Gluteal and thigh compartment syndrome after open abdominal aortic aneurysm repair.

Although compartment syndrome (CS) can occur in any myofascial compartment, the thigh and buttock are among the least common. CS is characterized by an increase in pressure of a myofascial compartment that results in a reduction of capillary blood flow and myonecrosis. Although >75% of cases of CS occur after long bone fractures, acute CS can also occur from nontraumatic and vascular etiologies. We report a case of gluteal and thigh CS resulting from ischemia-reperfusion injury after abdominal aortic aneurysm repair and left common iliac artery bypass.

The natural history of chronic limb-threatening ischemia after technical failure of endovascular intervention.

OBJECTIVES: The treatment for chronic limb-threatening ischemia (CLTI) has changed dramatically in the last few decades with a shift toward an endovascular-first approach and aggressive revascularization to achieve limb salvage. As the size of the CLTI population and intervention rates increase, patients will continue to experience technical failure (TF). Here, we describe the natural history of patients after TF of endovascular intervention for CLTI. METHODS: We conducted a retrospective cohort study of patients with CLTI who attempted endovascular intervention or bypass at our multidisciplinary limb salvage center from 2013 to 2019. Patient characteristics were collected according to the Society for Vascular Surgery's reporting standards. Primary outcomes included survival, limb salvage, wound healing, and revascularization patency. Product-limit Kaplan-Meier estimated survival functions for these outcomes, and between-group comparisons were made using Mantel-Cox log-rank nonparametric tests. RESULTS: We identified 242 limbs from 220 unique patients who underwent primary bypass (n = 30) or attempted endovascular intervention (n = 212) at our limb salvage center. Endovascular intervention was a TF in 31 (14.6%) limbs. After TF, 13 limbs underwent secondary bypass and 18 limbs were managed medically. Patients who experienced TF tended to be older (P < .001), male (P = .003), current tobacco users (P = .014), have longer lesions (P = .001), and have chronic total occlusions of target arteries (P < .001) as compared with those who experienced technical success. Furthermore, the TF group had worse limb salvage (P = .047) and slower wound healing (P = .028), but their survival was not different. Survival, limb salvage, and wound healing were not different in patients who received secondary bypass or medical management after TF. The secondary bypass group was older (P = .012) and had a lower prevalence of tibial disease (P = .049) than the primary bypass group and trended toward decreased survival, limb salvage, and wound healing (P = .059, P = .083, and P = .051, respectively). CONCLUSIONS: Increased age, male sex, current tobacco use, longer arterial lesions, and occluded target arteries are associated with TF of endovascular intervention. Limb salvage and wound healing are relatively poor after TF of endovascular intervention, but survival appears comparable with patients who experience technical success. Secondary bypass may not always rescue patients after TF, though our sample size limits statistical power. Interestingly, patients who received a secondary bypass after TF trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.

Vessel-by-vessel analysis of lower extremity 18F-NaF PET/CT imaging quantifies diabetes- and chronic kidney disease-induced active microcalcification in patients with peripheral arterial disease.

BACKGROUND: Positron emission tomography (PET)/computed tomography (CT) imaging with fluorine-18 (18F)-sodium fluoride (NaF) provides assessment of active vascular microcalcification, but its utility for evaluating diabetes mellitus (DM)- and chronic kidney disease (CKD)-induced atherosclerosis in peripheral arterial disease (PAD) has not been comprehensively evaluated. This study sought to use 18F-NaF PET/CT to quantify and compare active microcalcification on an artery-by-artery basis in healthy subjects, PAD patients with or without DM, and PAD patients with or without CKD. Additionally, we evaluated the contributions of DM, CKD, statin use and established CT-detectable calcium to 18F-NaF uptake for each lower extremity artery. METHODS: PAD patients (n = 48) and healthy controls (n = 8) underwent lower extremity 18F-NaF PET/CT imaging. Fused PET/CT images guided segmentation of arteries of interest (i.e., femoral-popliteal, anterior tibial, tibioperoneal trunk, posterior tibial, and peroneal) and quantification of 18F-NaF uptake. 18F-NaF uptake was assessed for each artery and compared between subject groups. Additionally, established calcium burden was quantified for each artery using CT calcium mass score. Univariate and multivariate analyses were performed to evaluate DM, CKD, statin use, and CT calcium mass as predictors of 18F-NaF uptake in PAD. RESULTS: PAD patients with DM or CKD demonstrated significantly higher active microcalcification (i.e., 18F-NaF uptake) for all arteries when compared to PAD patients without DM or CKD. Univariate and multivariate analyses revealed that concomitant DM or CKD was associated with increased microcalcification for all arteries of interest and this increased disease risk remained significant after adjusting for patient age, sex, and body mass index. Statin use was only associated with decreased microcalcification for the femoral-popliteal artery in multivariate analyses. Established CT-detectable calcium was not significantly associated with 18F-NaF uptake for 4 out of 5 arteries of interest. CONCLUSIONS: 18F-NaF PET/CT imaging quantifies vessel-specific active microcalcification in PAD that is increased in multiple lower extremity arteries by DM and CKD and decreased in the femoral-popliteal artery by statin use. 18F-NaF PET imaging is complementary to and largely independent of established CT-detectable arterial calcification. 18F-NaF PET/CT imaging may provide an approach for non-invasively quantifying vessel-specific responses to emerging anti-atherogenic therapies or CKD treatment in patients with PAD.

