Treatment of L5-S1 spondyloptosis with stand-alone anterior lumbar interbody fusion in a patient with neurofibromatosis.

BACKGROUND: Neurofibromatosis type 1 (NF1) is a multisystem disorder that causes multiple tumor formations throughout the nervous system. Common spinal dysplasias seen with NF1, such as dural ectasia (DE), often undergo modulation and predispose these patients to spondylolisthesis, making surgical treatment challenging. CASE DESCRIPTION: A patient with NF1 presented with a 12-year-history of back and left lower extremity radicular pain. Lumbar spine magnetic resonance imaging revealed developmental anomalies with severe DE and associated scalloping of the L4-S1 vertebral bodies and severe L5-S1 Meyerding grade 4 spondylolisthesis. During surgery, post-positioning x-rays demonstrated a grade 5 spondyloptosis. The patient underwent an L5-S1 stand-alone anterior lumbar interbody fusion (ALIF). The final construct was an ALIF cage with one screw into S1, without an anterior plate. By 3-months post-operative, there was complete resolution of preoperative symptoms and at 2 year follow-up the patient was asymptomatic with stable hardware and solid bony fusion. To the authors' knowledge, this is the first report of spondyloptosis treated with a stand-alone ALIF in a patient with NF1 and severe DE.

Atypical Pyoderma Gangrenosum in the Setting of Venous and Arterial Insufficiency.

Ulcers of mixed etiology are diagnostically elusive and challenging to treat, especially when rare conditions are superimposed. Pyoderma gangrenosum (PG) is an autoinflammatory, ulcerative skin disease that is difficult to diagnose. Diagnostic criteria exist but there are no specific clinical tests to identify it. We discuss a case of PG initially diagnosed as venous ulcer in the setting of peripheral artery disease, complicated by superinfection, refractory to standard wound care, multiple surgical debridements, revascularization, negative pressure therapy, and parenteral antibiotics. Findings differentiating PG from other wound etiologies are explored, with the aim of improving clinical recognition of this condition.

Pyoderma gangrenosum underrepresentation in non-dermatological literature.

BACKGROUND: Pyoderma gangrenosum (PG) is a chronic, ulcerative neutrophilic dermatosis. PG presents a diagnostic challenge, largely due to the many mimicking diseases, the lack of confirmatory laboratory or biological markers, and the absence of widely accepted diagnostic criteria. In particular, PG is often mistaken for necrotizing soft tissue infections (NSTI). METHODS: We reviewed four major textbooks each in general surgery, plastic surgery, trauma surgery, vascular surgery, emergency medicine, and dermatology. We also performed a search of review articles addressing NSTI and necrotizing fasciitis (NF). RESULTS: Ten out of the 20 non-dermatology textbooks did not list PG anywhere, and only two listed a differential diagnosis for PG. None of the non-dermatology textbooks indicated PG in the NSTI differential diagnosis, while three of the dermatology textbooks included PG in the NSTI differential diagnosis. PG was listed in all of the dermatology textbooks. Only one of the NSTI and NF articles mentioned PG in the differential diagnosis. CONCLUSIONS: There is an underrepresentation in major textbooks of surgery and emergency medicine and in NSTI and NF review articles when it comes to diagnosing PG. This might be leading to trainees and advanced providers in these fields being uninstructed on PG, and likely contributes to PG misdiagnosis and mismanagement. We recommend PG be included in the differential diagnosis of chronic ulcers and NSTI in non-dermatology textbooks. We also suggest adding identification and diagnosis of inflammatory mimickers of NSTI (e.g. PG) in teaching modules in surgical and emergency specialties to address this knowledge gap.

Peak systolic velocity and color aliasing are important in the development of duplex ultrasound criteria for external carotid artery stenosis.

