Network meta-analysis of drug-coated balloon angioplasty versus primary nitinol stenting for femoropopliteal atherosclerotic disease.

OBJECTIVE: Primary nitinol stenting (PNS) and drug-coated balloon (DCB) angioplasty are two of the most common endovascular interventions for femoropopliteal atherosclerotic disease. Although many prospective randomized controlled trials have compared PNS or DCB with plain balloon angioplasty (POBA), no studies have directly compared PNS against DCB therapy. The purpose of this network meta-analysis is to determine whether there is a significant difference in outcomes between PNS and DCB. METHODS: The primary outcome measure was binary restenosis, the secondary outcome measures were target lesion revascularization (TLR) and change in the ankle-brachial index (ABI). Outcomes were evaluated at 6, 12, and 24 months. A literature review identified all randomized controlled trials published before March 2020 that compared DCB with POBA or PNS with POBA in the treatment of native atherosclerotic lesions of the femoropopliteal artery. Studies were excluded if they contained in-stent stenosis or tibial artery disease that could not be delineated out in a subgroup analysis. Network meta-analysis was performed using the network and mvmeta commands in STATA 14. RESULTS: Twenty-seven publications covering 19 trials were identified; 8 trials compared PNS with POBA and 11 trials compared DCB with POBA. The odds of freedom from binary restenosis for patients treated with DCB compared with PNS at 6 months was 1.19 (95% confidence interval [CI], 0.63-2.22), at 12 months was 1.67 (95% CI, 1.04-2.68), and at 24 months was 1.36 (95% CI, 0.78-2.37). The odds of freedom from TLR for patients treated with DCB compared with PNS at 6 months was 0.66 (95% CI, 0.12-3.80), at 12 months was 1.89 (95% CI, 1.04-3.45), and at 24 months was 1.68 (95% CI, 0.82-3.44). The mean increase in ABI for patients treated with PNS compared with DCB at 6 months was 0.06 higher (95% CI, -0.03 to 0.15), at 12 months was 0.05 higher (95% CI, 0.00-0.09), and at 24 months was 0.07 higher (95% CI, -0.01 to 0.14). CONCLUSIONS: Both DCB and PNS demonstrated a lower rate of binary restenosis compared with POBA at the 6-, 12-, and 24-month timepoints. When comparing DCB with PNS through network meta-analysis, DCB had a statistically lower rate of a binary restenosis and TLR at the 12-month timepoint. This network meta-analysis demonstrates that both DCB and PNS are superior to POBA, and that PNS is a satisfactory substitute for DCB when paclitaxel is not desirable.

Early cannulation of bovine carotid artery grafts (Artegraft) after primary vascular access and fistula revision procedures.

OBJECTIVE: Tunneled dialysis catheter (TDC) use has been associated with increased infectious complications and mortality in hemodialysis-dependent patients. Unfortunately, patients who undergo fistula revisions or creation of a new arteriovenous fistula frequently require a TDC during the postoperative period. Bovine carotid artery grafts (BCAGs) can be used as an early-access dialysis conduit to reduce TDC dependence. This study describes the performance of BCAGs that were cannulated early (<3 days) after implantation and associated clinical outcomes. METHODS: BCAGs were implanted in 63 consecutive dialysis-dependent patients. Patients and dialysis centers were directly provided early cannulation instructions; 31 (49%) patients were cannulated early, and of the 31 patients cannulated early, 21 (68%) were cannulated during the first postoperative day. Early complications, primary patency, secondary patency, and TDC incidence were monitored through clinic visits, hospital records, and phone calls to dialysis centers. RESULTS: The primary patency of BCAGs at 1 year in the early and late cannulation cohorts was 28% and 39%, respectively. The secondary patency of BCAGs at 1 year in the early and late cannulation cohorts was 74% and 77%, respectively. Early complications occurred in 11 (19%) patients who received a BCAG. There were no significant differences in complication rates between early and late cannulation patients. Of the 24 patients who underwent the operation without a pre-existing TDC, only three (13%) required TDC placement during the 30-day postoperative period. CONCLUSIONS: BCAGs can be cannulated early without increased complication rates or a negative impact on midterm patency. Early cannulation of BCAGs obviates the need for a TDC postoperatively in dialysis-dependent patients undergoing primary vascular access or fistula revision procedures.

Prognostic Factors for Arteriovenous Fistula Maturation.