Extra-Anatomic Bypass and Excision is Superior to Graft Salvage Attempts with Antibiotic Beads to Treat Vascular Graft Infections in the Groin.

BACKGROUND: This study aimed to determine if conventional extra-anatomic bypass and graft removal versus aggressive attempts at graft preservation have better survival and limb salvage in patients with localized groin wound infections of vascular grafts. METHODS: We conducted a retrospective review of 53 consecutive patients with vascular graft infections presenting in the groin. Treatment groups consisted of group 1 (extra-anatomic bypass and graft excision, n = 22) and group 2 (initial graft preservation attempts with utilization of antibiotic beads, n = 31). In group 2, patients underwent serial debridement and placement of antibiotic beads until culture-negative wounds were achieved. Significantly more patients underwent muscle flap coverage in group 2 (27/31) compared with group 1 (7/22; P < 0.001). Data collected included demographics, comorbidities, intraoperative details, and outcomes, including patency, limb salvage, mortality, and number of procedures. Continuous variables were examined with Student's t-test, and dichotomous variables were examined with chi-squared test. Linear and logistic regressions were used to analyze factors associated with outcomes, in addition to Kaplan-Meier analysis with log rank for actuarial analysis. RESULTS: Both groups were similar with respect to demographics. The overall Kaplan-Meier 1- and 3-year survival rates were 66.2% and 34.1%, with no statistically significant difference between groups. The Kaplan-Meier 1- and 3-year limb salvage rates were 68.8% and 36.6% for group 1 vs. 58.5% and 38.7% for group 2 (P = not significant [NS]). The 1- and 3-year primary patency rates were 71% and 71% in traditional group 1 vs. 72% and 56% in group 2 (P = NS). One-year and 3-year secondary patency rates in traditional group 1 were 83% and 71% vs. 85% and 61% in group 2 (P = NS). Patients in group 1 underwent fewer total procedures when compared with group 2 (2.3 ± 0.2 vs. 5.1 ± 0.7, P = 0.03). The late reinfection rate was significantly less in group 1 (4.5%) compared with group 2 (26%; P = 0.04). Freedom from reinfection at 1 and 3 years were 94% and 94% in traditional group 1 vs. 74% and 62% in group 2 (P = 0.03). Multivariable analysis showed a higher incidence of amputation in patients who suffered reinfection (n = 13, P = 0.049). There was a higher mortality in patients with septic shock (n = 10, P = 0.007) and reinfection (n = 13, P = 0.036). Reinfection was associated with the highest mortality (P = 0.03). CONCLUSIONS: Conventional graft excision with extra-anatomic bypass resulted in similar mortality when compared with aggressive attempts at graft preservation and trended toward improved limb salvage and patency. However, attempts at graft preservation with antibiotic beads resulted in a significantly higher reinfection rate and greater number of procedures, and therefore, this approach should be used very selectively.

A prebifurcated axillobifemoral polytetrafluoroethylene graft simplifies carotid to carotid to subclavian bypass.

The use of thoracic endovascular aortic repair for thoracic aortic disease will necessitate cervical debranching in cases involving the proximal arch. We have presented the case of a 57-year-old athletic woman who had developed a type A dissection that extended to the bilateral iliac arteries. After hemiarch repair, she underwent staged cervical debranching with carotid-carotid-subclavian bypass using a prebifurcated axillobifemoral graft and subsequent thoracic endovascular aortic repair. We have detailed her successful clinical course and described the benefits of using a prebifurcated graft for cervical debranching in hybrid repairs of aortic arch pathology.

Long-term outcomes of transposed femoral vein arteriovenous fistula for abandoned upper extremity dialysis access.

