Outcomes of Femoral Popliteal Bypass in Octogenarians.

INTRODUCTION: Femoral-popliteal bypass (FPB) surgery is a common lower extremity revascularization procedure. As the population continues to age, this procedure is being performed increasingly on older patients. This study investigated whether outcomes differ in this population. MATERIALS AND METHODS: Patients over and less than 80 years old who underwent FPB between 2009-2013 were queried using an existing hospital registry. Demographics, comorbidities, intraoperative complications, perioperative outcomes, and two-year patencies were compared. RESULTS: Twenty-four patients in the octogenarian cohort (OC) and 72 patients in the non-octogenarian cohort (NOC) were identified. There was a lower prevalence of smoking (p=0.018) and higher prevalence of hypertension (p=0.021) among octogenarians. Other medical characteristics were similar (p<0.05). There were no differences in use of vein versus PTFE (p=0.002) as a conduit, or above (OC 20.0% vs. NOC 36.7%), versus below knee (OC 80.0% vs. NOC 63.3%) distal anastomosis (p>0.05) between the groups. There was a difference (p<0.01) in indication for procedure (OC/NOC): claudication (0%/44%), limb salvage (71%/31%), and rest pain (29%/25%). There were no differences in 30-day readmissions (17% vs. 21%; p=0.59) or incidence of postoperative (25% vs. 19%; p=0.56) or intraoperative complications (8.3% vs. 4.2%; p=0.52). Length of stay (LOS) was longer and statistically significant in octogenarians (12 days vs. 7 days; p=0.032) and remained significant after multivariate linear regression (p=0.015). Patencies in OC were lower and dropped faster after six months; however, there were no statistically significant differences in patencies at any time interval (p>0.05). The position of the distal anastomosis relative to the knee, conduit type, and indication were not independently predictive of patency outcomes (p>0.05). CONCLUSION: The safety and efficacy of FPB in octogenarians is similar to the general population despite LOS in octogenarians being 5.98 days longer. While the difference in indication suggests that vascular surgeons are more conservative in treating octogenarians, our analysis did not reveal significant differences between populations and suggests that lower extremity bypass can be performed safely with comparable results in this cohort. A larger cohort is needed to validate these results.

Determinants of Mortality and Mid-Term Outcomes After Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting.

OBJECTIVES: The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR. METHODS: Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors. RESULTS: A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke. CONCLUSIONS: Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal. CLINICAL IMPACT: The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.

Understanding and addressing varying perceptions of autonomy.

Recently, there has been a major shift in the concept of resident autonomy in the operating room. As a result, surgical residents' independence has decreased during their training years. This change has been secondary to multiple factors, including fragmented attending resident interactions, hospital demands for productivity, operating room efficiency, and the public's perception of resident participation in surgery. Multiple gender, personality, and racial biases have also influenced the autonomy of surgical residents. In this paper, we have analyzed the impact of all these factors on the current state of resident autonomy after reviewing relevant literature. We have proposed a strategy to increase resident autonomy via increased resident and faculty interactions, case planning, and encouraged recruitment of diverse vascular surgery trainees and faculty.

Women are Not at Higher Risk for Reintervention or Major Amputation after Lower Extremity Atherectomy for Peripheral Artery Disease.

