Effect of Chronic Steroid Use on Postoperative Wound Complications in Patients Undergoing Arterial Bypass Surgery for Lower Extremity Peripheral Arterial Disease.

OBJECTIVE: While existing literature reports adverse effects of chronic steroid use on surgical wound outcomes, there remains lack of data exploring the effect of steroids on postoperative outcomes following lower extremity arterial bypass surgery. This study aims to explore the effect of chronic steroid use on surgical outcomes in patients undergoing open revascularization for lower extremity arterial occlusive disease. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005 and 2020, all patients receiving aortoiliac or infrainguinal arterial bypass for peripheral arterial disease (PAD) were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and 30-day outcomes were compared using χ2 test and independent t-test, and association of chronic steroid use with wound complications was studied using multivariable logistic regression analysis. RESULTS: A total of 44,675 patients undergoing open lower extremity revascularization were identified, of which 1,807 patients were on chronic steroids and 42,868 patients were not on chronic steroids. On multivariable logistic regression analysis, being on chronic steroids was associated with higher rates of deep SSI (OR 1.37, 95% CI 1.03-1.83), any SSI (OR 1.22, 95% CI 1.04-1.43) and wound dehiscence (OR 1.42, 95% CI 1.03-1.96). Chronic steroid users also had significantly increased odds of developing sepsis (OR 1.56, 95% CI 1.19-2.04), pneumonia (OR 1.44, 95% CI 1.08-1.91), UTI (OR 1.54, 95% CI 11.13-2.09), DVT (OR 1.60, 95% CI 1.01-2.53), and 30-day readmission (OR 1.30, 95% CI 1.12-1.50), reoperation (OR 1.17, 95% CI 1.01-1.37) and mortality (OR 1.33, 95% CI 1.01-1.76) compared to non-chronic steroid users. CONCLUSION: This study confirms that chronic corticosteroid use is associated with higher risk of surgical site infections (SSIs) in patients undergoing lower extremity arterial bypass surgery. These patients typically have various underlying health issues, emphasizing the need for personalized treatment and management to reduce steroid-related postoperative complications and improve survival.

The feasibility of emergency department observation units in the management of mild to moderate hyponatremia.

OBJECTIVE: To describe the feasibility of managing hyponatremia patients under outpatient observation status in an academic medical center, and compare outcomes based on the use of an emergency department observation unit (EDOU). METHODS: This is a retrospective cohort study of emergency department hyponatremic patients managed in four hospitals within a large urban academic medical center over 27 months. All patients had an admit-to-observation order, ICD-10 codes for hyponatremia, and mild (130-135 mmol/L) to moderate (121-129 mmol/L) hyponatremia. Observation settings were divided into two groups: EDOU and Non-Observation Unit (NOU) inpatient beds. Severe hyponatremia (≤120 mmol/L) was excluded. Primary clinical outcomes were inpatient admit rate, length of stay (LOS), total direct cost, the rate of adverse events and 30-day recidivism. RESULTS: 188 patients were managed as an observation patient, with 64 managed in an EDOU setting (age 74.0 yr, 70.3% female) and 124 managed in a NOU setting (age 71.5 yr, 64.5% female). Patient subgroups were similar in terms of presenting complaints, comorbidities, and medication histories. Initial and final sodium levels were similar between settings: EDOU (125.1 to 132.6 mmol/L) vs NOU (123.5 to 132.0 mmol/L). However, outcomes differed by setting for observation to inpatient admit rate (EDOU 28.1% vs NOU 37.9%, adjusted effect 0.70), overall length of stay (EDOU 19.2 h vs NOU 31.9 h; adjusted effect -10.5 h and total direct cost ($1230 vs $1531; adjusted effect -$167). EDOU sodium correction rates were faster (EDOU 0.44 mmol/L/h vs 0.24 mmol/L/h; adjusted effect 0.15 mmol/L/h) and 30-day recidivism rate was similar (EDOU 13% vs NOU 15%). There were no index visit deaths or intensive care unit admissions. CONCLUSION: Management of selected hyponatremia patients under observation status is feasible, with the EDOU setting demonstrating lower admit rates, shorter length of stay, and lower total direct costs with similar clinical outcomes.

Predicting outcomes following lower extremity open revascularization using machine learning.