BACKGROUND: Recent studies have reported successful arteriovenous (AV) fistula maturation rates between 40% and 80%, with older age, distal fistula location, and small vein diameter associated with greater failure rates. Our objective is to determine if these findings are consistent with the outcomes at our institution. METHODS: A retrospective chart review was performed on patients who underwent upper extremity AV fistula creation at a single institution. Patient demographics and risk factors were analyzed, as well as fistula location and vein diameter based on preoperative ultrasound. Veins less than 2.5 mm were not used for fistula creation. Successful fistula maturation was defined as the fistula serving as the primary access for hemodialysis for 3 months or greater. Pearson Chi-Square, Fisher's Exact Test, and Mann-Whitney U-tests were used to determine significant associations. RESULTS: Between January 2012 and December 2013, 146 fistulas were created in 136 patients. The median age was 68. Median body mass index (BMI) was 27.8. Ninety-one fistulas were created in men and 55 in women. Ninety-two percent of patients had hypertension, 57% had diabetes, and 33% had coronary artery disease. Sixty percent of fistulas created were brachiocephalic, 24% were basilic vein transpositions, and 16% were radiocephalic. Median vein diameter was 3.7 (range 2.5-8.8). Eighty-four percent of patients were on hemodialysis at the time of fistula creation, and 21% had a prior fistula. One hundred five fistulas were accessed for 3 months or more, resulting in a successful overall maturation rate of 72%. BMI greater than 29.5 (P = 0.026) negatively impacted successful fistula maturation, whereas age, fistula location, and vein size did not. CONCLUSIONS: We noted a successful overall maturation rate of 72% at our institution when veins at least 2.5 mm in diameter were used. Our sole negative significant predictor for fistula maturation was BMI greater than 29.5. Therefore, in our experience, age, sex, and fistula location should not be used to preclude patients with a vein diameter of at least 2.5 mm from consideration for AV fistula creation.

Predictors and consequences of hemodynamic instability after carotid artery stenting.

BACKGROUND: The purpose of this study was to determine the predictors and consequences of hemodynamic instability (HI) after carotid artery stenting (CAS). METHODS: The records of all patients undergoing CAS in a single institution were reviewed. Patient demographics and risk factors were recorded. Indications for CAS, medications including statins, atropine, and beta blockers, anatomic risk factors, balloon and stent length and diameter, and degree of stenosis were noted. The presence of periprocedural hypertension (systolic blood pressure [SBP] >160), hypotension (SBP <90), and bradycardia (heart rate <60) lasting longer than 1 hr was documented, as was more transient HI. Rates of transient ischemic attack (TIA), stroke, myocardial infarction (MI), and death within 30 days of the procedure were calculated. Chi-squared analysis was used to determine the role of periprocedural factors in predicting the risk of HI and to determine if patients experiencing HI were more likely to experience major adverse events (MAEs) than those who did not. RESULTS: Between 2005 and 2012, 199 CAS were performed in 191 patients. One hundred seventeen were men and 74 were women. Their ages ranged from 46 to 92 years (mean, 73.6 years). Eighty-seven percent had hypertension, 48.5% were smokers, 48% had coronary disease, and 38% were diabetic. CAS was performed for asymptomatic stenosis in 55% of patients, 24% had previous TIA, and 20% previous stroke. Sixty-three percent of patients were on statins, 41.4% on beta blockers, and 92% received atropine before balloon dilatation or stent placement. Overall, 130 (65.3%) patients experienced HI and 67 patients (33.7%) experienced HI lasting longer than 1 hr. Octogenarians were more likely to experience both transient and prolonged HI, whereas angina or contralateral occlusion was predictive of any HI, and female sex was predictive of prolonged HI. Transient HI was not predictive of MAE. Patients with HI persisting longer than 1 hr were more likely to experience a TIA than those who did not (P = 0.045), but they were no more likely to experience stroke, MI, or death (P > 0.35 for each). CONCLUSIONS: Periprocedural HI occurs frequently during CAS even with prophylactic atropine administration. Although patients experiencing HI were more likely to experience a TIA, its presence is not associated with an increase in stroke, MI, or death.

Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis.