BACKGROUND: Our objective was to compare short-term and long-term differences in reintervention-free and major amputation-free survival between female and male patients undergoing lower extremity atherectomy for peripheral artery disease. METHODS: We analyzed lower extremity atherectomy procedures performed on 294 patients between January 2014 and September 2019. Reintervention was defined as either open bypass or endovascular procedure to the same region following the index operation. Kaplan-Meier (KM) survival analysis was performed to compare reintervention-free and major amputation-free survival between sexes. Multivariate logistic regression analyses were performed to determine the adjusted odds of reintervention and major amputation based on sex. We conducted subgroup analyses by anatomic region (femoropopliteal vs. tibial), indication (claudication vs. chronic limb-threatening ischemia (CLTI)), and balloon type (drug-coated balloon (DCB) versus plain balloon angioplasty (POBA)) across sexes. RESULTS: Of the 294 patients, 125 (42.5%) were female. Compared to men, women receiving atherectomy were more likely to be Black (28.0% vs. 16.6%; P = 0.018), a nonsmoker (44.8% vs. 21.3%; P < 0.001), and present with CLTI (55.2% vs. 43.2%; P = 0.042). There were no differences in atherectomy region, lesion type, or balloon type between sexes. KM analysis showed similar 4-year reintervention-free survival (68.8% vs. 75.1%; P = 0.88) and major amputation-free survival (97.6% vs. 97.6%; P = 0.41) between sexes. Women and men had similar reintervention-free survival when grouped by femoropopliteal (67.9% vs. 70.8%; P = 0.69) or tibial (76.2% vs. 83.9%; P = 0.68) atherectomy region. Indication (claudication versus CLTI) did not affect reintervention-free survival in either women (64.5% vs. 69.6%; P = 0.28) or men (68.5% vs. 76.7%; P = 0.84). KM curves for DCB versus POBA were also similar between sexes and showed an early benefit in reintervention rate favoring DCB, which dissipated in both women (65.4% vs. 72.7%; P = 0.61) and men (75.5% vs. 78.4%; P = 0.18) by 3 years. CONCLUSIONS: Compared to men, women demonstrate commensurate benefit from atherectomy for lower extremity revascularization. There were no differences seen in long-term reintervention or major amputation between sexes.

Double-barrel iliocaval reconstruction using closed-cell dedicated venous stents.

OBJECTIVE: Double-barrel iliocaval reconstruction is performed by deploying two stents simultaneously in a side-by-side, or "double-barrel," configuration in the inferior vena cava (IVC) with extension into the bilateral common iliac veins. The aim of this study was to examine the outcomes of double-barrel reconstruction using closed-cell dedicated venous stents for the treatment of iliocaval deep venous thrombosis and iliac vein compression syndrome. METHODS: All endovascular procedural reports comprising vascular surgery and interventional radiology operators from a single urban academic hospital between May 1, 2019, and April 30, 2021, were retrospectively searched. A cohort of 22 consecutive patients who underwent double-barrel iliocaval stenting with closed-cell dedicated venous stents for chronic or acute-on-chronic iliocaval venous disease without prior endovascular iliocaval repair was identified. Baseline characteristics, procedural data, and patient outcomes were determined via a manual review of preprocedure clinical notes, diagnostic imaging studies, procedure notes and images, and follow-up clinical notes. RESULTS: The median (range) age was 59 (27-81) years, and the cohort consisted of 59.1% female. The most common presenting symptoms of venous disease were lower extremity swelling (90.9%) and pain (50.0%). CEAP clinical classification was C3 in 86.4% of patients, whereas the remainder had C4 disease. Most patients (72.7%) had post-thrombotic syndrome, 22.7% had a nonthrombotic iliac vein lesion, and one patient (4.5%) had the congenital absence of the infrarenal IVC. A total of 40.9% of patients had a pre-existing IVC filter at the time of treatment. Six of the 22 patients underwent concurrent pharmacomechanical thrombectomy during the index iliocaval reconstruction and stenting procedure. The number of stents placed ranged from 2 to 5. With a mean follow-up period of 7.1 months, ranging from 12 days to 16.7 months, the freedom from reintervention rate was 90.9%. Twenty of 22 patients achieved subjective improvement or resolution of symptoms. The major adverse event rate was 9.1%, as two patients had access site complications requiring intervention. CONCLUSIONS: Double-barrel iliocaval reconstruction with closed-cell dedicated venous stents for the treatment of post-thrombotic syndrome or iliac vein compression syndrome is technically feasible and clinically effective with a low reintervention rate.

Sex Disparities in Failure to Rescue After Cardiac Surgery in California and New York.