BACKGROUND: The number and longevity of patients with end-stage renal disease requiring dialysis access have continued to increase, leading to challenging situations, including exhausted upper extremity access and severe central venous stenosis. This has led to an increase in the use of alternative access sites, including the lower extremities. The transposed femoral vein arteriovenous fistula for dialysis access is a previously described alternative, although limited data are available on its long-term patency. METHODS: Patients treated with a transposed femoral vein fistula were retrospectively reviewed. A transposed femoral vein fistula was created by harvesting the femoral vein and transposing it to the distal superficial femoral artery at the level of the adductor canal. The demographic information, perioperative characteristics, complications, and long-term outcomes were recorded and analyzed. RESULTS: A total of 21 patients had undergone transposed femoral vein fistula for dialysis access after an average of 5.3 ± 2.8 failed dialysis access procedures and a duration of 6.1 ± 4.9 years from the initiation of dialysis. The average age at the procedure was 53.5 ± 12.8 years. Ten patients (47.6%) had a history of diabetes mellitus and nine (42.9%) had a history of coronary artery disease. Technical success was achieved in 100% of cases, and 16 patients (76.2%) were discharged with anticoagulation therapy. The primary patency at 1, 3, and 5 years was 93%, 74%, and 74%, respectively. The secondary patency at 1, 3, and 5 years was 100%, 89%, and 89%, respectively. Two patients had compartment syndrome requiring fasciotomy, and six patients experienced wound complications. CONCLUSIONS: Transposed femoral vein fistula for dialysis access is a viable alternative for patients with an exhausted upper extremity access, with good long-term patency.

The State of Vascular Surgery Interest Groups in North America.

BACKGROUND: Vascular surgery interest groups (VSIGs) raise awareness and attract medical students to the specialty. There has been a plateauing of applicants interested in integrated programs. The goal of this survey was to assess the activities of VSIGs and identify factors associated with matriculation into vascular surgery residency. METHODS: A survey was administered to members of the association of program directors in vascular surgery. It inquired about the presence of a VSIG at the corresponding medical schools. The program directors at institutions lacking VSIGs were asked about possible hurdles in establishing one. The rest of the survey focused on the different activities of the VSIG. The VSIGs were divided into low enrollment if less than 10% of the students in that group pursue vascular surgery training and high enrollment if greater than 10% of the students pursue vascular surgery. Chi-squared test was used for comparison. RESULTS: There were 65/123 programs that responded (53% response rate). The responses came most commonly from programs in the Northeast (36.9%). Only 37% (n = 24) had a VSIG at their institutions. Lack of time (65.2%) and lack of a student champion (60.9%) were the most common hurdles encountered by the program directors who considered establishing a VSIG. Comparing the 2 groups of VSIGs, there was no difference in terms of the training paradigm, experience of program director, or geographical location. The VSIGs had comparable duration of activity, number of students, and meeting frequency. There was no difference in clinical exposure outside the curriculum between the 2 groups with observation on the wards and in clinic being most common. Endovascular simulation was significantly (P = 0.01) more common in low enrollment (83.3%) compared with high enrollment (33.3%) VSIG. There was a trend in the high enrollment group for more vascular anastomosis training (75% vs. 66.7%) that did not reach statistical significance (P = 0.65). There was no difference between the 2 groups in career development opportunities and education activities. Most VSIGs (75%) operated with a budget of less than $1,000 based on divisional or departmental funding (low enrollment = 66.7% versus high enrollment = 41.7%, P = 0.22). CONCLUSIONS: Only one-third of the vascular surgery training programs have an associated VSIG. Vascular surgery training programs should promote VSIG formation with equal emphasis on endovascular and open surgery, thus providing medical students an early exposure to the specialty.

Trends and perioperative outcomes of patients with human immunodeficiency virus (HIV) undergoing lower extremity revascularization.

The development of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients with human immunodeficiency virus (HIV), but has led to the rise of chronic conditions including peripheral artery disease (PAD). However, trends and outcomes among patients with HIV undergoing lower extremity revascularization are poorly characterized. The aim of this study was to investigate the trends and perioperative outcomes of lower extremity revascularization among patients with HIV and PAD in a national database. The National Inpatient Sample (NIS) was reviewed between 2003 and 2014. All hospital admissions with a diagnosis of PAD undergoing lower extremity revascularization were stratified based on HIV status. Outcomes were assessed using propensity score matching and multivariable regression. Among all patients undergoing lower extremity revascularization for PAD, there was a significant increase in the proportion of patients with HIV from 0.21% in 2003 to 0.52% in 2014 (p < 0.01). Patients with HIV were more likely to be younger, male, and have fewer comorbidities, including coronary artery disease and diabetes, at the time of intervention compared to patients without HIV. With propensity score matching and multivariable regression, HIV status was associated with increased total hospital costs, but not length of stay, major amputation, or mortality. Patients with HIV with PAD who undergo revascularization are younger with fewer comorbidities, but have increased hospital costs compared to those without HIV. Lower extremity revascularization for PAD is safe for patients with HIV without increased risk of in-hospital major amputation or mortality, and continues to increase each year.