OBJECTIVE: The external carotid artery (ECA) serves as a major collateral pathway for ophthalmic and cerebral artery blood supply. It is routinely examined as part of carotid duplex ultrasound, but criteria for determining ECA stenosis are poorly characterized and typically extrapolated from internal carotid artery data. This is despite the fact that the ECA is smaller in diameter, with a higher resistance and lower volume flow pattern. We hypothesized that using the cutoff of a peak systolic velocity (PSV) ≥125 cm/s, extrapolated from internal carotid artery data, will overestimate the prevalence of ≥50% ECA stenosis and aimed to determine a more appropriate criterion. METHODS: From December 2016 to July 2017, consecutive carotid duplex ultrasound studies performed in our university hospital Intersocietal Accreditation Commission-accredited vascular laboratory were prospectively identified and categorized with respect to prevalence and distribution of ECA PSVs and color aliasing, an indication of turbulent flow or flow acceleration. Presence of color aliasing was determined by two individual reviewers and agreement assessed by Cohen κ coefficient. ECA stenosis was calculated by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method in patients with computed tomography angiography (CTA) performed within 3 months of carotid duplex ultrasound without an intervening intervention. Receiver operating characteristic analysis was performed to identify best criteria for determining ≥50% ECA stenosis. RESULTS: There were 1324 ECAs from 662 patients analyzed; 174 patients had a total of 252 ECAs with PSV ≥125 cm/s (19% of the total sample). Of those ECAs with PSVs ≥125 cm/s, 30.5% were between 125 and 149 cm/s, 22.2% were between 150 and 174 cm/s, 13.1% were between 175 and 199 cm/s, and 34.1% were ≥200 cm/s. There were 341 ECAs that were analyzed for the presence of color aliasing. In 86 ECAs with PSV ≥200 cm/s, 58.1% had color aliasing, whereas in 255 ECAs with PSV <200 cm/s, only 19.2% had color aliasing (P = .0001). There were 325 CTA studies reviewed and assessed for the presence of a ≥50% ECA stenosis as determined by CTA. Overall, the combination of an ECA PSV ≥200 cm/s with the presence of color aliasing provided the highest combination of sensitivity (90%), specificity (96%), positive predictive value (83%), and negative predictive value (98%) and the greatest area under the curve of 0.971 for determining the presence of a ≥50% ECA stenosis based on CTA. CONCLUSIONS: A PSV ≥125 cm/s alone probably overestimates the prevalence of ≥50% ECA stenosis. A PSV ≥200 cm/s combined with color aliasing is highly predictive of >50% ECA stenosis based on correlation with CTA.

Experienced operators achieve superior patency and wound complication rates with endoscopic great saphenous vein harvest compared with open harvest in lower extremity bypasses.

OBJECTIVE: Prior studies have suggested improved wound complication rates but decreased primary patency in lower extremity bypasses performed with endoscopic vein harvest (EVH) vs open vein harvest (OVH). We hypothesize that the inferior patency reflects the initial learning curve for EVH and that improved patency can be achieved with experience. METHODS: This was a single-institution review of 113 patients with critical limb ischemia who underwent infrainguinal bypass with a continuous segment of great saphenous vein harvested endoscopically (n = 49) or through a single open incision (n = 64) from 2012 to 2017. EVH was performed by surgeons with >5 years' experience with this technique. Operative outcomes, patency, complications, and readmission rates were compared between the harvest methods. EVH data were also compared with our prior reported series of our initial experience with this technique to determine the effects of experience on outcomes. RESULTS: There were no significant differences in patient demographics, medications, operative indications, or inflow/outflow vessels between the two groups. Mean operative time was 322 minutes and median hospital length of stay was 6 days for OVH, and was 340 minutes and 5 days for EVH, which was not significant. Harvest-related wound complications were more frequent with OVH (28% vs 2%, P < .001). Primary patency at 1 and 3 years was 65% and 58% for OVH, and 79% and 71% for EVH, respectively (P = .18), assisted primary patency was 77% and 74% for OVH and 94% and 89% for EVH, respectively (P = .05), and secondary patency was 82% and 79% for OVH and 95% and 95% for EVH, respectively (P = .03). The 30-day readmission rates were similar between OVH (20%) and EVH (12%, P = .26), but 90-day readmissions were more frequent in the OVH group (34% vs 14%, P = .018). Compared with our earlier series of EVH, the current cohort had significantly improved 3-year primary (71% vs 42%, P = .012), primary assisted patency (89 vs 66%, P = .034), and secondary patency (95% vs 66%, P = .003). CONCLUSIONS: With experience, lower extremity bypass using EVH can result in improved patency compared with OVH and initial EVH use, while also resulting in fewer wound complications and readmissions, with comparable operative times and hospital length of stay. This technique should be more widely adopted by vascular surgeons as a primary method of vein harvest.