BACKGROUND: Women have a higher risk of mortality than men after cardiac surgery independent of other risk factors. The reason for this may not be limited to patient-specific variables. Failure to rescue (FTR) patients from death after a postoperative complication is a nationally endorsed quality care metric. We aimed to identify whether sex disparities exist in the quality of care after cardiac surgery using FTR rates. METHODS: A retrospective analysis of 30 973 men (70.4%) and 13 033 women (29.6%) aged over 18 years undergoing coronary artery bypass graft or valve surgery in New York (2016-2019) and California (2016-2018) who experienced at least one serious postoperative complication. The primary outcome was the FTR. Multivariable logistic regression was used to identify predictors of death after complication. Propensity matching was used to adjust for baseline differences between sexes and yielded 12 657 pairs. RESULTS: Female patients that experienced complications were older (mean age 67.8 versus 66.7, P<0.001), more frail (median frailty score 0.1 versus 0.07, P<0.001), and had more comorbidities (median Charlson score 2.5 versus 2.3, P<0.001) than male patients. The overall FTR rate was 5.7% (2524), men were less likely to die after a complication than women (4.8% versus 8%, P<0.001). Independent predictors of FTR included female sex (relative risk [RR]: 1.46 [CI, 1.30-1.62]), area-level poverty rate >20% (RR, 1.21 [CI, 1.01-1.59]), higher frailty (RR, 2.83 [CI, 1.35-5.93]), undergoing concomitant coronary artery bypass graft and valve surgeries (RR, 1.69 [CI, 1.49-1.9]), and higher number of postoperative complications (RR, 16.28 [CI, 14-18.89]). In the propensity-matched cohorts, the FTR rate remained significantly lower among men than women (6.0% versus 8.0%, P<0.001). CONCLUSIONS: Women are less likely to be rescued from death following postoperative complications, independent of socioeconomic and clinical characteristics. Further research is warranted to investigate the clinical practices contributing to this disparity in quality of care following cardiac surgery.

Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.

INTRODUCTION: Asymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. METHODS: Data from patients in the Vascular Quality Initiative database who underwent TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke occurring within 180 days before the procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic) and patients with a history of TIA/stroke occurring more than 180 days before the procedure (remote history of neurologic symptoms). The Student t-test and Pearson χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. RESULTS: There were 7158 patients who underwent TCAR (symptomatic: 2574, asymptomatic: 3689, and asymptomatic with a remote history of neurologic symptoms: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195, asymptomatic: 10,333, and asymptomatic with a remote history of neurologic symptoms: 1495). Regardless of symptom status, the mean patient age was 73 years for TCAR and 69 years for TFCAS. A total of 64% of patients in the study were male and 36% of patients were female. The mean long-term follow-up data ranged between 208 and 331 days within the three patient groups. Carotid stenosis patients with a remote history of neurologic symptoms had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic patients, and these rates were similar to those of symptomatic patients. Comparing TCAR and TFCAS among patients with a remote history of neurologic symptoms, there were statistically significant reductions in the odds of stroke/death (odds ratio: 0.46, 95% confidence interval: 0.27-0.84, P = .011) and stroke/death/myocardial infarction (odds ratio: 0.51, 95% confidence interval: 0.30-0.87, P = .013) after TCAR. This was likely driven by the increased rate of death after TFCAS in patients with a remote history of neurologic symptoms (0.9%) compared with asymptomatic patients (0.6%). CONCLUSIONS: Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.

Comparison of Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting Based on High Risk Anatomic Characteristics.