Lower extremity open revascularization is a treatment option for peripheral artery disease that carries significant peri-operative risks; however, outcome prediction tools remain limited. Using machine learning (ML), we developed automated algorithms that predict 30-day outcomes following lower extremity open revascularization. The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent lower extremity open revascularization for chronic atherosclerotic disease between 2011 and 2021. Input features included 37 pre-operative demographic/clinical variables. The primary outcome was 30-day major adverse limb event (MALE; composite of untreated loss of patency, major reintervention, or major amputation) or death. Our data were split into training (70%) and test (30%) sets. Using tenfold cross-validation, we trained 6 ML models. Overall, 24,309 patients were included. The primary outcome of 30-day MALE or death occurred in 2349 (9.3%) patients. Our best performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve (95% CI) of 0.93 (0.92-0.94). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.08. Our ML algorithm has potential for important utility in guiding risk mitigation strategies for patients being considered for lower extremity open revascularization to improve outcomes.

Predicting Outcomes Following Endovascular Abdominal Aortic Aneurysm Repair Using Machine Learning.

OBJECTIVE: To develop machine learning (ML) models that predict outcomes following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). BACKGROUND: EVAR carries non-negligible perioperative risks; however, there are no widely used outcome prediction tools. METHODS: The National Surgical Quality Improvement Program targeted database was used to identify patients who underwent EVAR for infrarenal AAA between 2011 and 2021. Input features included 36 preoperative variables. The primary outcome was 30-day major adverse cardiovascular event (composite of myocardial infarction, stroke, or death). Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 ML models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Model robustness was evaluated with calibration plot and Brier score. Subgroup analysis was performed to assess model performance based on age, sex, race, ethnicity, and prior AAA repair. RESULTS: Overall, 16,282 patients were included. The primary outcome of 30-day major adverse cardiovascular event occurred in 390 (2.4%) patients. Our best-performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve (95% CI) of 0.95 (0.94-0.96) compared with logistic regression [0.72 [0.70-0.74)]. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.06. Model performance remained robust on all subgroup analyses. CONCLUSIONS: Our newer ML models accurately predict 30-day outcomes following EVAR using preoperative data and perform better than logistic regression. Our automated algorithms can guide risk mitigation strategies for patients being considered for EVAR.

Epidural Catheters for Cervical Epidural Steroid Injections to Target Higher Cervical Pathology: Clinical Images in Practice.

Cervical radicular pain is commonly treated with cervical epidural steroid injections. The transforaminal approach allows for direct treatment of the steroid at a particular nerve root or level. Still, it carries a significant risk of morbidity and mortality with thromboembolism or injury to cervical vasculature. The interlaminar approach is commonly utilized as it avoids vascular structures. However, the epidural space becomes narrower at higher levels, limiting the ability to perform this approach at higher cervical levels. Cervical epidural catheters can be used and advanced to target higher cervical pathology through the interlaminar approach. We present clinical images demonstrating the utility of a cervical catheter for treating higher cervical levels.

Predicting Major Adverse Cardiovascular Events Following Carotid Endarterectomy Using Machine Learning.

Background Carotid endarterectomy (CEA) is a major vascular operation for stroke prevention that carries significant perioperative risks; however, outcome prediction tools remain limited. The authors developed machine learning algorithms to predict outcomes following CEA. Methods and Results The National Surgical Quality Improvement Program targeted vascular database was used to identify patients who underwent CEA between 2011 and 2021. Input features included 36 preoperative demographic/clinical variables. The primary outcome was 30-day major adverse cardiovascular events (composite of stroke, myocardial infarction, or death). The data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 machine learning models were trained using preoperative features. The primary metric for evaluating model performance was area under the receiver operating characteristic curve. Model robustness was evaluated with calibration plot and Brier score. Overall, 38 853 patients underwent CEA during the study period. Thirty-day major adverse cardiovascular events occurred in 1683 (4.3%) patients. The best performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve of 0.91 (95% CI, 0.90-0.92). In comparison, logistic regression had an area under the receiver operating characteristic curve of 0.62 (95% CI, 0.60-0.64), and existing tools in the literature demonstrate area under the receiver operating characteristic curve values ranging from 0.58 to 0.74. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.02. The strongest predictive feature in our algorithm was carotid symptom status. Conclusions The machine learning models accurately predicted 30-day outcomes following CEA using preoperative data and performed better than existing tools. They have potential for important utility in guiding risk-mitigation strategies to improve outcomes for patients being considered for CEA.