BACKGROUND: Carotid endarterectomy (CEA) as treatment in patients with asymptomatic carotid stenosis is the subject of much debate. METHODS: The National Surgical Quality Improvement Program database from 2005 to 2012 was queried. Patients undergoing CEA for asymptomatic carotid stenosis were identified. Preoperative risk factors and patient demographics were compared using chi-square analysis and logistic regression to determine their relation with stroke and death. RESULTS: During an 8-year period, 24,211 CEAs performed for asymptomatic carotid stenosis were identified. Patients with dependent functional status (12.5%), recent myocardial infarction (6.3%), chronic heart failure (5.0%), hypoalbuminemia (4.8%), angina (4.1%), dialysis dependence (3.4%), steroid dependence (3.4%), chronic obstructive pulmonary disease (3.3%), and American Society of Anesthesiologists > 3 (3.2%) had a clinically significant increase in risk of stroke and death. Patients with none of the above risk factors had a stroke and death rate of 1.08%, which was significantly less than the overall stroke and death rate (P < .001). CONCLUSIONS: A high-risk subset of patients undergoing CEA for asymptomatic carotid stenosis can be identified. If patient selection is optimized and perioperative morbidity and mortality are minimized, CEA will continue to play an important role in stroke prevention for those with significant asymptomatic carotid stenosis.

Oversedation in postoperative patients requiring ventilator support greater than 48 hours: a 4-year National Surgical Quality Improvement Program-driven project.

Prolonged mechanical ventilation of postoperative patients can contribute to an increase in morbidity. Every effort should be made to wean patients from the ventilator after surgery. Oversedation may prevent successful extubation. Cases identified by the National Surgical Quality Improvement Program (NSQIP) for Huntington Hospital were reviewed. Oversedation, days on the ventilator, type and duration of sedation, and cost were studied. Data were collected from the NSQIP database and patient charts. Oversedation was determined by the Richmond Agitation Sedation Score (RASS) of each patient. The hospital pharmacy provided data on propofol. Forty-three (35%) patients were oversedated. Propofol was used in 111 (90%) cases with an average use of 4.8 days. Propofol was used greater than 48 hours in 77 (62%) cases. After identifying inconsistent nurse documentation of sedation, corrective actions helped decrease oversedation, average number of days on the ventilator, number of days on propofol, hospital expenditure on propofol, and number of patients on the ventilator greater than 48 hours. Oversedation contributed to prolonged mechanical ventilation. Standardization of RASS and physician sedation order sheets contributed to improving our NSQIP rating. Sedation use decreased and fewer patients spent less time on the ventilator. NSQIP is an effective tool to identify issues with quality in surgical patients.

Agreement among observers in the assignment of TransAtlantic Inter-Society Consensus classification and runoff score.

OBJECTIVE: Productive communication among clinical practitioners is essential if recommendations regarding practice are to exist. The durability of vascular procedures is often influenced by factors such as lesion classification and runoff quality. It is the purpose of this article to determine how reproducible these measures are in the hands of various specialists who deal extensively with peripheral arterial disease. METHODS: The peripheral arteriograms of 100 patients undergoing percutaneous intervention were distributed to six specialists (three vascular surgeons, two interventional radiologists, and one interventional cardiologist). Each was provided with the reference document describing TASC II classification, Society for Vascular Surgery (SVS) runoff score, and simplified runoff score. With no further instruction, each individual was asked to assign each angiogram a TASC II class, SVS runoff score, and a simplified runoff score. Comparisons between the scores assigned were made using kappa statistic. RESULTS: When using the simplified runoff score for grading peripheral arterial disease, there was excellent correlation among readers (k = 0.81; P = .001), even across different specialties. When using TASC II class to grade lesions, there was a greater degree of variation when compared with the simplified runoff score (k = 0.44; P < .05). Finally, there was poor correlation between readers when using the SVS runoff score (k = 0.10; P < .05) and the modified SVS runoff score (k = 0.26; P = .001). CONCLUSIONS: Descriptors of clinical disease severity are not universally reproducible. The simplified runoff score is reproducible when interpreted by multiple readers across different specialties and can be used without further modification. The TASC II classification may need minor alterations in description to obtain good correlation among readers. Before the SVS runoff score can be universally adapted, it will need to be described in much better detail or significantly modified.

American College of Surgeons National Surgical Quality Improvement Program as a quality improvement tool: a single institution's experience with vascular surgical site infections.