Predictors of perioperative morbidity and mortality in open abdominal aortic aneurysm repair.

INTRODUCTION: The major advantage of endovascular abdominal aortic aneurysm repair (EVAR) over open repair (OAR) is improved perioperative morbidity and mortality. Long term results of the two modalities are comparable. We sought to quantify factors predicting perioperative morbidity and mortality in patients undergoing OAR. METHODS: Consecutive non-ruptured OAR were analyzed for patient demographic factors, perioperative variables including blood pressure, temperature, and glucose control, intraoperative factors, and complications including wound, pulmonary, renal and cardiac, and 30-day mortality. Uni- and multivariate analysis was performed to determine predictors of morbidity and mortality. RESULTS: 240 elective open AAA repairs over 10 consecutive years were performed. 46% required suprarenal clamping. At least one complication occurred in 47% and 30-day mortality was 5.4%. By multivariate analysis, independent predictors of morbidity (any complication) were suprarenal clamping (OR 1.8, 95% CI 1.1-3.2, p = 0.029), operative time (OR 1.005, 95% CI 1.002-1.008, p = 0.002), and low postoperative temperature (OR 1.6, 95% CI 1.1-2.3, p = 0.025). Multivariate predictors of 30 day mortality included advanced age (OR 1.2, 95% CI 1.1-1.3, p = 0.002) and operative time (OR 1.007, 95% CI 1.001-1.013, p = 0.024). Glucose control did not predict morbidity or mortality. CONCLUSIONS: Control of postoperative temperature is a potentially modifiable factor that may reduce morbidity in patients undergoing open AAA repair, thereby minimizing the early advantage of EVAR.

Two-level reverse Bohlman transsoseous approach for treatment of symptomatic pseudarthrosis.

Surgical treatment for high-grade spondylolisthesis with high sacral slope remains controversial and no definitive gold standard procedure has been identified. The Bohlman technique, in which a fibular strut is reamed posteriorly across the L5-S1 disc space in an oblique, inferior to superior trajectory, has been increasingly utilized. Recently, a Reverse Bohlman technique has been described, in which a graft is reamed anteriorly across a single disc space in a superior to inferior trajectory. Case Report A 55 year-old male with complete lumbarization of S1 (referred to as L6) and previous L5-L6-S1 posterior instrumented fusion presented, with progressively worsening low back pain and lower extremity radicular pain. After failing conservative management, he underwent a 2-level Reverse Bohlman approach to place a titanium mesh interbody graft (cage) anteriorly from L5 to S1, crossing the L5-6 and L6-S1 disc spaces. Here we describe for the first time a Reverse Bohlman technique spanning two disc spaces in a patient with a transitional lumbosacral anomaly and high sacral slope. At 6 months post-operative follow up, the patient reported near complete resolution of symptoms.

Characterization of profunda femoris vein thrombosis.

OBJECTIVE: The incidence of and risk factors for profunda femoris vein (PFV) thrombosis are poorly characterized. We prospectively identified patients with PFV deep venous thrombosis (DVT) to characterize the demographics and anatomic distribution of proximal DVT in patients with PFV DVT. METHODS: A prospective study was conducted of patients at a tertiary care university hospital with DVT diagnosed by venous duplex ultrasound scanning between June 2014 and June 2015. DVT patients were categorized as having PFV involvement (yes or no), and the anatomic distribution of other sites of ipsilateral venous thrombi was further stratified to determine whether there was external iliac vein (EIV), common femoral vein (CFV), or femoropopliteal vein (FPV) DVT. Demographic characteristics of the patients were compared between groups, PFV DVT vs proximal DVT without PFV DVT. RESULTS: Of 4584 lower extremity venous duplex ultrasound studies performed, 398 (8.7%) scans were positive for proximal DVT from 260 patients; 23.1% of patients with DVT (60/260) had DVT involving the PFV. Of 112 patients who had CFV DVT, 55 (49.1%) also had ipsilateral involvement of the PFV. Of 60 patients with PFV DVT, 55 (91.7%) had involvement of the ipsilateral CFV. Patients in the PFV DVT group were more likely to have a history of a hypercoagulable disorder (26.7% vs 14.5%; P = .029) and a history of immobility (58.3% vs 42%; P = .026) compared with those with proximal DVT without PFV DVT. There were no differences in smoking, recent surgery, personal or family history of DVT, other medical comorbidities, inpatient status, or survival. There was no difference in laterality of DVT between the PFV DVT and proximal DVT without PFV DVT groups (35% vs 41.5% left, 35% vs 33.5% right, 30% vs 25% bilateral; P = .619). There was a higher proportion of PFV DVT with EIV involvement (21.7% vs 2.5%; P < .00001) and a higher proportion of PFV DVT with CFV + FPV involvement (65.0% vs 19%; P < .00001) compared with proximal DVT without PFV DVT. There was no difference in survival between the PFV DVT and proximal DVT without PFV DVT groups. CONCLUSIONS: Patients with PFV thrombosis tend to have more thrombus burden with more frequent concurrent DVT in the EIV and FPV. Patients with PFV DVT are also more likely to have a history of hypercoagulable disorder and immobility. Ultrasound protocols for assessment of DVT should include routine examination of the PFV as a potential marker of a more virulent prothrombotic state.

Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit.

OBJECTIVE: Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients. METHODS: All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia. RESULTS: There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 ± 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P = .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P = .05) and hyperlipidemia (42% vs 24%; P = .03) and to undergo finger amputations (16% vs 5%; P = .03). CONCLUSIONS: Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.

Ambulation and functional outcome after major lower extremity amputation.

OBJECTIVE: Major lower extremity amputations (MLEAs) remain a significant source of disability. It is unknown whether postamputation functional outcomes and outcome predictability have changed with a population of increasingly aging and obese patients. Accordingly, we sought to evaluate contemporary trends. METHODS: A retrospective chart review was performed to identify patients undergoing MLEA using Current Procedural Terminology codes in a university hospital. Demographics, comorbidities, perioperative variables, and outcomes were obtained. Descriptive statistics, t-tests, and χ2 and multivariate logistic regression modeling were used where appropriate. Survival analyses were performed with the Kaplan-Meier method. RESULTS: From October 2005 to November 2016, 206 patients (147 male; mean age, 63 ± 13.5 years) underwent 256 MLEAs (90.9% below-knee amputations, 1.3% through-knee amputations, and 7.8% above-knee amputations [AKAs]) related to acute and critical limb ischemia, infection, or other causes. Mean follow-up was 178.7 ± 266.9 days. Conversion from below-knee amputation to AKA was 3.5%. Estimated 1-year survival was 83%, and it was 15% lower in nonambulatory patients (75% vs 90%; P = .04). Overall 1-year postamputation ambulatory rate was 46.1%. Nonambulatory patients had a higher body mass index (30.9 ± 8.0 vs 25.6 ± 5.4; P < .001), lower preoperative hematocrit (31.0% ± 7.4% vs 33.3% ± 8.1%; P < .05), higher modified frailty index (mFI; 8.4 ± 1.0 vs 5.4 ± 1.2; P < .0001), higher chronic alcohol use (9% vs 1%; P = .01), dependent preoperative functional status (29% vs 2.1%; P < .01), and lack of family support (66.3% vs 17.9%; P < .01); they were less likely to be married (83.2% vs 35.8%; P < .01) and more likely to have an AKA (20% vs 52.6%; P = .004). There were no patients with dementia, on dialysis, or with bilateral MLEAs who were ambulatory after amputation. Factors predictive of nonambulatory status after MLEA with multivariate logistic regression analysis included increased body mass index (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.81-0.98; P = .017) and an increased mFI (OR, 0.23; 95% CI, 0.16-0.34; P < .0001); a higher hemoglobin level was protective (OR, 1.3; 95% CI, 1.03-1.62; P = .019). CONCLUSIONS: Patients should be counseled that <50% of patients receiving MLEAs are ambulatory after amputation. Educating patients about the deleterious effects of obesity on ambulatory status after MLEA may motivate patients to improve their level of fitness to achieve successful ambulation. Patients with an elevated mFI, patients with dementia, and those on dialysis should be considered for AKAs.

Tibial artery duplex ultrasound-derived peak systolic velocities may be an objective performance measure after above-knee endovascular therapy for arterial stenosis.

