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.

Improving follow-up of incomplete lower extremity venous duplex ultrasound examinations performed for deep and superficial vein thromboses.

OBJECTIVE: A lower extremity venous duplex ultrasound (LEVDUS) examination is the standard diagnostic test to evaluate patients for lower extremity deep vein thrombosis (DVT). However, some studies will be incomplete for a variety of reasons, including patient-related factors such as pain, edema, a large leg circumference, or the presence of overlying bandages or orthopedic devices. We previously reported that the frequency of obtaining a follow-up examination after an incomplete and negative (I/N) LEVDUS examination was low but that the rates of DVT found on the follow-up studies of initially I/N LEVDUS studies were similar to the rates of DVT found with initially complete LEVDUS examinations. Therefore, we recommended process improvements to increase follow-up LEVDUS studies after an I/N LEVDUS examination. In the present study, we have described the results of appending a recommendation to obtain a follow-up LEVDUS study to preliminary and final reports of I/N LEVDUS. METHODS: Starting in January 2019 through December 2019, a recommendation to obtain a repeat LEVDUS examination after an I/N study was appended to the preliminary and final reports of all I/N LEVDUS examination of patients who did not, otherwise, have an indication for anticoagulation (group 2). The patients were identified on an ongoing basis through the study period and entered into an Excel database (Microsoft Corp, Redmond, Wash). Group 2 was compared with a previously reported historic control cohort of patients identified from January 2017 to December 2017 (group 1). We compared groups 1 and 2 with respect to the frequency of the repeat studies performed within 4 weeks after an I/N LEVDUS examination and the DVT rates found from the follow-up LEVDUS examinations after an I/N LEVDUS study. RESULTS: Of the patients in groups 1 and 2, 187 and 229 had had I/N LEVDUS examinations, with 28% and 40.2% of group 1 and 2 studies having follow-up LEVDUS examinations (P < .01). Previously unidentified lower extremity thrombi were discovered in 21% of the group 2 follow-up examinations. Also, the rate of new thrombi detected was not different between groups 2 and 1 (historic controls; DVT, 14.3% vs 18.5% [P = .25]; SVT, 6.3% vs 3.3% [P = .15]). A definitive finding of either positive or negative for DVT and SVT with a complete examination in 50% of the group 2 patients with follow-up examinations. CONCLUSIONS: A recommendation to obtain a follow-up examination appended to the preliminary and final I/N LEVDUS reports was associated with an increased rate of follow-up examinations, which revealed many previously undetected DVTs and SVTs or had allowed for definitive exclusion of DVT.

Hybrid Repair of an Iatrogenic Left Subclavian Artery Injury: A Case Report.

We present the case of an iatrogenic injury to the left subclavian artery during placement of a port for chemotherapy. The artery was inadvertently accessed at its infraclavicular position, and then was perforated centrally, entering the mediastinum at the origin of the left vertebral artery. Given that the patient's posterior circulation was largely dependent on the left vertebral artery, it could not be sacrificed. To preserve her left vertebral artery and to avoid the need for a sternotomy, which would more substantially delay initiation of chemotherapy, we elected to perform a hybrid repair: an open left carotid to vertebral artery bypass with reversed great saphenous vein followed by repair of the proximal left subclavian injury with a covered stent graft, which was delivered via the left axillary artery. The patient recovered uneventfully. This case demonstrates a hybrid open and endovascular repair for a complex iatrogenic arterial injury. We were able to obtain a desirable outcome by careful assessment of the anatomic particulars of her injury and the technical constraints in proposed methods of repair, all in the context of the patient's overall goals of care.

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.

Providing Gender Confirmation Surgery at an Academic Medical Center: Analysis of Use, Insurance Payer, and Fiscal Impact.

BACKGROUND: Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center. METHODS: This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix. RESULTS: A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018. CONCLUSIONS: We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.

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.

The efficacy and safety of a catheter removal only strategy for the treatment of PICC line thrombosis versus standard of care anticoagulation: a retrospective review.

Peripherally-inserted central catheters (PICCs) are commonly used during hospitalization. Unfortunately, their use can be complicated by catheter-related thrombosis (CRT). Current guidelines recommend 3-6 months of anticoagulation for patients with CRT after catheter removal. This recommendation is based on extrapolation of data on lower extremity thrombosis, as data is lacking regarding the efficacy and safety of more specific management strategies. Many providers feel catheter removal alone is a reasonable treatment option, particularly for patients at risk for bleeding. We performed a retrospective analysis of hospitalized adult patients diagnosed with CRT at our center. We determined rates of progressive thrombosis and bleeding in cohorts of patients who underwent catheter removal vs those who had catheters removed and received anticoagulation. Among 83 total patients, 62 were treated with PICC removal alone, while 21 underwent PICC removal followed by therapeutic anticoagulation. Patients treated with PICC removal alone were more likely to have hematologic malignancy, receive chemotherapy, develop thrombocytopenia, and have brachial vein thrombosis. No patients in the PICC removal plus anticoagulation arm developed progressive thrombosis, while 6.4% of patients treated with catheter removal alone developed a secondary VTE event, including one PE, three DVTs, and five patients (8%) who developed progressive symptoms leading to initiation of anticoagulation. Major bleeding was significantly more common in the PICC removal + anticoagulation arm (28.5% vs. 4.8% p = 0.007). Catheter-removal alone results in significantly reduced major bleeding compared with catheter-removal plus anticoagulation. In select patients, catheter removal alone may be an option for CRT.