Vascular surgical site infections (VSSIs) result in significant patient morbidity and hospital cost. The objective of this study is to report a single hospital's experience using the National Surgical Quality Improvement Program (NSQIP) as an instrument to decrease VSSIs. After review of initial NSQIP data, changes in antibiotic dosage and timing, surgical preparation, patient warming, and oxygenation were put into practice. Records of all patients undergoing vascular surgical operations during a two-year period were reviewed and VSSIs were identified. Statistical comparisons were made between groups before and after implementation of these changes. A total of 478 cases met our criteria. Practice changes were introduced in October 2009 and fully implemented by January 2010. Two hundred forty-three cases were performed in 2009 and 235 in 2010. When operations during the two time periods were compared, significantly fewer VSSIs were identified in 2010 than in 2009 (P = 0.036). NSQIP enabled our institution to identify an unacceptably high level of VSSIs. By implementing changes in our clinical practice, we were able to significantly lower our rate of VSSI.

Using distal revascularization with interval ligation as the primary treatment of hand ischemia after dialysis access creation.

BACKGROUND: Arterial steal syndrome after angioaccess surgery can lead to potentially devastating complications. Past treatments either ensured loss of the newly created access through ligation or attempted salvage by increasing resistance within the fistula. None of these proved to be entirely satisfactory. In 1994, we began to employ distal revascularization with interval ligation (DRIL) as our primary method of relieving hand ischemia after dialysis access creation. Described here is our experience with this procedure. METHODS: After institutional review board approval, the charts of patients undergoing the DRIL procedure for relief of hand ischemia after dialysis access surgery were reviewed. Patient demographics, risk factors, types of fistulas, and indications for operation were recorded. The clinical results of DRIL surgery, as well as fistula and bypass graft patency, were noted. RESULTS: Between May 1994 and August 2011, 81 DRIL procedures were performed on 77 patients ranging from 37 to 94 (mean, 65) years of age. Forty-four were female and 33 were male, with diabetes present in 83.3%. DRIL procedures were performed for ischemic symptoms after 37 autogenous brachiocephalic, 30 prosthetic bridge, and 14 autogenous brachiobasilic fistulas. Thirty-eight DRIL procedures were performed for ischemic rest pain (46.9%), 21 for digital ulceration (25.9%), 16 for neurological deficits (19.7%), and six for digital gangrene (7.4%). Complete symptom resolution was seen in 31 patients with ischemic rest pain (81.6%), 19 patients with digital ulcerations (90.5%), nine patients with neurological deficits (56.3%), and five patients with digital gangrene (83.3%). Fistula and brachial-brachial bypass survival 60 months after the DRIL procedure was 56% and 96.9%, respectively. The overall complication rate was 17.2%, and no patients died within 30 days of operation. CONCLUSIONS: The DRIL procedure is a very effective treatment for symptomatic steal syndrome and is associated with low morbidity and mortality. It is extremely effective in the treatment of ischemic hand pain and tissue loss, but less so for neurological sequelae. It can allow for prolonged fistula utilization.

The number of patent tibial vessels does not influence primary patency after nitinol stenting of the femoral and popliteal arteries.

OBJECTIVE: Initial TransAtlantic Inter-Society consensus (TASC) II classification has been shown to influence the patency of stented femoral and popliteal arteries. Although several studies have shown the effect of the number of runoff vessels on the durability of infrainguinal angioplasty without stenting, the influence of tibial vessel runoff on the patency of primarily stented femoral and popliteal arteries has not been as well defined. The purpose of this study was to determine whether the number of patent tibial vessels affects primary patency after primary stenting of the femoral and popliteal arteries. METHODS: The records of all patients undergoing angioplasty and primary nitinol stenting of the femoral and popliteal arteries, by or under the supervision of one vascular surgeon, were reviewed. Results were analyzed by both the number of patent tibial vessels documented on periprocedural angiography and by using a modified Society for Vascular Surgery runoff score. TASC II classification was also recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. Fisher exact and χ(2) tests were used to compare categoric factors. RESULTS: During a 7-year period, 289 limbs in 236 patients underwent primary stenting of the femoral and popliteal arteries. Overall primary patency was 70.3% at 12 months, 52.4% at 24 months, and 39.1% at 36 months. Limbs classified as TASC A or B had significantly better patency rates than those classified as TASC C or D (P < .001). While the number of runoff vessels decreased with worsening of the TASC classification (P = .024), overall (P = .355), and within individual TASC classes (P ≥ .092 for each), there was no difference in the primary patency of stented segments with good runoff and those with compromised runoff. Limbs with poor runoff (one or no vessels) were no more likely to fail with occlusion than their counterparts with two or three patent tibial vessels (P = .383). The number of patent tibial vessels at the time of initial stenting did not impact ultimate limb salvage (P = .063). CONCLUSIONS: The number of patent tibial vessels does not influence the primary patency of primarily stented femoral and popliteal arteries. TASC II classification appears to be significantly more predictive of initial failure after angioplasty and stenting of these vessels.