Redesigning a Department of Surgery during the COVID-19 Pandemic.

BACKGROUND: COVID-19 has created an urgent need for reorganization and surge planning among departments of surgery across the USA. METHODS: Review of the COVID-19 planning process and work products in preparation for a patient surge. Organizational and process changes, workflow redesign, and communication plans are presented. RESULTS: The planning process included widespread collaboration among leadership from many disciplines. The department of surgery played a leading role in establishing clinical protocols, guidelines, and policies in preparation for a surge of COVID-19 patients. A multidisciplinary approach with input from clinical and nonclinical stakeholders is critical to successful crisis planning. A clear communication plan should be implemented early and input from trainees, staff, and faculty should be solicited. CONCLUSION: Major departmental and health system reorganization is required to adapt academic surgical practices to a widespread crisis. Surgical leadership, innovation, and flexibility are critical to successful planning and implementation.

Surgery for the Very Old: Are Nonagenarians Different?

Octogenarians and nonagenarians are considered the "very old" and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007-2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30-1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.

SPECT/CT Imaging: A Noninvasive Approach for Evaluating Serial Changes in Angiosome Foot Perfusion in Critical Limb Ischemia.

Objective: To investigate the feasibility of serial radiotracer-based imaging as a noninvasive approach for quantifying volumetric changes in microvascular perfusion within angiosomes of the foot following lower extremity revascularization in the setting of critical limb ischemia (CLI). Approach: A CLI patient with a nonhealing foot ulcer underwent single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of the feet before and after balloon angioplasty of the superficial femoral artery (SFA) and popliteal artery. SPECT/CT imaging was used to evaluate serial changes in angiosome perfusion, which was compared to quantitative changes in peripheral vascular anatomy and hemodynamics, as assessed by standard clinical tools that included digital subtraction angiography (DSA), ankle-brachial index (ABI), and toe-brachial index (TBI). Results: Following revascularization, upstream quantitative improvements in stenosis of the SFA (pre: 35.4% to post: 11.9%) and popliteal artery (pre: 59.1% to post: 21.7%) shown by DSA were associated with downstream angiosome-dependent improvements in SPECT microvascular foot perfusion that ranged from 2% to 16%. ABI measurement was not possible due to extensive arterial calcification, while TBI values decreased from 0.26 to 0.16 following revascularization. Innovation: This is the first study to demonstrate the feasibility of assessing noninvasive volumetric changes in angiosome foot perfusion in response to lower extremity revascularization in a patient with CLI by utilizing radiotracer-based imaging. Conclusion: SPECT/CT imaging allows for quantification of serial perfusion changes within angiosomes containing nonhealing ulcers and provides physiological assessment that is complementary to conventional anatomical (DSA) and hemodynamic (ABI/TBI) measures in the evaluation of lower extremity revascularization.

Approaches to the Salvage of Axillary Bilateral Femoral Bypass in Patients with Claudication due to Demand Ischemia.

The axillary bilateral femoral bypass is often utilized as an alternative to in-line aortic reconstruction in patients with multiple medical comorbidities, who would be unable to tolerate open abdominal surgery with an aortic clamp, or patients with mycotic aneurysms, or infected grafts. Idealized fluid mechanics suggest that there would be equal flow in an axillary bilateral femoral bypass when compared to in-line reconstruction. However, in a non-idealized state, friction results in kinetic energy loss and decreased volume flow to the lower extremities in the longer, smaller diameter graft. Although older or less active people may tolerate the lower volume flow of a long segment extra-anatomic bypass, there is growing evidence that a subset of patients will be symptomatic from reduced flow volumes. Here we present 3 patients in whom symptomatic relief was achieved with the addition of a contralateral axillary femoral bypass and ligation of the previous femorofemoral component.

A Pilot Study of a Standardized Smoking Cessation Intervention for Patients with Vascular Disease.