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.

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.

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.

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.

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.

Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli.

We sought to determine if symptomatic cardiogenic limb emboli have a random distribution or if there are demographic or echocardiographic factors that predict site of embolization, limb salvage and mortality. Upper (UE) and lower extremity (LE) emboli were evaluated over a 16-year period (1996-2012). Demographic (age, gender, smoking, medical comorbidities) and echocardiographic data were analyzed to determine predictors of embolic site. All symptomatic patients underwent surgical revascularization. Limb salvage and mortality were compared with Kaplan-Meier analysis. A total of 161 patients with symptomatic cardiogenic emboli were identified: 56 UE and 105 LE. The female-to-male ratio for UE emboli (70%:30%) was significantly higher than for LE emboli (47%:53%, p=0.008). No other demographic factors were statistically different. Upper extremity patients were more likely to have atrial fibrillation (50% vs 29.8%, p=0.028), while LE patients had a higher percentage of aortic or mitral valvular disease or intracardiac thrombus (71.4% vs 52.5%, p=0.038). The 30-day limb salvage was higher for UE compared to LE (100% vs 88%, p=0.008). There was a trend toward higher 30-day mortality in the LE group (14% vs 5%, p=0.11). Survival at 1, 3, and 5 years were similar (UE: 62.2%, 44.2%, 35.3%; LE: 69.1%, 47.5%, 30.3%; p=ns). Upper extremity emboli are more frequent in women and patients with atrial fibrillation. Lower extremity emboli are more frequent in the presence of valvular disease or intracardiac thrombus, and are associated with increased 30-day limb loss and mortality. These findings suggest gender- and cardiac-specific differences in patterns of blood flow leading to preferential sites of peripheral embolization.

Management of catheter-associated upper extremity deep venous thrombosis.

Central venous catheters or peripherally inserted central catheters are major risk factors for upper extremity deep venous thrombosis (UEDVT). The body and quality of literature evaluating catheter-associated (CA) UEDVT have increased, yet strong evidence on screening, diagnosis, prevention, and optimal treatment is limited. We herein review the current evidence of CA UEDVT that can be applied clinically. Principally, we review the anatomy and definition of CA UEDVT, identification of risk factors, utility of duplex ultrasound as the preferred diagnostic modality, preventive strategies, and an algorithm for management of CA UEDVT.

The role of axillofemoral bypass in current vascular surgery practice.

BACKGROUND: In the era of increasing endovascular approaches for aortoiliac disease, we sought to determine the role of axillofemoral bypass in contemporary practice. METHODS: All axillofemoral bypasses performed at our institution from 2006 to 2013 were reviewed for indication, patency, and survival and compared with our prior published series before the widespread use of endovascular techniques (1996 to 2001). RESULTS: During the study period, 90 bypasses (29 axillofemoral and 61 axillobifemoral) bypasses were performed. The number of procedures performed decreased from an average of 24 to 12 procedures per year in historical and contemporary groups, respectively. Indications have changed significantly with more urgent or emergent procedures. Overall patency at 1 and 2 years was 74.6% and 67.8%, respectively. Median survival was 40.3 months, with overall survival 67.0% and 54.2% at 1 and 2 years, respectively. CONCLUSIONS: Axillofemoral bypass is an increasingly uncommon procedure and more likely performed for limb salvage in urgent or emergent settings.

The Natural History of Indeterminate Blunt Cerebrovascular Injury.