The use of the StarClose device for obtaining femoral artery hemostasis.

BACKGROUND: Following percutaneous intervention, obtaining femoral artery hemostasis quickly and reliably with few complications is of considerable importance. While the StarClose device has been studied in patients undergoing cardiac catheterization, its use in patients undergoing treatment for peripheral vascular disease has rarely been reported. It is the purpose of this report to determine whether the Starclose is able to deliver safe and effective femoral artery closure in this group of patients. METHODS: The records of all patients undergoing StarClose closure of the femoral artery by or under the supervision of a single vascular surgeon were reviewed. Indication, type of intervention, and size of the vascular sheath employed were noted. Times to mobilization and discharge were tabulated. Complications including hemorrhage, pseudoaneurysm, infection, and vessel occlusion were recorded. RESULTS: Between February 2006 and September 2009, 603 StarClose nitinol clip closure devices were deployed in 478 patients. In all, 97 procedures were diagnostic and 506 included therapeutic interventions. A total of 97 5F sheaths, 465 6F sheaths, and 41 7F sheaths were employed. Time to ambulation and discharge was 44.2 ± 13.2 minutes and 119.3 ± 22.6 minutes in patients in whom a 5F sheath was used, 112.5 ± 13.5 minutes and 157.5 ± 20.6 minutes when a 6F sheath was used, and 121.9+/-38.8 minutes and 160.2+/-43.2 minutes when a 7F sheath was employed. The clip could not be successfully deployed in 21 arteries (3.5%) and manual compression was successful in achieving hemostasis in 17 patients without complication. Three patients (0.5%) developed major hematomas requiring transfusion; 1 patient developed a pseudoaneurysm (0.17%) requiring thrombin injection. A single patient (0.17%) occluded his common femoral artery following StarClose deployment and 1 patient (0.17%) developed a femoral artery stenosis requiring balloon dilatation. No patient developed a groin infection. CONCLUSIONS: The StarClose provides a safe and reliable method of achieving femoral artery closure following percutaneous intervention for peripheral arterial disease. When successfully deployed, it allows for early ambulation and discharge. Since it remains entirely extraluminal, it offers advantages over other closure devices and can be safely used in the vast majority of patients with peripheral vascular disease.

Carotid stenting: a surgeon's perspective.

BACKGROUND: Recent multicenter studies have determined that the results of carotid stenting (CAS) are comparable to those of endarterectomy. Because most of these trials were performed in academic centers, it will be necessary to determine whether similar results can be obtained in community settings. This study reviewed the results of a single surgeon's experience with CAS performed in a university-affiliated community hospital. STUDY DESIGN: All patients were treated with CAS during a 5-year period. Major and minor perioperative stroke and death, transient ischemic attack, myocardial infarction, restenosis, and late stroke were documented. A 2-tailed t-test was used to compare variables between groups. RESULTS: A total of 162 carotid artery stents were placed in 149 patients. Ninety-three stents (57.41%) were placed for asymptomatic stenosis, and 69 (42.59%) were placed for symptomatic carotid disease. There were 8 neurologic complications, including 3 transient ischemic attacks (1.85%), 3 minor strokes (1.85%), and 2 major strokes (1.23%). Seven of 8 neurologic events including both major strokes occurred in patients older than 80 years. Octogenarians were significantly more likely to suffer a neurologic event or stroke than those younger than 80 years (p = 0.0004 and p = 0.0179, respectively). There was 1 death within 30 days of the procedure, and there were no symptomatic myocardial infarctions. CONCLUSIONS: When CAS was performed by a vascular surgeon in patients younger than 80 years, the rate of neurologic events was acceptable and similar to the results of carotid endarterectomy in previously published studies. However, the risk of stroke is disproportionately high in octogenarians undergoing CAS. These patients may best be treated surgically.

Impact of race on infrainguinal angioplasty and stenting.