BACKGROUND: Anatomic details affecting the adverse outcomes following carotid artery stenting have not been well characterized. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients stratified by degree of lesion calcification and aortic arch type. METHODS: Data from patients in the Society for Vascular Surgery's Vascular Quality Initiative database undergoing TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) and had non-missing grading on carotid artery calcification or aortic arch type was analyzed. Degree of calcification was stratified into 3 groups: none, ≤ 50% calcification, and >50% calcification. Arch type was stratified as Type I, Type II, and Type III. RESULTS: A total of 9,868 patients (TCAR: 4,224; TFCAS: 5,644) were included in the calcification analysis. TCAR patients were generally older, white, smokers, and had more comorbidities than TFCAS patients. Among the symptomatic patients, there was no difference in rates of stroke, stroke/transient ischemic attack (TIA), and myocardial infarction (MI) by calcification severity between TCAR and TFCAS. However, there was a trend towards increased risk in all 3 events with higher calcification only after TFCAS. Symptomatic patients with severe (>50%) calcification had lower rates of death (TCAR: 0.9% vs. TFCAS: 2.8%, P = 0.013), stroke/death (TCAR: 2.7% vs. TFCAS: 5.8%, P = 0.006), stroke/death/MI (TCAR: 3.3% vs. TFCAS: 6.5%, P = 0.007), and postop complications (TCAR: 6.0% vs. TFCAS: 12.4%, P < 0.001) after TCAR compared to TFCAS. Furthermore, TCAR had lower risk of mortality at all degrees of calcification compared to TFCAS. Similar findings were noted among asymptomatic TCAR patients with >50% calcification, in which the rates of death (TCAR: 0.4% vs. TFCAS: 1.1%, P = 0.080) and stroke/death (TCAR: 1.5% vs. TFCAS: 3.1%, P = 0.029) were reduced. A comparison of TCAR to TFCAS by arch type showed that rates of stroke/death after TCAR were similar regardless of arch complexity (Type I: 2.6% vs. Type II: 2.8%), but increased after TFCAS with complex, high risk anatomy (Type I: 4.2% vs. Type II: 5.2%). CONCLUSIONS: While increased calcification increased rates of adverse events after TFCAS, this trend was not observed after TCAR, which also had lower rates of death and stroke/death among patients with severe calcification. Furthermore, TCAR had lower risk of mortality than TFCAS across all degrees of calcification. TFCAS was associated with increased risk of stroke/death with complex aortic arch anatomy, however, rates of stroke/death after TCAR were similar regardless of arch complexity. Our results suggests that TCAR should be preferentially considered in revascularization of patients with anatomy considered high-risk for TFCAS.

Follow-up after acute thrombotic events following COVID-19 infection.

OBJECTIVE: COVID-19 infection results in a hypercoagulable state predisposing patients to thrombotic events. We report the 3- and 6-month follow-up of 27 patients who experienced acute arterial thrombotic events in the setting of COVID-19 infection. METHODS: Data were prospectively collected and maintained for all vascular surgery consultations in the Mount Sinai Health System from patients who presented between March 16 and May 5, 2020. RESULTS: Twenty-seven patients experienced arterial thrombotic events. The average length of stay was 13.3 ± 15.4 days. Fourteen patients were treated with open surgical intervention, six were treated with endovascular intervention, and seven were treated with anticoagulation only. At 3-month follow-up, 11 patients (40.7%) were deceased. Nine patients who expired did so during the initial hospital stay. The 3-month cumulative primary patency rate for all interventions was 72.2%, and the 3-month primary patency rates for open surgical and endovascular interventions were 66.7 and 83.3, respectively. There were 9 (33.3%) readmissions within 3 months. Six-month follow-up was available in 25 (92.6%) patients. At 6-month follow-up, 12 (48.0%) patients were deceased, and the cumulative primary patency rate was 61.9%. The 6-month primary patency rates of open surgical and endovascular interventions were 66.7% and 55.6%, respectively. The limb-salvage rate at both 3 and 6 months was 89.2%. CONCLUSIONS: Patients with COVID-19 infections who experienced thrombotic events saw high complication and mortality rates with relatively low patency rates.

Sex-based differences in loss of independence after lower extremity bypass surgery.

INTRODUCTION: This study analyzes sex-based differences in the risk of discharge to a nonhome facility (loss of independence) after lower extremity revascularization and resultant outcomes. METHODS: Data from the NSQIP database for years 2015-2017 was utilized to assess sex-based differences in loss of independence and associated unplanned readmission and 30-day amputation using chi-square, student t-test, and multivariate logistic regression analyses where appropriate. RESULTS: There was increased loss of independence in women (34.9% vs. 26.1 %, p < .01) and associated increase in unplanned readmission (18.4% vs. 13.6 %, p = .01) and length of stay (12.1 days vs 6.5 days, p < .01). Endovascular revascularization was associated with decreased likelihood of loss of independence (OR 0.43, CI 0.36-0.50). CONCLUSION: Loss of independence after lower extremity bypass surgery affects women more than men and it is associated with worse postoperative outcomes.