Predicting outcomes following open revascularization for aortoiliac occlusive disease using machine learning.

OBJECTIVE: Open surgical treatment options for aortoiliac occlusive disease carry significant perioperative risks; however, outcome prediction tools remain limited. Using machine learning (ML), we developed automated algorithms that predict 30-day outcomes following open aortoiliac revascularization. METHODS: The National Surgical Quality Improvement Program (NSQIP) targeted vascular database was used to identify patients who underwent open aortoiliac revascularization for atherosclerotic disease between 2011 and 2021. Input features included 38 preoperative demographic/clinical variables. The primary outcome was 30-day major adverse limb event (MALE; composite of untreated loss of patency, major reintervention, or major amputation) or death. The 30-day secondary outcomes were individual components of the primary outcome, major adverse cardiovascular event (MACE; composite of myocardial infarction, stroke, or death), individual components of MACE, wound complication, bleeding, other morbidity, non-home discharge, and unplanned readmission. Our data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, we trained six ML models using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was evaluated with calibration plot and Brier score. Variable importance scores were calculated to determine the top 10 predictive features. Performance was assessed on subgroups based on age, sex, race, ethnicity, symptom status, procedure type, and urgency. RESULTS: Overall, 9649 patients were included. The primary outcome of 30-day MALE or death occurred in 1021 patients (10.6%). Our best performing prediction model for 30-day MALE or death was XGBoost, achieving an AUROC of 0.95 (95% confidence interval [CI], 0.94-0.96). In comparison, logistic regression had an AUROC of 0.79 (95% CI, 0.77-0.81). For 30-day secondary outcomes, XGBoost achieved AUROCs between 0.87 and 0.97 (untreated loss of patency [0.95], major reintervention [0.88], major amputation [0.96], death [0.97], MACE [0.95], myocardial infarction [0.88], stroke [0.93], wound complication [0.94], bleeding [0.87], other morbidity [0.96], non-home discharge [0.90], and unplanned readmission [0.91]). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.05. The strongest predictive feature in our algorithm was chronic limb-threatening ischemia. Model performance remained robust on all subgroup analyses of specific demographic/clinical populations. CONCLUSIONS: Our ML models accurately predict 30-day outcomes following open aortoiliac revascularization using preoperative data, performing better than logistic regression. They have potential for important utility in guiding risk-mitigation strategies for patients being considered for open aortoiliac revascularization to improve outcomes.

Lower limb amputation following venous cannulation for VA-ECMO: a case report.

Lower limb amputation following arterial cannulation for VA-ECMO has been described in the literature. Limb ischemia however following venous cannulation is very rare and not quite understood. We present a case of limb ischemia following venous cannulation. A combination of venous congestion, compartment syndrome and subsequent arterial insufficiency is the proposed pathophysiology. Shock and use of vasopressors are compounding factors. Limb ischemia can be transient and reversible if diagnosed immediately and treated by early removal of the cannula. Our patient was unstable and ECMO dependent, and removal of the cannula was not an option. This resulted in limb loss and eventual above knee amputation. Use of the smallest appropriate venous cannula and early fasciotomy, in addition to hemodynamic optimization are measures that could help in preventing major amputation.

Thromboembolectomy for acute lower limb ischemia: Contemporary outcomes of two surgical methods from a single tertiary center.

OBJECTIVES: The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE). METHODS: This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis. RESULTS: Over 10 years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p-value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p-value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p-value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p-value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p-value < .001) and bypass (2.6% vs 22.7%, p-value = .01). CONCLUSION: ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

General Versus Locoregional Anesthesia in TEVAR: An NSQIP Analysis.