OBJECTIVE: The ankle-brachial index (ABI) is a well-established measure of distal perfusion in lower extremity ischemia; however, the ABI is of limited value in patients with noncompressible lower extremity arteries. We sought to demonstrate whether duplex ultrasound-determined tibial artery velocities can be used as an alternative to ABI as an objective performance measure after endovascular treatment of above-knee arterial stenosis. METHODS: Thirty-six patients undergoing above-knee endovascular intervention had preprocedure and postprocedure duplex ultrasound examination within 6 months of intervention. Preprocedure vs postprocedure changes in tibial artery mean peak systolic velocity (PSV; mean of proximal, mid, and distal velocities) were compared with changes in ABI and a reference (control) cohort of 68 patients without peripheral vascular disease. RESULTS: Thirty-six patients (41 limbs) had an above-knee endovascular intervention and had preprocedure and postprocedure duplex ultrasound examinations of the ipsilateral extremity including the tibial arteries. Before the procedure, mean tibial artery PSVs in the 36 patients undergoing intervention were outside (below) the 95% confidence intervals for the control patients. In comparing preprocedure and postprocedure PSVs, the mean anterior tibial (P < .01), mean peroneal (P < .01), and mean posterior tibial (P < .01) PSVs all increased and correlated with an increase in ABI (P < .01). After endovascular intervention, duplex ultrasound-derived mean PSVs fell within or near established reference ranges for patients without peripheral arterial disease. Mean tibial artery PSV increases were similar in patients with and without noncompressible vessels. CONCLUSIONS: Tibial artery PSVs increase, correlate with an increase in ABI, and fall within or near confidence intervals for normal controls after above-knee endovascular interventions. After endovascular intervention, tibial artery PSVs can supplement ABI as an objective performance measure in patients with and in particular without compressible tibial arteries.

Interhospital vascular surgery transfers to a tertiary care hospital.

OBJECTIVE: Interhospital transfers (IHTs) to tertiary care centers are linked to lower operative mortality in vascular surgery patients. However, IHT incurs great health care costs, and some transfers may be unnecessary or futile. In this study, we characterize the patterns of IHT at a tertiary care center to examine appropriateness of transfer for vascular surgery care. METHODS: A retrospective review was performed of all IHT requests made to our institution from July 2014 to October 2015. Interhospital physician communication and reasons for not accepting transfers were reviewed. Diagnosis, intervention, referring hospital size, and mortality were examined. Follow-up for all patients was reviewed. RESULTS: We reviewed 235 IHT requests for vascular surgical care involving 210 patients during 15 months; 33% of requested transfers did not occur, most commonly after communication with the physician resulting in reassurance (35%), clinic referral (30%), or further local workup obviating need for transfer (11%); 67% of requests were accepted. Accepted transfers generally carried life- or limb-threatening diagnoses (70%). Next most common transfer reasons were infection or nonhealing wounds (7%) and nonurgent postoperative complications (7%). Of accepted transfers, 72% resulted in operative or endovascular intervention; 20% were performed <8 hours of arrival, 12% <24 hours of arrival, and 68% during hospital admission (average of 3 days); 28% of accepted patients received no intervention. Small hospitals (<100 beds) were more likely than large hospitals (>300 beds) to transfer patients not requiring intervention (47% vs 18%; P = .005) and for infection or nonhealing wounds (30% vs 10%; P = .013). Based on referring hospital size, there was no difference in IHTs requiring emergent, urgent, or nonurgent operations. There was also no difference in transport time, time from consultation to arrival, or death of patients according to hospital size. Overall patient mortality was 12%. CONCLUSIONS: Expectedly, most vascular surgery IHTs are for life- or limb-threatening diagnoses, and most of these patients receive an operation. Transfer efficiency and surgical case urgency are similar across hospital sizes. Nonoperative IHTs are sent more often by small hospitals and may represent a resource disparity that would benefit from regionalizing nonurgent vascular care.

Nonatherosclerotic vascular causes of acute abdominal pain.