Placement of Simultaneous Inferior Vena Cava Filter During Emergent Open Pulmonary Thromboembolectomy.

BACKGROUND: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava (IVC) filter and separate (SEP) IVC filter placement with open pulmonary thromboembolectomy (PTE) in pulmonary embolism and its clinical outcomes. MATERIALS AND METHODS: From November 2006 to May 2014, 23 patients (14 females and 9 males; median age 58 years; range, 21-88 years) underwent emergent PTE for submassive (12) or massive (11) pulmonary embolism (PE). All had a preoperative computed tomography (CT) scan and echocardiography consistent with right ventricular (RV) strain. Mean cardiopulmonary bypass times and temperatures; chest tube outputs; length of stay; perioperative complications; and survival were compared between groups. RESULTS: There were 13 patients in the SIM group and 10 in the SEP group. PE consisted of 14 acute (60.9%) and nine acute on chronic (39.1%). There were seven deaths (30.4%). Median follow up was 44 days (range, 2-2204 days). Follow up was 81% complete in surviving patients. Actuarial survival at one and three years was 83% for the SIM group and 43% for the SEP group, respectively. There were no differences in cardiopulmonary bypass (CPB) times and temperatures, chest tube outputs, or length of stay between groups. Using multivariable logistic regression, we found SIM was associated with increased survival (p=0.09). Further analysis showed patients >55 years in the SEP group were at significantly higher risk of death (hazard ratio [HR]=7.1:1; 95% confidence interval [CI]: 1.55, 32.5, p=0.011). CONCLUSION: IVC filter placement can be performed simultaneously and safely at PTE. Age >55 years and PTE with IVC filter placed separately were at significantly higher risk of death. A larger cohort is needed to evaluate efficacy of simultaneous IVC filter placement and PTE.

A review of acute limb ischemia in COVID-positive patients.

This literature review discusses the current evidence on acute limb ischemia (ALI) in patients with COVID-19. Throughout the pandemic, these patients have been at increased risk of arterial thrombotic events and subsequent mortality as a result of a hypercoagulable state. The exact mechanism of thrombosis is unknown; however arterial thrombosis may be due to invasion of endothelial cells via angiotensin-converting enzyme 2 (ACE2) receptors, endothelial injury from inflammation, or even free-floating aortic thrombus. Multiple studies have been performed evaluating the medical and surgical management of these patients; the decision to proceed with operative intervention is dependent on the patient's clinical status as it relates to COVID-19 and morbidity of that disease. The interventions afforded typically include anticoagulation in patients undergoing palliation; alternatively, thrombectomy (endovascular and open) is utilized in other patients. There is a high risk of rethrombosis, despite anticoagulation, given persistent endothelial injury from the virus. Postoperative mortality can be high in these patients.

Neutrophil-to-Lymphocyte Ratio Associated With Adverse Events After Endovascular Aneurysm Repair (EVAR).

BACKGROUND: The blood neutrophil-to-lymphocyte ratio (NLR) is a surrogate biomarker of systemic inflammation with important prognostic significance in multiple disease processes, including cardiovascular diseases. It is inexpensive, widely available, and may be related to the outcomes of patients after surgery. We aimed to investigate the possible association of NLR with the outcomes of patients following endovascular aneurysm repair (EVAR). METHODS: This single-center, retrospective study of a prospectively maintained database evaluated 777 patients with a diagnosed abdominal aortic aneurysm (AAA) who underwent EVAR and were longitudinally followed between 2001 and 2017. NLR was defined as the ratio of absolute neutrophil count to absolute lymphocyte count. The mortality and reinterventions were used to evaluate outcomes using the appropriate univariate models, and the effect of clinical variables on NLR was further investigated using multivariate modelling. RESULTS: The median NLR for all patients was 3 IQR [2.2 - 4.6]. A cut-off point of 3.6 was uncovered in a training set of 388 patients using the maximally ranked statistic method. Patients with NLR < 3.6 had significantly improved mortality rates (P< 0.0001) in the training set, and results were internally validated in a testing set of 389 patients (P = 0.042). Multivariate analysis revealed that high NLR (HR 1.4 95% CI [1.0 - 2.0]; P< 0.05) remained an independent predictor of mortality in a multivariate analysis controlling for characteristics such as comorbidities, age, and maximal aortic diameter. 5-year mortality and 30-day, 1-year and 5-year reinterventions were all higher in the high NLR group. CONCLUSION: High NLR was significantly associated with higher rates of death at 5 years as well as higher rates of reinterventions at 30 days, 1 year and 5 years. We also suggest that an internally validated cut-off point of NLR >3.6 may be clinically important to help segregate patients into high and low NLR categories. It remains unclear whether NLR is directly linked to adverse events post-EVAR or whether it is a surrogate for an inflammatory state that predisposes patients to higher risk of death or reinterventions.