BACKGROUND: The goal of this study is to evaluate the efficacy of a smoking cessation intervention performed by a vascular surgery provider compared with current smoking cessation practices. METHODS: Patients with peripheral arterial and aneurysmal disease who presented to the vascular surgery service at a tertiary care center over a 9-month period were randomized to either control or intervention group. Both control and intervention groups received 2 weeks of free nicotine patches and referral to an outpatient smoking-cessation program. The intervention group additionally received a brief presentation by a vascular surgeon regarding the benefits of smoking cessation, with a focus on vascular complications. At enrollment and at follow-up, patients underwent carbon monoxide breath testing and completed a survey. The primary outcome was smoking cessation or reduction among control and intervention groups in patients who underwent medical management, endovascular procedures, or open surgical procedures. Fisher's exact test was used to assess the primary outcome among groups. RESULTS: Fifty-nine patients were enrolled in the trial initially, but 55 had 1-month follow-up (control n = 28, intervention n = 27) and 52 had long-term follow-up (control n = 28, intervention n = 24). By long-term follow-up, 40 patients (77%) had reduced smoking by at least 50% and 16 patients (31%) had quit completely. At long-term follow-up, 88% of patients in the intervention group and 68% of patients in the control group reduced smoking (P = 0.1). CONCLUSIONS: A large proportion of vascular patients who received 2 weeks of nicotine replacement with or without the addition of brief smoking cessation counseling delivered by a vascular surgery provider were able to reduce smoking and maintain reduction after 6 months. Delivery of a brief standardized smoking cessation counseling session by a vascular surgery provider is safe and feasible. Additional randomized controlled trials with large enrollment periods and long follow-up are needed to determine the efficacy of this intervention in comparison to standard care.

Safety and efficacy of venous ablation in octogenarians.

OBJECTIVE: Venous ablation (VA) is the recommended treatment of superficial venous insufficiency affecting the lower extremities. The safety and efficacy of the procedure in octogenarians have not been well studied. We postulate that VA in octogenarians is as safe and effective as in younger age groups. METHODS: A retrospective single-center review of consecutive patients undergoing VA using radiofrequency in an outpatient office was performed. Patients, imaging, and procedural characteristics were reviewed from the medical records. A telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 before and after treatment was conducted. Patients were divided into three groups based on age: <65 years, 65 to 79 years, and ≥80 years. Clinical success was defined by patients' reporting improvement or resolution of symptoms and was reported per leg. Technical success was defined by vein closure on duplex ultrasound and was reported per vein. Patients and outcomes were compared between the three groups using χ2 or analysis of variance test in SAS software (SAS Institute, Cary, NC). RESULTS: There were 362 patients who underwent 627 VAs in 512 legs. Octogenarians constituted 9.4% of the patient population and were more likely to have cardiovascular comorbidities. Octogenarians were significantly more likely to have advanced venous disease as determined by the Clinical, Etiology, Anatomy, and Pathophysiology classification compared with younger patients (P = .005). On ultrasound, younger patients had significantly larger vein diameters (P = .04) and longer reflux times (P < .001). There was no significant difference in the types of veins (P = .08) or the mean number of veins (P = .37) treated in the three groups; however, there was a trend toward younger patients' requiring more adjunctive procedures (P = .1). The clinical success (P = .86), technical success (P = .19), and complications (P = .36) were not different between octogenarians and younger patients. The survey results demonstrated similar findings with no difference in pain improvement (P = .27) or recurrence (P = .36). CONCLUSIONS: Octogenarians treated with VA present at a more advanced clinical stage compared with younger patients but have less severe ultrasound findings. VA is safe and effective in all age groups. Age should not be used to deny patients VA.

Costs and complications of endovascular inferior vena cava filter retrieval.