BACKGROUND: To examine the epidemiology, treatments, and outcomes of acute symptomatic non-atherosclerotic mesenteric vascular disease. METHODS: Subjects were reviewed over a six year period. Categories included embolism (EM), dissection (DI), and aneurysm (AN). Presentation, demographics, treatment and outcomes were compared. RESULTS: 46 patients were identified (EM:20, AN:15, DI:11). Age at presentation differed (EM: 66.3, AN 62.4, DI 54.6, p < .05). EM more likely affected the superior mesenteric artery (EM80%, AN20%, DI45%, p = .002), DI hepatic artery (EM20%, AN13%, DI55%, p < .05), and AN mesenteric branches (EM5%, AN47%, DI0%; p = .001). EM more likely had history of arrhythmia (EM40%, AN7%, DI0%, p,0.05) and diarrhea (EM30%, AN7%, DI0%, p < .05). Treatment was most often surgical in EM (EM85%, AN33%, DI9%, p < .001), endovascular in AN (EM5%, AN40%, DI 9%, p < .02), and conservative in DI (EM15%, AN 33%, DI82%, p < .05). In hospital mortality was infrequent (EM10%, AN7%, DI0%, p = ns). Mean hospital length of stay differed by mechanism (EM13.6days, AN9.2, DI2.3, p = .005). Median follow up was 61 months. Survival at 1, 3 and 5 years for emboli was 75%, 70% and 59%, for aneurysms 93%, 86%, and 77%, and for dissections 100% at all time points (p = .043 log rank). CONCLUSIONS: Patients with EM, AN, and DI differ in age, anatomic distribution and method of treatment. The etiology significantly affects long term survival.

Risk Factors for Mortality Among Individuals With Peripheral Arterial Disease.

Morbidity and mortality from peripheral arterial disease (PAD) continues to increase. Traditional cardiovascular risk factors are implicated in the development of PAD, yet the extent to which those risk factors correlate with mortality in such patients remains insufficiently assessed. Using data from the 1999 to 2004 National Health and Nutrition Examination Survey, Cox proportional hazards models were used to examine the association of cardiovascular risk factors and all-cause and cardiovascular mortality. A total of 647 individuals ≥40 years old with PAD (i.e., ankle-brachial index [ABI] ≤ 0.9) were followed for a median of 7.8 years. There were 336 deaths, of which 98 were attributable to cardiovascular disease. Compared with never smokers, current (hazard ratio [HR] 2.45, 95% confidence interval [CI] 1.62 to 3.71) and former (HR 1.62, 95% CI 1.14 to 2.29) smokers with PAD had higher rates of death. Moderate or vigorous physical activity of ≥10 minutes monthly was associated with lower death rates (HR 0.63, 95% CI 0.44 to 0.91). Also associated with increased rates of cardiovascular death were an ABI of <0.5 (HR 2.56, 95% CI 1.28 to 5.15, compared with those with an ABI of 0.7 to 0.9) and diabetes mellitus (HR 2.50, 95% CI 1.33 to 4.73). Neither C-reactive protein nor body mass index was associated with mortality. In conclusion, tobacco use increased the risk of all-cause and cardiovascular death, whereas physical activity was associated with a decreased mortality risk. A low ABI and diabetes were also predictive of cardiovascular death.

Patterns of Care in Hospitalized Vascular Surgery Patients at End of Life.

Importance: There is limited literature reporting circumstances surrounding end-of-life care in vascular surgery patients. Objective: To identify factors driving end-of-life decisions in vascular surgery patients. Design, Setting, and Participants: In this cohort study, medical records were reviewed for all vascular surgery patients at a tertiary care university hospital who died during their hospitalization from 2005 to 2014. Main Outcomes and Measures: Patient, family, and hospitalization variables potentially important to influencing end-of-life decisions. Results: Of 111 patients included (67 [60%] male; median age, 75 [range, 24-94] years), 81 (73%) were emergent vs 30 (27%) elective admissions. Only 15 (14%) had an advance directive. Of the 81 (73%) patients placed on comfort care, 31 (38%) had care withheld or withdrawn despite available medical options, 15 (19%) had an advance directive, and 28 (25%) had a palliative care consultation. The median time from palliative care consultation to death was 10 hours (interquartile range, 3.36-66 hours). Comparing the 31 patients placed on comfort care despite available medical options with an admission diagnosis-matched cohort, we found that more than 5 days admitted to the intensive care unit (odds ratio [OR], 4.11; 95% CI, 1.59-10.68; P < .001), more than 5 days requiring ventilator support (OR, 9.45; 95% CI, 3.41-26.18; P < .001), new renal failure necessitating dialysis (OR, 14.48; 95% CI, 3.69-56.86; P < .001), and new respiratory failure necessitating tracheostomy (OR, 23.92; 95% CI, 2.80-204; P < .001) correlated with transition to comfort care. Conclusions and Relevance: Palliative care consultations may be underused at the end of life. A large percentage of patients were transitioned to comfort measures despite available treatment, yet few presented with advance directives. In high-risk patients, discussions regarding extended stays in the intensive care unit, prolonged ventilator management, and possible dialysis and tracheostomy should be communicated with patients and families at time of hospitalization and advance directives solicited.