Trends, factors, and disparities associated with length of stay after lower extremity bypass for tissue loss.

OBJECTIVE: The objective of this study was to determine predictors of increased length of stay (LOS) in patients who underwent lower extremity bypass for tissue loss. METHODS: Using 2011 to 2016 National Surgical Quality Improvement Program vascular targeted databases, we compared demographics, comorbidities, procedural characteristics, and 30-day outcomes of patients who had expected LOS vs extended LOS (>75th percentile, 9 days) after nonemergent lower extremity bypass for tissue loss. We also compared factors associated with short LOS (<25th percentile, 4 days) and extended LOS (>75th percentile, 9 days) vs the interquartile range of LOS (4-9 days). Yearly trends and independent predictors were determined by linear and logistic regression. This study was exempt from Institutional Review Board approval. RESULTS: In 4964 analyzed patients, there were no significant yearly trends or changes in LOS in the recent 5 years (P > .05). Overall 30-day mortality, major amputation, and reintervention rates were 1.6%, 4.5%, and 4.8%, respectively, also with no significant yearly trends (all P > .05). On univariate analysis, nonwhite race, dependent functional status, transfers, dialysis, congestive heart failure, hypertension, beta blockers, distal bypass targets, and extended operative time were associated with extended LOS (P < .05). Extended LOS was also associated with higher rates of 30-day major adverse limb and cardiac events, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility but lower 30-day readmission rates. After adjustment for covariates, the independent factors for extended LOS included dialysis, beta blockers, prolonged operative time, reintervention, major amputation, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility (P < .05). On the other hand, multivariable analysis showed that patients with expected LOS were significantly more likely to have been of white race or readmitted postoperatively (P < .05). CONCLUSIONS: From 2011 to 2016, there were no significant changes in LOS. Efforts to decrease LOS without increasing readmission rates while focusing on some of the identified factors, including preventable postoperative complications and pre-existing socioeconomic factors, may improve the overall vascular care of these challenging patients.

Acute thrombotic manifestations of coronavirus disease 2019 infection: Experience at a large New York City health care system.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel coronavirus that has typically resulted in upper respiratory symptoms. However, we have encountered acute arterial and venous thrombotic events after COVID-19 infection. Managing acute thrombotic events from the novel virus has presented unprecedented challenges during the COVID-19 pandemic. In our study, we have highlighted the unique treatment required for these patients and discussed the role of anticoagulation for patients diagnosed with COVID-19. METHODS: The data from 21 patients with laboratory-confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. The demographics, comorbidities, home medications, laboratory markers, and outcomes were analyzed. The primary postoperative outcome of interest was mortality, and the secondary outcomes were primary patency and morbidity. To assess for significance, a univariate analysis was performed using the Pearson χ2 and Fisher exact tests for categorical variables and the Student t test for continuous variables. RESULTS: A total of 21 patients with acute thrombotic events met our inclusion and exclusion criteria. Most cases were acute arterial events (76.2%), with the remainder venous cases (23.8%). The average age for all patients was 64.6 years, and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil/lymphocyte ratio (8.8) and D-dimer level (4.9 µg/mL). Operative intervention included percutaneous angiography in 25.00% of patients and open surgical embolectomy in 23.8%. Most of the patients who had undergone arterial intervention had developed a postoperative complication (53.9%) compared with a 0% complication rate after venous interventions. Acute kidney injury on admission was a factor in 75.0% of those who died vs 18.2% in the survivors (P = .04). CONCLUSIONS: We have described our experience in the epicenter of the pandemic of 21 patients who had experienced major thrombotic events from infection with COVID-19. The findings from our cohort have highlighted the need for increased awareness of the vascular manifestations of COVID-19 and the important role of anticoagulation for these patients. More data are urgently needed to optimize treatment and prevent further vascular complications of COVID-19 infections.