BACKGROUND: Over the last decade, catheter-based interventions on lower extremity arteries have been used with increasing frequency. However, the effect of racial background on the outcome of lower extremity endovascular interventions for peripheral arterial disease is unknown. The purpose of this study was to determine the effect of patients' race on the durability of angioplasty and stenting performed on the superficial femoral and popliteal arteries. METHODS: The records of all patients undergoing percutaneous intervention on the lower extremity arteries during a 14-year period were reviewed. During a 44-month period (2003-2007), all patients underwent primary stenting as part of a prospective study protocol. Indication for intervention, TransAtlantic InterSociety Consensus II classification, runoff anatomy, site of intervention, and the placement of stents were noted. Results were analyzed by race. Kaplan-Meier life survival curves were plotted and differences between groups tested by log-rank method. Cox proportional hazards regression model was used to perform the multivariate analysis. RESULTS: Between 1994 and 2007, a total of 374 percutaneous interventions were performed on the superficial femoral and popliteal arteries in 280 patients. Of these, 182 procedures were angioplasties and 192 included both angioplasty and stenting. The study group consisted of 60% Caucasians, 23% Hispanics, 12% African Americans, and 5% Asians. No difference in primary patency rates was noted between individuals belonging to different races. However, in those undergoing angioplasty alone, Caucasians had the highest rate of failure, followed by Hispanics, African Americans, and then Asians (p < 0.002). No difference in patency rates between races was seen in patients undergoing angioplasty with stenting. For the entire group, dyslipidemia, TransAtlantic InterSociety Consensus II C and D lesions, and angioplasty without stenting negatively affected primary patency. CONCLUSIONS: Race does not appear to influence the durability of catheter-based procedures performed on the superficial femoral and popliteal arteries. However, in patients who underwent angioplasty alone, it was noted that Caucasians had the highest rates of failure and Asians the lowest. However, this difference was no longer apparent when stents were used.

Clinical outcomes and implications of failed infrainguinal endovascular stents.

OBJECTIVE: While the influence of initial TransAtlantic InterSociety Consensus (TASC) II classification has been clearly shown to influence the primary patency of infrainguinal stenting procedures, its effect on outcomes once stent failure has occurred is less well documented. It is the objective of this paper to determine whether clinical outcomes and implications of anatomic stent failure vary according to initial TASC II classification. METHODS: Results were analyzed by TASC II classification. Kaplan-Meier survival curves were plotted and differences between groups tested by log-rank method. A Cox proportional hazards regression model was used to perform the multivariate analysis. RESULTS: During a 5-year period, 239 angioplasties and stents were performed in 192 patients. Primary patency was lost in 69 stented arteries. Failure was due to one or more hemodynamically significant stenoses in 43 patients, and occlusion in 26 patients. After primary stenting, limbs initially classified as TASC C and D were more likely to fail with occlusion (P < .0001), require open operation (P = .032), or lose run-off vessels (P = .0034) than those classified as TASC A or B. In two patients initially classified as TASC C, stent failure changed the level of open operation to a more distal site. Percutaneous reintervention was performed on 35 limbs. Successful reintervention improved the patency of TASC A and B lesions to 92%, 85%, and 64% and TASC C and D lesions to 78%, 72%, and 50% at 12, 24, and 36 months, respectively. Initial TASC classification was highly predictive of first anatomic failure (P < .0001), but it did not predict the durability of subsequent catheter based reintervention (P = .32). Ten patients with stent failure required operation, and five underwent amputation; all had failed with occlusion. Overall limb salvage was 89% and peri-procedural mortality was 0.4%. CONCLUSIONS: Following primary stenting of the superficial femoral artery (SFA) and popliteal artery, lesions classified as TASC C or D are more likely to fail with occlusion, lose run-off vessels, and alter the site of subsequent open operation than their TASC A and B counterparts. Although these complications are infrequent, they may negatively impact later attempts at revascularization, and this must be considered when deciding upon the proper treatment strategy for patients with infrainguinal occlusive disease.

Primary stenting of the superficial femoral and popliteal artery.