OBJECTIVE: Advanced endovascular techniques are frequently used for challenging inferior vena cava (IVC) filter retrieval. However, the costs of IVC filter retrieval have not been studied. This study compares IVC filter retrieval techniques and estimates procedural costs. METHODS: Consecutive IVC filter retrievals performed at a tertiary center between 2009 and 2014 were retrospectively reviewed. Procedures were classified as standard retrieval (SR) if they required only a vascular sheath and a snare device and as advanced endovascular retrieval (AER) if additional endovascular techniques were used for retrieval. Cost data were based on hospital bills for the procedures. Patients' characteristics, filter dwell time, retrieval procedure details, complications, and costs were compared between the groups. All statistical comparisons were performed using SAS 9.3 software. RESULTS: There were 191 IVC filter retrievals (SR, 157; AER, 34) in 183 patients (mean age, 55 years; 51% male). Fifteen filters (7.9%) were placed at an outside hospital. The indications for placement were mostly therapeutic (76% vs 24% for prophylaxis). All IVC filters were retrievable, with Bard Eclipse (Bard Peripheral Vascular, Tempe, Ariz; 34%) and Cook Günther Tulip (Cook Medical, Bloomington, Ind; 24%) the most common. Venous ultrasound examination of the lower extremities of 133 patients (70%) was performed before retrieval, whereas only 5 patients (2.6%) received a computed tomography scan of the abdomen. There was no difference in the mean filter dwell time in the two groups (SR, 147.9 ± 146.1 days; AER, 161.4 ± 91.3 days; P = .49). AERs were more likely to have had prior attempts at retrieval (23.5%) compared with SRs (1.9%; P < .001). The most common AER techniques used were the wire loop and snare sling (47.1%) and the stiff wire displacement (44.1%). Bronchoscopy forceps was used in four cases (11.8%); this was the only off-label device used. AERs were more likely to require more than one venous access site for the retrieval procedure (23.5% vs 0%; P < .001). AERs were significantly more likely to have longer fluoroscopy time (34.4 ± 18.3 vs 8.1 ± 7.9 minutes; P < .001) and longer total procedural time (102.8 ± 59.9 vs 41.1 ± 25.0 minutes; P < .001) compared with SRs. The complication rate was higher with AER (20.6%) than with SR (5.2%; P = .006). Most complications were abnormal radiologic findings that did not require additional intervention. The procedural cost of AER was significantly higher (AER, $14,565 ± $6354; SR, $7644 ± $2810; P < .001) than that of SR. This translated to an average increase in cost of $6921 ± $3544 per retrieval procedure for AER. CONCLUSIONS: Advanced endovascular techniques provide a feasible alternative when standard IVC filter retrieval techniques do not succeed. However, these procedures come with a higher cost and higher rate of complications.

Hybrid surgery for bilateral lower extremity inflow revascularization.

OBJECTIVE: Aortobifemoral (ABF) bypass is the preferred method of bilateral inflow revascularization, with axillobifemoral (AXBF) bypass reserved for high-risk patients. Hybrid (HYB) surgery in the form of femorofemoral bypass and retrograde endovascular aortoiliac intervention is increasingly being used to achieve the same goal. This study compared the perioperative outcomes of HYB surgery with traditional surgery for bilateral inflow revascularization. METHODS: The American College of Surgeons National Surgical Quality Improvement Program files for the years 2012 to 2015 were reviewed, and all patients undergoing ABF bypass, AXBF bypass, and HYB surgery (femoral-femoral bypass and retrograde endovascular intervention) were included. Patients' demographics, comorbidities, and outcomes were compared between the three groups. A propensity-matched analysis was subsequently performed to compare HYB surgery with ABF bypass only. The χ2 test and analysis of variance with post hoc analysis were conducted to evaluate between-group differences in risk factors and outcomes. SPSS statistical software (IBM Corp, Armonk, NY) was used. RESULTS: There were 1426 patients (ABF bypass, 976; AXBF bypass, 257; HYB surgery, 193). There were significant differences in the three populations of patients, with ABF bypass patients significantly more likely to have age <70 years (ABF bypass, 84.2%; AXBF bypass, 49.8%; HYB surgery, 58%; P < .001) and more likely to be independent (ABF bypass, 98%; AXBF bypass, 89.1%; HYB surgery, 93.2%; P < .001). Patients undergoing AXBF bypass were significantly more likely to be treated for critical limb ischemia (ABF bypass, 46.5%; AXBF bypass, 72.4%; HYB surgery, 51.8%; P < .001) under emergent conditions (ABF bypass, 0.9%; AXBF bypass, 5.1%; HYB surgery, 3.6%; P < .001). There was no difference in mortality between the three groups (P = .178). After propensity matching, a total of 571 patients with ABF bypass were compared with HYB surgery patients. HYB surgery patients had significantly less pneumonia (ABF bypass, 8.7%; HYB surgery, 1.6%; P < .001), unplanned intubation (ABF bypass, 7.7%; HYB surgery, 3.1%; P = .032), cardiac arrest (ABF bypass, 3.7%; HYB surgery, 0.5%; P = .025), transfusion (ABF bypass, 44.4%; HYB surgery, 18.1%; P < .001), and composite morbidity (ABF bypass, 55%; HYB surgery, 32.6%; P < .001). Patients undergoing ABF bypass had significantly higher mortality (ABF bypass, 4.2%; HYB surgery, 1%; P = .043) and 30-day reoperation (ABF bypass, 17.5%; HYB surgery, 9.3%; P = .009) and longer total hospital length of stay (ABF bypass, 9.79 ± 10.69 days; HYB surgery, 5.79 ± 9.72 days; P < .001). There was no difference in major amputation (P = .607) and readmission (P = .495) between the two groups. CONCLUSIONS: ABF bypass is the most common surgery for bilateral lower extremity revascularization in the American College of Surgeons National Surgical Quality Improvement Program database and continues to have good outcomes. In selected patients, HYB surgery was associated with improved perioperative, 30-day outcomes compared with ABF bypass.