Arterial duplex for diagnosis of peripheral arterial emboli.

BACKGROUND: Whether duplex ultrasound (DUS) imaging alone can be used to successfully plan revascularization for peripheral arterial embolism (PAE) is unknown. This study evaluated the utility of DUS imaging alone for the diagnosis and treatment of PAE. METHODS: Patients with cardiogenic PAE to the lower or upper extremities during a 20-year period were retrospectively evaluated. Patients with visceral or cerebral PAE were excluded. Diagnosis by DUS imaging alone was compared with contrast angiography (CA) or computed tomography angiography (CTA). Patient demographics, use of intraoperative CA, need for reintervention, length of revascularization procedure, and rate of fasciotomy and amputation were compared. Mean peak systolic velocity (PSV; cm/s) measured at the proximal, middle, and distal segment of each artery from the common femoral to the distal tibial arteries was also compared with surgical outcomes. RESULTS: We identified 203 extremities in 182 patients with PAE. Preoperative imaging was obtained in 89%, including DUS imaging alone (44%), CA (37%), and CTA (7%). DUS imaging was used more frequently than CA or CTA in women, older patients, patients with congestive heart failure, upper extremity PAE, and patients on antiplatelet agents preoperatively. Use of intraoperative CA, need for reintervention, rate of fasciotomy and limb loss, and hospital length of stay were similar between the two groups. No upper extremities required amputation. Patients with lower extremity emboli who underwent fasciotomy had lower mean PSVs than those free from fasciotomy at the popliteal (4 ± 6 cm/s vs 31 ± 62 cm/s; P = .03), anterior tibial (1 ± 3 cm/s vs 10 ± 16 cm/s; P = .004), and posterior tibial (2 ± 3 cm/s vs 9 ± 15 cm/s; P = .03) arteries. The 30-day mortality for the series was 25% with a median follow-up of 7.4 months. The only predictor of 30-day mortality on multivariate analysis was tobacco use (odds ratio, 3.1; 95% confidence interval, 1.4-7.0). CONCLUSIONS: Surgical outcomes and survival for patients evaluated by preoperative DUS imaging alone for PAE are equivalent to patients evaluated with CA or CTA. PSVs in the tibiopopliteal arteries may predict the need for fasciotomy. Preoperative DUS imaging alone is sufficient for operative planning in patients with symptoms suggestive of PAE.

Use of an extracorporeal bypass for renal preservation to treat a rare case of a true mycotic aneurysm in a renal transplant patient.

True mycotic aneurysms of the abdominal aorta are extremely rare after organ transplantation. We report a renal transplant recipient who presented with Pseudomonas aeruginosa bacteremia and a new saccular infrarenal aortic aneurysm. A temporary extracorporeal axillofemoral bypass was placed to maintain perfusion to the transplant kidney. A contained rupture was found, and excision and in-line reconstruction were performed using a cryopreserved human aortic allograft. At 3 years, the patient remained well, with normal renal function while on oral antibiotic suppressive therapy. Use of an extracorporeal bypass was a viable technique with minimal morbidity for renal transplant preservation during open aortic replacement.

Inhibition of intestinal epithelial apoptosis improves survival in a murine model of radiation combined injury.

