (ALN) of breast cancer patients. BACKGROUND: The presence of ALN metastases remains one of the most valuable prognostic indicators in women with breast cancer. However, the clinical relevance of molecular detection of micrometastatic breast cancer in sentinel lymph nodes (SLN) and nonsentinel ALN has not been established. METHODS: Four hundred eighty-nine patients with T1-T3 primary breast cancers were analyzed in a prospective, multi-institutional cohort study. ALN were analyzed by standard histopathology (H&E staining) and by multimarker, real-time RT-PCR analysis (mam, mamB, muc1, CEA, PSE, CK19, and PIP) designed to detect breast cancer micrometastases. RESULTS: A positive marker signal was observed in 126 (87%) of 145 subjects with pathology-positive ALN, and in 112 (33%) of 344 subjects with pathology-negative ALN. In subjects with pathology-negative ALN, a positive marker signal was significantly associated with traditional indicators of prognosis, such as histologic grade (P = 0.0255) and St. Gallen risk category (P = 0.022). Mammaglobin was the most informative marker in the panel. CONCLUSION: This is the first report to show that overexpression of breast cancer-associated genes in breast cancer subjects with pathology-negative ALN correlates with traditional indicators of disease prognosis. These interim results provide strong evidence that molecular markers could serve as valid surrogates for the detection of occult micrometastases in ALN. Correlation of real-time RT-PCR analyses with disease-free survival in this patient cohort will help to define the clinical relevance of micrometastatic disease in this patient population.