BACKGROUND: Thoracic Endovascular Aortic Repair (TEVAR) is a minimally invasive surgery for repairing thoracic aneurysms and dissections. This study aims to compare postoperative outcomes of TEVAR performed under general versus locoregional anesthesia. METHODS: Utilizing the 2008-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients older than the age of 18 years who received TEVAR, were identified using the following current procedural terminology codes: 33,880, 33,881, 33,883, 33,884, or 33,886. Patients who underwent concomitant procedures, those with both thoracoabdominal and abdominal aortic pathologies, and trauma cases were excluded. Standard descriptive statistics, in addition to χ2, Fisher's exact test, and Mann-Whitney U-tests were used to compare patient baseline characteristics and postoperative outcomes between general and locoregional anesthesia groups as appropriate. Univariable and multivariable logistic regression analyses were performed to assess independent predictors of hospital length of stay (LOS) greater than 7 days. RESULTS: Of the 1,028 patients included in the study, 86.5% received general anesthesia, and 13.5% received locoregional anesthesia, such as local anesthesia with monitored anesthesia care or regional anesthesia. No significant differences were found between patients receiving locoregional versus general anesthesia in mortality (3.6% vs. 7.9%, respectively, P = 0.071) and morbidity (18.7% and 24.8%, respectively, P = 0.121) within 30 days post-TEVAR, including any wound, pulmonary, thromboembolic, renal, septic, and cardiac arrest complications. Patients who received general anesthesia had significantly higher median LOS compared to those who received locoregional anesthesia [5 days (interquartile range (IQR): 3-10) versus 4 days (IQR: 2-7), P = 0.002], with 34.3% of the general anesthesia group having an LOS greater than 7 days compared to 21.6% of locoregional anesthesia group, P = 0.003. On multivariable logistic regression analysis, general anesthesia was found to be an independent predictor of prolonged LOS greater than 7 days (odds ratio (OR): 1.72, 95% confidence interval (CI): 1.05-2.81, P = 0.031). CONCLUSIONS: Locoregional anesthesia results in significantly lower postoperative hospital LOS with similar postoperative mortality and morbidity compared to general anesthesia in patients undergoing TEVAR.

Outcomes and Cost-Analysis of Open Versus Endovascular Abdominal Aortic Aneurysm Repair in a Developing Country: A 15-year Experience at a Tertiary Medical Center.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has become the most common procedure for treating abdominal aortic aneurysms based on multiple studies conducted in the western world. The implication of such findings in developing countries is not well demonstrated. The objective of this study was to compare medical outcomes and costs of EVAR and open surgical repair (OSR) in a developing country. METHODS: This is a retrospective study of all patients undergoing elective abdominal aortic aneurysm repair between 2005 and 2020 at a tertiary medical center in a developing country. Medical records were used to retrieve demographics, comorbidities, and perioperative complications. Medical records were also used to provide data on the need of reintervention, date of last follow-up, and mortality. RESULTS: The study included a total of 164 patients. Median follow-up time was 41 months. The mean age was 69.9 +/- 7.84 years and 90.24% (n = 148) of patients were males. Regarding long-term mortality outcomes, no significant difference was detected between both groups; OSR patients had a survival rate of 91.38% and 74.86% at 5 and 10 years, compared to 77.29% and 56.52% in the EVAR group (P value = 0.10). Both groups had comparable long-term reintervention rates (P value = 0.334). The OSR group was charged significantly less than the EVAR group ($27,666.35 vs. $44,528.04, P value = 0.008). CONCLUSIONS: OSR and EVAR have comparable survival and reintervention outcomes. Unlike what was reported in developed countries, patients undergoing OSR in countries with low hospital stay costs incur lower treatment costs.

Automated Measurement of Net Water Uptake From Baseline and Follow-Up CTs in Patients With Large Vessel Occlusion Stroke.

Quantifying the extent and evolution of cerebral edema developing after stroke is an important but challenging goal. Lesional net water uptake (NWU) is a promising CT-based biomarker of edema, but its measurement requires manually delineating infarcted tissue and mirrored regions in the contralateral hemisphere. We implement an imaging pipeline capable of automatically segmenting the infarct region and calculating NWU from both baseline and follow-up CTs of large-vessel occlusion (LVO) patients. Infarct core is extracted from CT perfusion images using a deconvolution algorithm while infarcts on follow-up CTs were segmented from non-contrast CT (NCCT) using a deep-learning algorithm. These infarct masks were flipped along the brain midline to generate mirrored regions in the contralateral hemisphere of NCCT; NWU was calculated as one minus the ratio of densities between regions, removing voxels segmented as CSF and with HU outside thresholds of 20-80 (normal hemisphere and baseline CT) and 0-40 (infarct region on follow-up). Automated results were compared with those obtained using manually-drawn infarcts and an ASPECTS region-of-interest based method that samples densities within the infarct and normal hemisphere, using intraclass correlation coefficient (ρ). This was tested on serial CTs from 55 patients with anterior circulation LVO (including 66 follow-up CTs). Baseline NWU using automated core was 4.3% (IQR 2.6-7.3) and correlated with manual measurement (ρ = 0.80, p < 0.0001) and ASPECTS (r = -0.60, p = 0.0001). Automatically segmented infarct volumes (median 110-ml) correlated to manually-drawn volumes (ρ = 0.96, p < 0.0001) with median Dice similarity coefficient of 0.83 (IQR 0.72-0.90). Automated NWU was 24.6% (IQR 20-27) and highly correlated to NWU from manually-drawn infarcts (ρ = 0.98) and the sampling-based method (ρ = 0.68, both p < 0.0001). We conclude that this automated imaging pipeline is able to accurately quantify region of infarction and NWU from serial CTs and could be leveraged to study the evolution and impact of edema in large cohorts of stroke patients.