Patient perspectives on inferior vena cava filter retrieval.

OBJECTIVE: Inferior vena cava (IVC) filter retrieval rates remain low. Previous literature identified provider and system factors to enhance retrieval, but patients' perspectives have not been studied. This study compared the attitudes of men and women with retained filters to identify patient factors that would increase compliance and facilitate retrieval when indicated. METHODS: A retrospective single-center review of all patients undergoing IVC filter placement between 2009 and 2011 was performed. The electronic medical records were reviewed to identify patients with retained filters who were potential candidates for removal. Patients' demographics, comorbidities, and indication for filter placement were noted. A telephone survey inquiring about the patient's awareness of IVC filters and risks of leaving them permanently in place was conducted. Additional questions addressed patient-physician relations, preferences in communication, and attitudes toward television commercials on IVC filter lawsuits. Patients' characteristics and survey responses were compared between men and women. RESULTS: There were 604 patients who underwent IVC filter placement. The overall retrieval rate was 30%. Telephone survey was conducted for 42 patients with retained filters who were identified as possible candidates for retrieval. There was no difference between the men and women in terms of demographics and comorbidities. The survey demonstrated that 12% of patients were not aware of having an IVC filter, and only 23% knew that it can be removed. Women were significantly more likely than men to know the risks and benefits of IVC filter placement (42.8% vs 14.2%; P <. 03), but there was no significant difference in knowledge of the long-term complications of indwelling filters. Even though the majority of patients (88%) had an established relation with a primary care provider, only 21.4% followed up with the team of physicians of the hospitalization for IVC filter placement. Better education about IVC filters would have improved follow-up in the opinion of 97.6% of patients. Also, 50% relocated since filter placement and 35.7% changed their telephone number. There was no difference regarding use of Internet and interest in receiving educational material, but women (42.8%) significantly preferred receiving health-related communication by electronic mail, whereas men (64%) preferred telephone calls (P = .03). The majority of patients (59.5%) had watched commercials for IVC filter lawsuits, among whom 26% claimed to seek discussion with a medical provider after watching the commercial. The predominant cause for no follow-up was "unaware of risks of leaving the filter" (69%). CONCLUSIONS: In this era of modern medicine, vascular specialists must educate the patient and family about IVC filters and long-term effects to optimize the patient's compliance. Electronic communication for follow-up may help capture patients who relocate and change phone numbers and seems to be particularly attractive to women.

Intravascular Ultrasound in Venous Thoracic Outlet Syndrome.

BACKGROUND: Venous thoracic outlet syndrome (vTOS) is a rare disease with no defined guidelines regarding treatment. Patients with first rib resection with anterior scalenectomy (FRRS) often have residual subclavian vein stenosis. The aim of this study was to evaluate the use of intravascular ultrasound (IVUS) in the treatment of vTOS patients who have been surgically decompressed with FRRS. METHODS: Patients treated with venography after FRRS for vTOS during 2015-2017 were retrospectively reviewed. Patients were included if they received a venogram with IVUS after FRRS. The axillosubclavian vein at the site of the thoracic outlet was imaged using single-plane venography and IVUS. A greater than 50% diameter stenosis on venography or 50% cross-sectional area reduction on IVUS was considered significant and treated with balloon venoplasty. RESULTS: During the 2-year period, 14 patients underwent 24 upper extremity venograms performed after surgical decompression for vTOS, 18 of which included IVUS. Of the 18 cases with IVUS, 5 (27.8%) stenoses >50% were detected by IVUS, which were not apparent on venography, leading to intervention. IVUS detected a greater degree of stenosis than venography. Seven patients required repeat venograms. Overall, IVUS detected significant venous stenosis in 94.4% of patients compared with 66.7% of patients with venography after FRRS for vTOS. CONCLUSIONS: These results suggest that IVUS detected greater levels of stenosis than venography, leading to more interventions. Just as IVUS being ideal for identifying occult iliac venous lesions, it may have a similar role in identifying venous lesions not evident on single-plane venography for postsurgical decompression in vTOS patients. Further studies may show this technique to increase the number of stenoses identified and improve long-term symptom relief.