OBJECTIVES: Over the last decade, the number of endovascular procedures performed on the superficial femoral (SFA) and popliteal arteries (PA) has significantly increased. There is no consensus on the optimal form of intervention used in this arterial segment. While some have advocated balloon angioplasty alone, others have championed either selective or primary stenting of these lesions. It is the purpose of this study to determine the efficacy and durability of primary stenting of the superficial femoral and popliteal artery. METHODS: All patients undergoing peripheral angioplasty by a single vascular surgeon were prospectively enrolled in an Institutional Review Board-approved, primary-stenting protocol. During a 44-month period, all patients undergoing percutaneous transluminal angioplasty of the SFA or PA also received primary arterial stenting with bare, self-expanding nitinol stents. Patient demographics and risk factors were identified. TransAtlantic InterSociety Consensus (TASC) classifications were determined for all lesions. Loss of primary patency was said to have occurred when an occlusion or a 50% or greater stenosis in any treated arterial segment was diagnosed by arterial duplex or angiography. Only time to loss of primary patency was recorded. Kaplan-Meier survival curves were plotted and differences between groups tested by log rank method. RESULTS: Between January 16, 2004 and August 13, 2007, 201 angioplasties with primary stenting were performed on 161 patients. One hundred twenty-three stents were placed for claudication, and 78 for critical limb ischemia. Forty-six segments treated were TASC A, 82 were TASC B, 38 were TASC C, and 35 were TASC D. Patient follow-up ranged from three to 1329 days (mean: 426 days). Primary patency rates for TASC A and B lesions were 79%, 67%, and 57% at 12, 24, and 36 months. For TASC C and D lesions, primary patency rates were 52.7%, 36%, and 19% at the same time intervals. Primary patency rates for TASC A and B lesions were significantly higher than for C and D lesions (P < .001). The limb salvage rate was 88.5% in patients with critical limb ischemia. Distal runoff did not influence patency (P = .827). CONCLUSIONS: Primary stenting of the SFA and PA provides durable results in patients with TASC A and B lesions and may be an effective treatment strategy. This approach is significantly less effective when used in treating those with TASC C and D disease. Based on the results in this series, the use of primary stenting does not extend the anatomic limits of the current treatment recommendations for catheter-based intervention in patients with infrainguinal occlusive disease.

Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients: a single institutional experience in 69 consecutive patients.

PURPOSE: To assess the functional status and long-term outcomes of endovascular management for the treatment of central veno-occlusive disease in patients undergoing hemodialysis. MATERIALS AND METHODS: Retrospective chart evaluation of 600 patients with threatened upper extremity dialysis access showed central veno-occlusive disease in 69 patients (11%; 30 women and 39 men; mean age, 63.9 years; age range, 26-92 years). A total of 92 venous segments were involved with disease. Initial endovascular procedures consisted of transvenous angioplasty (n = 88) and stent placement (n = 6); there were 134 repeat interventions (14 stents). The mean follow-up was 14.5 months (range, 1-44 months). Angiographic data were reviewed prospectively by two independent observers for the extent of veno-occlusive disease. Technical failures were defined as residual stenosis of at least 30% or lesions that were unable to be dilated or crossed. Statistical analysis, including interobserver agreement and Kaplan-Meier analysis, was performed. RESULTS: Technical success rates for initial and follow-up interventional procedures were 90% (81 of 92 segments) and 96% (129 of 134 interventions), respectively. Two complications required treatment with interventional procedures. There was excellent interobserver agreement (kappa = 0.84; 95% confidence interval: 0.67, 0.93) for grading the degree of venous stenoses. Primary patency rates of hemodialysis access at 1, 6, and 12 months were 81%, 46%, and 22%, respectively, which significantly (P = .001) improved to assisted patency rates of 91%, 77%, and 63% at 1, 6, and 12 months, respectively. CONCLUSIONS: Endovascular management including a combination of angioplasty and selective stent placement can be effectively used to treat central veno-occlusive disease and preserve functional access in patients with threatened upper extremity dialysis access.

Are octogenarians at high risk for carotid endarterectomy?

BACKGROUND: Several prospective randomized trials have proved carotid endarterectomy to be safe and effective for both symptomatic and asymptomatic patients younger than 80 years of age. Recently, carotid artery stenting (CAS) has been approved for use in selected high-risk patients. It has been proposed that being an octogenarian places patients in this high-risk category. STUDY DESIGN: All patients between the ages of 80 to 89 years undergoing carotid endarterectomy during a 12-year period were included in the study. Information included indications for carotid endarterectomy, associated risk factors, length of stay, and hospital course. Perioperative morbidity and mortality, including neurologic events and myocardial infarction, were recorded. RESULTS: A total of 103 carotid endarterectomies were performed in 95 octogenarians. Procedures were performed on 59 men and 36 women. Indications for operation included symptomatic carotid stenosis in 44 patients (43%) and asymptomatic carotid stenosis in 59 (57%). Associated risk factors included diabetes mellitus (17%), hypertension (76%), coronary artery disease (28%), hyperlipidemia (39%), and history of smoking (42%). There were 4 perioperative neurologic complications, which included 1 transient ischemic attack (0.97%), 2 minor strokes (1.94%), and 1 major stroke (0.97%). There were no deaths. CONCLUSIONS: Combined end points for adverse events are acceptable in the octogenarian. Carotid endarterectomy remains the gold standard for treatment of extracranial carotid disease in all age groups. Age alone should not place patients in the high-risk category for carotid endarterectomy.