Acute STEMI Due to Severe Triple-Vessel Spasm After IV Adenosine Injection During Cryo-Balloon Isolation.

Adenosine IV is commonly used after pulmonary vein isolation to check for dormant electrical conduction. Herein, we present the case of a 60-year-old patient who exhibited marked hypotension, conduction abnormalities, and ST-segment elevation after routine adenosine injection. Coronary angiography revealed diffuse coronary spasm that was successfully treated with intracoronary nitroglycerin. (Level of Difficulty: Intermediate.).

Face-to-face versus distance learning of basic suturing skills in novice learners: a quantitative prospective randomized trial.

BACKGROUND AND AIM: Traditionally, practical skills are taught on face-to-face (F-F) basis. COVID-19 pandemic brought distance learning (DL) to the spotlight because of the social distancing mandates. We sought to determine the acceptability and effectiveness of DL of basic suturing in novice learners. METHODS: A prospective randomized controlled trial involving 118 students was conducted. Participants were randomized into two groups for learning simple interrupted suturing: F-F and DL-groups. Evaluation was conducted by two assessors using a performance checklist and a global rating tool. Agreement between the assessors was calculated, and performance scores of the participants were compared. Participants' satisfaction was assessed via a questionnaire. RESULTS: Fifty-nine students were randomized to the F-F group and 59 to the DL-group. Satisfactory agreement between the assessors was demonstrated. All participants were successful in placing three interrupted sutures, with no significant difference in the performance between the groups. 25(44.6%) of the respondents in the DL-group provided negative comments related to the difficulties of remotely learning visuospatial concepts, 16(28.5%) preferred the F-F approach. CONCLUSION: DL of basic suturing is as effective as the F-F approach in novice learners. It is acceptable by the students despite the challenges related to the remote learning of practical skills.

Correlates of Blood Pressure Awareness, Treatment, and Control Among Adults 50 Years or Older by HIV Status in Northwestern Tanzania.

PURPOSE OF REVIEW: The objective of this study was to describe the increasing incidence and risk of cardiovascular disease among persons living with HIV (PLWH) in Sub-Saharan Africa. We also used data to compare hypertension (a common NCD among PLWH) outcomes between PLWH and HIV-uninfected individuals among older adults in Northwestern Tanzania. RECENT FINDINGS: Hypertension is increasingly common in Sub-Saharan Africa and a leading cause of cardiovascular disease for PLWH. Among those with hypertension, PLWH have a 50% higher risk of incident myocardial infarction compared to the general population. In response to the rising incidence of these non-communicable diseases (NCDs) among PLWH, recently, the Joint United Nations Program on HIV/AIDS supported the integration of NCD care into routine clinical care for HIV. However, data are lacking on levels of awareness of hypertension status, diagnosis, and antihypertensive medication adherence. Given the higher likelihood of elevated blood pressure among PLWH, there is an urgent need to implement interventions to improve blood pressure control in this population. Researchers should evaluate treatment barriers at multiple levels including health system, healthcare providers, and patients' level and tailor evidence-based interventions to increase achievement of blood pressure control for PLWH.

Comparison of tissue biomarkers in arterial and vein (arteriovenous fistula) aneurysms.