IMPORTANCE: The Denver criteria grade blunt cerebrovascular injuries (BCVIs) but fail to capture many patients with indeterminate findings on initial imaging. OBJECTIVE: To evaluate outcomes and clinical significance of indeterminate BCVIs (iBCVIs). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of all patients treated for BCVIs at our institution from January 1, 2007, through July 31, 2014, was completed. Patients were divided into 2 groups: those with true BCVIs as defined by the Denver criteria and those with iBCVIs, which was any initial imaging suggestive of a cerebrovascular arterial injury not classifiable by the Denver criteria. MAIN OUTCOMES AND MEASURES: Primary outcomes were rate of resolution of iBCVIs, freedom from cerebrovascular accident (CVA) or transient ischemic attack (TIA), and 30-day mortality. RESULTS: We identified 100 patients with 138 BCVIs: 79 with true BCVIs and 59 with iBCVIs. With serial imaging, 23 iBCVIs (39.0%) resolved and 21 (35.6%) remained indeterminate, whereas 15 (25.4%) progressed to true BCVI. The rate of CVA or TIA in the iBCVI group was 5.1% compared with 15.2% in the true BCVI group (P = .06). Of the 15 total CVAs or TIAs, 11 (73.3%) resulted from carotid injury and 4 (26.7%) from vertebral artery occlusion (P = .03). By Kaplan-Meier analysis, there was no difference in freedom from CVA or TIA for the 2 groups (P = .07). Median clinical follow-up was 91 days. Overall and 30-day mortality for the entire series were 17.4% and 15.2%, respectively. There was no difference in long-term or 30-day mortality between true BCVI and iBCVI groups. CONCLUSIONS AND RELEVANCE: Detection of iBCVI has become a common clinical conundrum with improved and routine imaging. Indeterminate BCVI is not completely benign, with 25.4% demonstrating anatomical progression to true BCVI and 5.1% developing cerebrovascular symptoms. We therefore recommend serial imaging and antiplatelet therapy for iBCVI.

Incidence and outcomes of intraoperative vascular surgery consultations.

OBJECTIVE: Vascular surgeons may aid in primarily nonvascular procedures. Such activity has not been quantified, and hospital administrators may be unaware of the importance of vascular surgeons to support other hospital-based surgical programs. This study reviewed intraoperative consultations by vascular surgeons to support other surgical services. METHODS: Intraoperative vascular consultations were reviewed from January 2006 to January 2014 for consulting service, indication, and whether consultation occurred with advanced notice. Patient demographics, operative times, estimated blood loss, length of stay, and relative value units (RVUs) assigned for each consultation were also assessed. Consultations for trauma and iatrogenic injuries occurring outside the operating theater were excluded. RESULTS: Vascular surgeons performed 225 intraoperative consultations in support of procedures by nonvascular surgeons. Requesting services were surgical oncology (46%), orthopedics (17%), urology (11%), otolaryngology (7%), and others (19%). Reasons for consultation overlapped and included vascular reconstruction (53%), control of hemorrhage (39%), and assistance with difficult dissections (43%). Seventy-four percent were for intra-abdominal procedures, and venous (53%) and arterial (50%) problems were encountered equally with some overlap. Most patients were male (59%), overweight (56%; body mass index ≥25 kg/m(2)), had previous surgery (72%) and were undergoing elective procedures (89%). Mean total procedural anesthesia time was 9.4 hours, mean procedural operating time was 7.9 hours, and mean total and vascular-related estimated blood loss was 1702 mL and 327 mL, respectively. Mean length of stay was 14.7 days, mean intensive care unit stay was 2.9 days, and 30-day mortality was 6.2%. Mean nonvascular RVUs per operation were 46.0, and mean vascular RVUs per operation were 30.9. CONCLUSIONS: Unexpected intraoperative need for vascular surgical expertise occurs often enough that vascular surgeons should be regarded as an essential operating room resource to the general operating room, nonvascular surgeons, and their patients. Intraoperative vascular surgical consultation in support of other surgeons requires a high level of open technical operative skills and is time and labor intensive.

Nasal methicillin-resistant Staphylococcus aureus colonization is associated with increased wound occurrence after major lower extremity amputation.

OBJECTIVE: Wound occurrence (WO) after major lower extremity amputation (MLEA) can be due to wound infection or sterile dehiscence. We sought to determine the association of nasal methicillin-resistant Staphylococcus aureus (MRSA) colonization and other patient factors with overall WO, WO due to wound infection, and WO due to sterile dehiscence. METHODS: The medical records of all patients undergoing MLEA from August 1, 2011, to November 1, 2013, were reviewed. Demographic data, hemoglobin A1c level, albumin concentration, dialysis dependence, peripheral vascular disease (PVD), nasal MRSA colonization, and diabetes mellitus (DM) were examined as variables. The overall WO rate was determined, and the cause of WO was categorized as either a sterile dehiscence or a wound infection. RESULTS: Eighty-three patients underwent 96 MLEAs during a 27-month period. The rates of overall WO, WO due to infection, and WO due to sterile dehiscence were 39%, 19%, and 19%, respectively (1% developed a traumatic wound). On univariate analysis, PVD, MRSA colonization, DM, and dialysis dependence were all associated with higher rates of overall WO (P < .05). On multivariate analysis, MRSA colonization was associated with higher rates of overall WO (P = .03) and WO due to wound infection (11% vs 45%; P < .01). DM and PVD were associated with higher rates of overall WO and WO due to sterile dehiscence on both univariate and multivariate analysis (P < .05). CONCLUSIONS: Nasal MRSA colonization is associated with higher rates of overall WO and WO due to wound infection. DM and PVD are associated with higher rates of overall WO and WO due to sterile dehiscence but are not associated with WO due to wound infection. Further studies addressing the effect of nasal MRSA eradication on postoperative wound outcomes after MLEA are warranted.