Change in practice patterns of an academic division of vascular surgery.

HYPOTHESIS: Technological advances have required that faculty of academic divisions of vascular surgery acquire new technical skills and significantly alter their past clinical practice patterns. DESIGN: Retrospective medical record review. SETTING: An academic tertiary referral center and a community teaching hospital. PATIENTS: All patients undergoing 10 specific vascular procedures during a 5-year period. MAIN OUTCOME MEASURES: We analyzed volumes for 10 specific open and endovascular index procedures performed by 5 vascular surgeons during a 60-month period. Procedures reviewed included open abdominal aortic aneurysm repair, endovascular abdominal aortic aneurysm repair, carotid endarterectomy, carotid artery stent, suprainguinal arterial reconstruction, suprainguinal percutaneous transluminal angioplasty/stent (PTA/S), infrainguinal arterial reconstruction, infrainguinal PTA/S, renal and visceral arterial reconstruction, and renal and visceral PTA/S. In-hospital length of stay was compared between open procedures and their endovascular counterparts. RESULTS: In 2000, 453 open and 44 endovascular index procedures were performed. In contrast, by 2005, open index cases had decreased by 47.0% (239) and endovascular index cases had increased by 679.5% (299). Open abdominal aortic aneurysm repairs had decreased by 54.5% (68 vs 31), carotid endarterectomies by 28.8% (139 vs 99), suprainguinal arterial reconstructions by 47.5% (40 vs 21), infrainguinal arterial reconstructions by 56.5% (186 vs 81), and renal/visceral arterial reconstructions by 65.0% (20 vs 7). In 2005, 62 endovascular abdominal aortic aneurysm repairs and 45 carotid stents were performed, whereas none were performed in 2000. In addition, infrainguinal PTA/S had increased by 675.0% (12 vs 81) and suprainguinal PTA/S by 20.0% (20 vs 24). CONCLUSIONS: Although the total number of procedures performed has remained relatively constant, there has been a dramatic increase in the number of endovascular procedures as well as an associated decline in the number of open procedures. This change in practice pattern has allowed the members of our division to maintain a significant role in the care of patients undergoing vascular surgery, as evidenced by stable overall procedural volume. This will provide a platform for future outcome-related analyses of open vs endovascular procedures performed within a single specialty group.

Peripheral angioplasty with same-day discharge in patients with intermittent claudication.

BACKGROUND: As the number of endovascular interventions increase and resources become scarce, surgeons need to be aware of cost-effective and efficient practice options. Many surgeons routinely admit their patients for overnight observation after uneventful endovascular interventions. Although this may be appropriate for patients with tissue loss and rest pain, we believe that peripheral angioplasty in patients with claudication can be safely performed as an outpatient procedure with significant cost savings. METHODS: All patients with intermittent claudication undergoing peripheral angioplasty by a single vascular surgeon were enrolled prospectively in a same-day discharge protocol. Involved arteries and use of stent and closure device were recorded. Time to mobilization and time to discharge were determined. Patients were observed in an observation unit by a registered nurse, and were examined by the surgeon at the time of ambulation and before discharge. Patients were admitted to the hospital if complications arose during the predetermined observation period. Periprocedural complications and reasons for admission were noted. Patients were evaluated at 1 week, 6 weeks, and 3 to 6 months after the intervention. RESULTS: During 27 months, 112 interventions were performed in 97 patients. The superficial femoral artery was the most frequent site of intervention (47%). Multiple sites had angioplasty in 27 (24%) procedures. Nine (8%) procedures resulted in admission. One patient was admitted for a major puncture site hematoma requiring blood transfusion, two patients for observation of a minor hematoma at the puncture site, one for chest pain, and one for observation of transient bradycardia. The mean time to mobilization was 1.4 +/- 1.3 hours, and the mean time to discharge was 2.8 +/- 1.2 hours. The average postprocedural cost for patients undergoing same-day discharge was $320 per patient, which contrasts with $1800 for routine overnight observation. No deaths or unplanned admissions to the hospital occurred < or =30 days of intervention. CONCLUSIONS: Same-day discharge after peripheral angioplasty is safe and cost-effective. Need for admission is evident within 2 hours. Routine admission after peripheral angioplasty for patients with claudication is unnecessary and should no longer be the standard of care.