Acute thrombotic events as initial presentation of patients with COVID-19 infection.

We describe three patients with COVID-19 who presented with an acute vascular event rather than with typical respiratory symptoms. These patients were all subsequently found to have laboratory-confirmed COVID-19 infections as the likely cause of their thrombotic event. The primary presentation of COVID-19 infection as a thrombotic event rather than with respiratory symptoms has not been described elsewhere. Our cases and discussion highlight the thrombotic complications caused by COVID-19; we discuss management of these patients and explore the role of anticoagulation in patients diagnosed with COVID-19.

Safety and feasibility of transradial infrainguinal peripheral arterial disease interventions.

OBJECTIVE: Transradial access (TRA) has traditionally been favored for coronary interventions. Tools with up to 200 cm length now allow operators to treat infrainguinal peripheral arterial disease (PAD) using TRA. This study aims to assess the safety and feasibility of TRA infrainguinal interventions. METHODS: Patients with infrainguinal PAD who underwent intervention via TRA from July 2013 through June 2019 were retrospectively reviewed. Exclusion criteria included Barbeau D waveform, a radial artery diameter of greater than 2 mm, radial artery occlusion, Raynaud syndrome, or peripheral vasculitis. Procedural success (adequate inline flow to the foot), TRA alone failure (crossover or use of an additional access site), clinical success (defined as improvement in ankle brachial index, clinical symptoms, or wound healing) and adverse events were recorded from procedure notes and follow-up visits. RESULTS: Thirty-six procedures were attempted using TRA in 32 patients (mean age, 65.8 years; range, 29-86; 22 male, 14 female) with mean height of 65.8 inches (range, 59.0-72.0 inches) and a body mass index of 28.7 (range, 19.1-43.9). Preprocedure Rutherford classification (II/III/IV/V/VI) was 8/15/2/7/4, respectively. The left radial artery was used for 35 of 36 procedures (97.2%). Treated vessels included the common femoral (n = 4), superficial femoral (n = 25), deep femoral (n = 1), popliteal (n = 10), tibioperoneal trunk (n = 2), tibial (n = 4), and plantar (n = 1) arteries. Interventions included angioplasty (n = 32, 100%), atherectomy (n = 8, 25%), and stenting (n = 13, 41%). Procedural success was 100%, the TRA alone failure rate was 11.1%, and clinical success was 89.3%. The median follow-up was 286.5 days (range, 0-919 days). Adverse events included radial artery pseudoaneurysm (n = 1), access site hematoma/bleeding (n = 3), radial artery occlusion (n = 1), groin hematoma (n = 1), popliteal artery dissection treated with stenting (n = 2), and a small superficial femoral artery perforation (n = 1) treated with prolonged balloon tamponade. No patients experienced signs of cerebrovascular events or distal embolism. CONCLUSIONS: TRA is a useful option for treating patients with PAD; however, several limitations still exist.

Persistent symptoms after endovenous thermal ablation may suggest proximal venous outflow obstruction.