World conditions place large populations at risk from ionizing radiation (IR) from detonation of dirty bombs or nuclear devices. In a subgroup of patients, ionizing radiation exposure would be followed by a secondary infection. The effects of radiation combined injury are potentially more lethal than either insult in isolation. The purpose of this study was to determine mechanisms of mortality and possible therapeutic targets in radiation combined injury. Mice were exposed to IR with 2.5 Gray (Gy) followed four days later by intratracheal methicillin-resistant Staphylococcus aureus (MRSA). While either IR or MRSA alone yielded 100% survival, animals with radiation combined injury had 53% survival (p = 0.01). Compared to IR or MRSA alone, mice with radiation combined injury had increased gut apoptosis, local and systemic bacterial burden, decreased splenic CD4 T cells, CD8 T cells, B cells, NK cells, and dendritic cells, and increased BAL and systemic IL-6 and G-CSF. In contrast, radiation combined injury did not alter lymphocyte apoptosis, pulmonary injury, or intestinal proliferation compared to IR or MRSA alone. In light of the synergistic increase in gut apoptosis following radiation combined injury, transgenic mice that overexpress Bcl-2 in their intestine and wild type mice were subjected to IR followed by MRSA. Bcl-2 mice had decreased gut apoptosis and improved survival compared to WT mice (92% vs. 42%; p<0.01). These data demonstrate that radiation combined injury results in significantly higher mortality than could be predicted based upon either IR or MRSA infection alone, and that preventing gut apoptosis may be a potential therapeutic target.

The endogenous bacteria alter gut epithelial apoptosis and decrease mortality following Pseudomonas aeruginosa pneumonia.

The endogenous bacteria have been hypothesized to play a significant role in the pathophysiology of critical illness, although their role in sepsis is poorly understood. The purpose of this study was to determine how commensal bacteria alter the host response to sepsis. Conventional and germ-free (GF) C57Bl/6 mice were subjected to Pseudomonas aeruginosa pneumonia. All GF mice died within 2 days, whereas 44% of conventional mice survived for 7 days (P = 0.001). Diluting the dose of bacteria 10-fold in GF mice led to similar survival in GF and conventional mice. When animals with similar mortality were assayed for intestinal integrity, GF mice had lower levels of intestinal epithelial apoptosis but similar levels of proliferation and intestinal permeability. Germ-free mice had significantly lower levels of tumor necrosis factor and interleukin 1ß in bronchoalveolar lavage fluid compared with conventional mice without changes in systemic cytokine production. Under conventional conditions, sepsis unmasks lymphocyte control of intestinal epithelial apoptosis, because sepsis induces a greater increase in gut apoptosis in Rag-1 mice than in wild-type mice. However, in a separate set of experiments, gut apoptosis was similar between septic GF Rag-1 mice and septic GF wild-type mice. These data demonstrate that the endogenous bacteria play a protective role in mediating mortality from pneumonia-induced sepsis, potentially mediated through altered intestinal apoptosis and the local proinflammatory response. In addition, sepsis-induced lymphocyte-dependent increases in gut epithelial apoptosis appear to be mediated by the endogenous bacteria.

Mechanisms of methicillin-resistant Staphylococcus aureus pneumonia-induced intestinal epithelial apoptosis.

Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia-induced sepsis is a common cause of morbidity in the intensive care unit. Although pneumonia is initiated in the lungs, extrapulmonary manifestations occur commonly. In light of the key role the intestine plays in the pathophysiology of sepsis, we sought to determine whether MRSA pneumonia induces intestinal injury. FVB/N mice were subjected to MRSA or sham pneumonia and killed 24 h later. Septic animals had a marked increase in intestinal epithelial apoptosis by both hematoxylin-eosin and active caspase 3 staining. Methicillin-resistant S. aureus-induced intestinal apoptosis was associated with an increase in the expression of the proapoptotic proteins Bid and Bax and the antiapoptotic protein Bcl-xL in the mitochondrial pathway. In the receptor-mediated pathway, MRSA pneumonia induced an increase in Fas ligand but decreased protein levels of Fas, FADD, pFADD, TNF-R1, and TRADD. To assess the functional significance of these changes, MRSA pneumonia was induced in mice with genetic manipulations in proteins in either the mitochondrial or receptor-mediated pathways. Both Bid-/- mice and animals with intestine-specific overexpression of Bcl-2 had decreased intestinal apoptosis compared with wild-type animals. In contrast, Fas ligand-/- mice had no alterations in apoptosis. To determine if these findings were organism-specific, similar experiments were performed in mice subjected to Pseudomonas aeruginosa pneumonia. Pseudomonas aeruginosa induced gut apoptosis, but unlike MRSA, this was associated with increased Bcl-2 and TNF-R1 and decreased Fas. Methicillin-resistant S. aureus pneumonia thus induces organism-specific changes in intestinal apoptosis via changes in both the mitochondrial and receptor-mediated pathways, although the former may be more functionally significant.