INTRODUCTION AND OBJECTIVES: Aneurysms are distinguished by inflammation, matrix degradation, and apoptosis of smooth muscle cells. In this study, specialized aneurysms tissue markers including venous and arterial aneurysms were studied. MATERIAL AND METHODS: The present cross-sectional study was conducted throughout January-September 2021. Tissue samples were collected during surgery. Hematoxylin and eosin (H&E) stains, have been utilized to identify different aneurysm types and the morphologic alterations that serve as the foundation for aneurysm diagnosis. Measurement of collagen type III, IV, CCR2, metalloproteinase (2 and 13), and granzyme K was done by ELISA method. Results were presented as the mean ± standard deviation and analyzed by t tests (Graph Pad Prism 8.4.3.686). RESULTS: During the period from January to September 2021, 14 patients with peripheral venous and arterial aneurysms were referred to Alavi Vascular Surgery Hospital and underwent surgery. Of these, 10 patients were matched and remained available for study. The level of type 3 collagen was significantly reduced in arterial aneurysm compared to venous aneurysm (p < 0.05). Granzyme K in arterial aneurysm showed increase compared to venous aneurysm (p < 0.05). Metalloproteinase 2 in arterial aneurysms higher than venous aneurysm (p < 0.001). Metalloproteinase 13 in arterial aneurysm also showed increase compared to venous aneurysm (p < 0.05). CONCLUSION: Results of this study shows differences in the level of tissue biomarkers in arterial and vein (arteriovenous fistula) aneurysms.

Incidence and Predictors of Surgical Site Infection Complications in Diabetic Patients Undergoing Lower Limb Amputation.

BACKGROUND: Surgical site infections (SSIs) following lower extremity amputations (LEAs) are a major cause of patient morbidity and mortality. The objectives of this study are to investigate the annual incidence of SSI and risk factors associated with SSI after LEA in diabetic patients. METHODS: LEAs performed on diabetic patients between 2005 and 2017 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Incidence rates were calculated and analyzed for temporal change. Multivariable logistic regression was conducted to identify the independent predictors of SSIs in LEA. RESULTS: In 21,449 diabetic patients, the incidence of SSIs was 6.8% after LEA, with an overall decreasing annual trend (P = 0.013). Amputation location (below-knee in reference to above-knee) [OR (95% CI): 1.35 (1.20 - 1.53), P <0.001], smoking [OR (95% CI): 1.25 (1.11 - 1.41), P <0.001)], female sex [OR (95% CI): 1.16 (1.03 - 1.30)], preoperative sepsis [OR (95% CI): 1.24 (1.10 - 1.40), P <0.001], P = 0.013], emergency status [OR (95% CI): 1.38 (1.17 - 1.63), P <0.001], and obesity [OR (95% CI): 1.59 (1.12 - 2.27), P = 0.009] emerged as independent predictors of SSIs, while moderate/severe anemia emerged as a risk-adjusted protective factor [OR (95% CI): 0.75 (0.62 - 0.91), P = 0.003]. Sensitivity analysis found that moderate/severe anemia, not body mass index (BMI) class, remained a significant risk factor in the development of SSIs in below-the-knee amputations; in contrast, higher BMI, not preoperative hematocrit, was significantly associated with an increased risk for SSI in above-the-knee amputations. CONCLUSIONS: The incidence of SSIs after LEA in diabetic patients is decreasing. Overall, below-knee amputation, smoking, emergency status, and preoperative sepsis appeared to be associated with SSIs. Obesity increased SSIs in above-the-knee amputations, while moderate/severe preoperative anemia appears to protect against below-the-knee SSIs. Surgeons should take predictors of SSI into consideration while optimizing care for their patients, and future studies should investigate the role of preoperative hematocrit correction and how it may influence outcomes positively or negatively.

Citrobacter koseri Surgical Site Infection after Femoropopliteal Vein Bypass for Popliteal Artery Aneurysm Treated with a Graft Preserving Strategy.

Background: A 69-year-old man underwent ligation and evacuation of a popliteal artery aneurysm with a femoral-to-popliteal vein bypass. He had a history of Citrobacter koseri prostatitis two months prior to the surgery. One month postoperatively, he presented with extremity swelling, redness, and fluid collections around the graft. Methods: A graft preserving strategy was adopted. The patient underwent operative drainage, washing, and received long-term antibiotic therapy. Fluid culture grew Citrobacter koseri, previously not reported as cause of surgical site infection with infrainguinal graft involvement. Results: The infection was treated successfully, and the patient is remains symptom free 18 months post-operatively. Conclusions: This case highlights the importance of considering culturing the aneurysm content in the presence of infectious history.