A survey of vascular specialists' practice patterns of inferior vena cava filter placement and retrieval.

OBJECTIVES: The placement of inferior vena cava filters (IVCF) continues to rise. Vascular specialists adopt different practices based on local expertise. This study was performed to assess the attitudes of vascular specialists towards the placement and retrieval of IVCF. METHODS: An online survey of 28 questions related to practice patterns regarding IVCF was administered to 1429 vascular specialists. Vascular specialists were categorized as low volume if they place less than three IVCF per month and high volume if they place at least three IVCF per month. The responses of high volume and low volume were compared using two-sample t-tests and Chi-square tests. RESULTS: A total of 259 vascular specialists completed the survey (18% response rate). There were 191 vascular surgeons (74%) and 68 interventional radiologists (26%). The majority of responders were in academic practice (67%) and worked in tertiary care centers (73%). The retrievable IVCF of choice was Celect (27%) followed by Denali (20%). Forty-two percent used a temporary IVCF and left it in situ instead of using a permanent IVCF. Eighty-two percent preferred placing the tip of the IVCF at or just below the lowest renal vein. Thirty-one percent obtained a venous duplex of the lower extremities prior to retrieval while 24% did not do any imaging. There were 132 (51%) low volume vascular specialists and 127 (49%) high volume vascular specialists. Compared to low volume vascular specialists, significantly more high volume vascular specialists reported procedural times of less than 30 min for IVCF retrieval (57% vs. 42%, P = 0.026). There was a trend for high volume to have fewer unsuccessful attempts at IVCF retrieval but that did not reach statistical significance ( P = .061). High volume were more likely to have attempted multiple times to retrieve an IVCF (66% vs. 33%, P < .001), and to have used bronchoscopy forceps (32% vs. 14%, P = .001) or a laser sheath (14% vs. 2%, P < .001) for IVCF retrieval. In general, vascular specialists were not comfortable using bronchoscopy forceps (65%) or a laser sheath (82%) for IVCF retrieval. CONCLUSIONS: This study underscores significant variability in vascular specialists practice patterns regarding IVCF. More studies and societal guidelines are needed to define best practices.

Hybrid femoropopliteal procedures are associated with improved perioperative outcomes compared with bypass.

OBJECTIVE: Hybrid procedures have gained momentum as less invasive operations that can potentially improve outcomes for patients. However, there is a paucity of data comparing hybrid procedures with traditional bypass. This study compares the perioperative outcomes of hybrid and bypass surgery for femoropopliteal (FP) revascularization. METHODS: The American College of Surgeons National Surgical Quality Improvement Program files (2012-2015) were reviewed, and three groups of patients undergoing isolated FP revascularization were identified by Current Procedural Terminology codes. All patients underwent femoral endarterectomy. The hybrid group (HYB) had a concomitant antegrade endovascular FP intervention and was compared with patients with concomitant FP bypass with vein (BPV) and FP bypass with nonvein graft (BPG). The demographics, comorbidities, and outcomes of the three groups were analyzed. The χ2 and analysis of variance tests with post hoc analysis were used. A multivariable logistic regression analysis was performed to identify predictors of readmission, reoperation, and mortality. RESULTS: There were 1480 patients in the analysis. Compared with patients undergoing BPV and BPG, patients in the HYB group tended to be older (P = .016) and were less likely to be smokers (P < .001). They had fewer infected wounds (P = .001) and were more likely to have American Society of Anesthesiologists score ≤3 (P = .01) and claudication (P < .01). HYB patients had significantly fewer bleeding transfusions (P = .01) and less overall morbidity (P < .001) compared with BPV and BPG patients. The three treatment groups did not differ in frequencies of mortality and major amputation. Among the groups, BPV was associated with the longest operating time (P < .001), whereas HYB had significantly shorter hospital stay (P < .001). HYB was also associated with significantly lower rates of reoperation (P = .017) and readmission (P = .007). On multivariable regression, patients undergoing BPG were at increased risk of readmission (odds ratio [OR], 1.48 [1.00-2.17]) compared with HYB. HYB surgery was associated with less morbidity compared with BPV (OR, 1.38 [1-1.9]) and BPG (OR, 1.77 [1.3-2.38]). CONCLUSIONS: Hybrid procedures have favorable perioperative outcomes compared with open bypass for FP revascularization. Additional research on the long-term outcomes of hybrid procedures is needed.