OBJECTIVE: Proximal venous outflow obstruction (PVOO) in the iliac veins and superficial venous disease are inter-related in ways not fully understood. We observed among our patients undergoing vein stent placement for PVOO a significant number having had prior endovenous thermal ablations (EVTA) in their history. This study was undertaken to better characterize these patients and develop an algorithm in their management. METHODS: In a combined retrospective and prospective data registry of 682 patients who underwent vein stent placement for chronic PVOO at a single institution from March 2013 to November 2017, 100 limbs of 99 patients (14.5% of all patients) had a history of EVTA or other superficial venous procedures before their vein stenting. Limbs with dilated truncal veins on ultrasound examination or limbs that underwent poststent EVTA or superficial venous procedures were excluded. The mean age of these 99 patients was 60.2 years (range, 28-88 years; standard deviation, 13.855). Fifty-one percent of the patients were male. The most common presenting symptom of the patient cohort was edema (n = 59), followed by venous-related skin changes (n = 22). RESULTS: Bilateral stents were performed in 58%, with a mean number of 2.06 stents per patient. EVTA was the primary superficial vein procedure in 97%. Bilateral EVTA were performed in 53% and unilateral EVTA in 47%. The mean time between the first EVTA to vein stenting was 1202.7 days. Patients were followed at 30 days, 90 days, 6 months, 1 year, and >1 year. The outcome for each patient at each postoperative visit was compared with preoperative parameters (subject's assessment, physical examination, and provider assessment) and was scored as follows: -1 (worse than preoperative), 0 (no change), +1 (mildly improved), +2 (significantly improved), or +3 (completely recovered). The mean outcome score at 30 days was 1.63 (84 patients), 2.05 at 90 days (62 patients), 2.09 at 6 months (74 patients), 1.93 at 1 year (54 patients), and 1.97 at >1 year (39 patients). CONCLUSIONS: Approximately 15% of patients undergoing vein stent placement for chronic PVOO have an antecedent history of superficial venous disease and EVTA. PVOO should be considered and the patient evaluated accordingly if symptoms persisted or recurred after EVTA. Vein stent placement among these patients with PVOO will result in further symptomatic relief, but complete symptomatic relief is not observed in everyone. The algorithm for the management of these patients warrants further investigation.

Mechanochemical ablation as an alternative to venous ulcer healing compared with thermal ablation.

OBJECTIVE: We aimed to compare mechanochemical ablation (MOCA) and thermal ablation (radiofrequency ablation and endovenous laser therapy) for venous ulcer healing in patients with clinical class 6 chronic venous insufficiency. METHODS: Electronic medical records were reviewed of patients with venous ulcers who underwent truncal or perforator ablation between February 2012 and November 2015. These records contained history of venous disease and ulcer history, procedures, complications, follow-up, method of wound care, and current status of the ulcer. The patients were grouped according to the method of ablation for comparison. RESULTS: In 66 patients, 82 venous segments were treated, 29 with thermal methods and 53 with MOCA; 16% of patients had prior venous intervention. Before ablation, three patients in the thermal group had a history of deep venous thrombosis compared with seven in the MOCA group. On average, patients treated with MOCA were older (thermal ablation, 57.2 years; MOCA, 67.9 years; P = .0003). Ulcer duration before intervention ranged from 9.2 months for thermal ablation to 11.2 months for MOCA (P = NS). In total, 74% of patients treated with MOCA healed their ulcers compared with 35% of those treated with thermal ablation (P = .01). A healed ulcer was defined as elimination of ulcer depth and superficial skin coverage. The mean time to heal was 4.4 months in the thermal ablation group compared with 2.3 months with MOCA (P = .01). The mean length of follow-up was 12.8 months after thermal ablation and 7.9 months after MOCA (P = .02). Both age (P = .03) and treatment modality (P = .03) independently had an impact on ulcer healing on multiple logistic regression analysis. All but two patients were treated with an Unna boot after venous ablation. Complications included readmission of two patients with nonaccess-related infections, one nonocclusive deep venous thrombosis, and one late death unrelated to the procedure second to pneumonia in the setting of advanced colon cancer. There were three recurrent ulcers at 1 week, 2 months, and 7 months after MOCA that rehealed with Unna boot therapy and continued compression. CONCLUSIONS: MOCA is safe and effective in treating chronic venous ulcers and appears to provide comparable results to methods that rely on thermal ablation. Younger age and use of MOCA favored wound healing. MOCA was an independent predictor of ulcer healing. Randomized studies are necessary to further support our findings.