Journal of Vascular Surgery

A single nucleotide polymorphism in the p27Kip1 gene is associated with primary patency of lower extremity vein bypass grafts

2013-01-11

Objective: Factors responsible for the variability in outcomes after lower extremity vein bypass grafting (LEVBG) are poorly understood. Recent evidence has suggested that a single nucleotide polymorphism (SNP) in the promoter region of the p27Kip1 gene, a cell-cycle regulator, is associated with coronary in-stent restenosis. We hypothesized an association with vein graft patency.Methods: This was a retrospective genetic association study nested within a prospective cohort of 204 patients from three referral centers undergoing LEVBG for claudication or critical ischemia. The main outcome measure was primary vein graft patency.Results: All patients were followed up for a minimum of 1 year with duplex graft surveillance (median follow-up, 893 days; interquartile range, 539-1315). Genomic DNA was isolated and SNP analysis for the p27Kip1-838C>A variants was performed. Allele frequencies were correlated with graft outcome using survival analysis and Cox proportional hazards modeling. The p27Kip1-838C>A allele frequencies observed were CA, 53%; CC, 30%; and AA, 17%, satisfying Hardy-Weinberg equilibrium. Race (P = .025) and history of coronary artery disease (P = .027) were different across the genotypes; all other baseline variables were similar. Primary graft patency was greater among patients with the -838AA genotype (75% AA vs 55% CA/CC at 3 years; P = .029). In a Cox proportional hazards model including age, sex, race, diabetes, critical limb ischemia, redo (vs primary) bypass, vein type, and baseline C-reactive protein level, the p27Kip1-838AA genotype was significantly associated with higher graft patency (hazard ratio for failure, 0.4; 95% confidence interval, 0.17-0.93). Genotype was also associated with early (0-1 month) changes in graft lumen diameter by ultrasound imaging.Conclusions: These data suggest that the p27Kip1-838C>A SNP is associated with LEVBG patency and, together with previous reports, underscore a central role for p27Kip1 in the generic response to vascular injury.

The Comprehensive Risk Assessment for Bypass (CRAB) facilitates efficient perioperative risk assessment for patients with critical limb ischemia

2013-02-01

Objective: Specific perioperative risk assessment models have been developed for bariatric, pancreatic, and colorectal surgery. A similar instrument, specific for patients with critical limb ischemia (CLI), could improve patient-centered clinical decision making. We describe a novel tool to predict 30-day major morbidity and mortality (M&M) after bypass surgery for CLI.Methods: Data for 4985 individuals from the 2007 to 2009 National Surgical Quality Improvement Program were used to develop and internally validate the model. Outcome measures included mortality, major morbidity, and a composite end point (M&M). M&M included mortality and the most severe postoperative morbidities that were highly associated with death (eg, sepsis and major cardiopulmonary complications). More than 30 preoperative factors were tested for association with 30-day mortality, major morbidity, and M&M. Significant predictors in multivariate models were assigned integer values (points), which were added to calculate a patient's Comprehensive Risk Assessment For Bypass (CRAB) score. Performance was assessed (C-index) across all outcome measures and compared with other general tools (American Society of Anesthesiologists class, Surgical Risk Scale) and existing CLI-specific survival prediction models (Finnvasc score, Edifoligide for the Prevention of Infrainguinal Vein Graft Failure [PREVENT III] score) on a distinct validation sample (n = 1620).Results: In the derivation data set (n = 3275), the 30-day mortality rate was 2.9%. The rate of any major morbidity was 19.1%. The composite end point M&M occurred in 10.1%. Significant predictors of M&M by multivariate analysis included age >75 years, prior amputation or revascularization, tissue loss, dialysis dependence, severe cardiac disease, emergency operation, and functional dependence. Applied to a distinct validation sample of 1620 patients, higher CRAB scores were significantly associated with higher rates of mortality, all major morbidities, and M&M (P < .0001). Comparison with other models by assessment of area under the receiver-operating characteristic curve revealed the CRAB was a more accurate predictor of mortality, all major morbidity, and M&M.Conclusions: The CRAB is a CLI-specific, risk assessment instrument derived from multi-institutional American College of Surgeons-National Surgical Quality Improvement Program surgical outcomes data that out-performs existing prognostic risk indices in the prediction of clinically significant adverse events after bypass surgery. Use of the CRAB as a risk assessment tool provides an evidence basis for patient-centered clinical decision making and may have a role in identifying patients at higher risk for surgical revascularization in whom an endovascular approach is preferable.

Invited commentary

Thomas S. Huber — 2013-05-01

The authors have developed a risk assessment tool to predict perioperative morbidity and mortality after infrainguinal bypass in patients with critical limb ischemia using the National Surgical Quality Improvement Program database. They reported an overall mortality rate of 2.9% with a major morbidity rate of 19%. Not surprisingly, they identified advanced age, prior revascularization/amputation, tissue loss, dialysis dependence, severe cardiac disease, emergent operation, and functional dependence as predictors of adverse outcome. The sum of the weighted values assigned to these predictors correlated well with the adverse outcomes in their internal validation and the model itself compared favorably with others reported in the literature. Despite the quality of the study and the importance of predicting perioperative outcome, it is not clear how the model should be used in clinical practice. Critical limb ischemia is a difficult problem with poor long-term outcomes in terms of wound healing, ambulation, limb salvage, functional independence, and survival. The model defines perioperative outcome in a select group of patients presumably deemed adequate risk to undergo open revascularization. Unfortunately, it fails to model any of these other important outcome measures that may be far more relevant from a patient perspective. It is not clear that the data can be used to support an endovascular approach as an alternative to open revascularization as suggested by the authors. With the widespread proliferation of the endovascular therapies, most providers (ie, vascular surgeons, interventional radiologists, cardiologists) have adopted an “endovascular first” approach and presumably many of the patients in the current study would not have been endovascular candidates based upon their distribution of occlusive disease and/or extent of tissue loss. Notably, 70% of the patients in the current study had tissue loss, and 55% had undergone a previous revascularization or amputation. Furthermore, it is conceivable that “medical management” with local wound care or major amputation may be a better treatment option in the highest-risk cohort of patients with critical limb ischemia. I commend the authors for their excellent contribution and look forward to their planned, future studies detailing perioperative and longer-term outcomes after the other treatment options in this difficult patient population.

Changing presentation of knee dislocation and vascular injury from high-energy trauma to low-energy falls in the morbidly obese

2013-02-05

Objective: Reports in the literature of low-energy (LE) knee dislocation (KD) in obese patients have been increasing. This study was undertaken to define the risk factors for KD by LE mechanisms and the outcomes of these patients compared with those with high-energy (HE) trauma.Methods: All patients with a complete KD presenting to the emergency department of a large urban level I trauma center were reviewed. Patient information collected included age, sex, weight, height, body mass index (BMI), injury mechanism, neurovascular and orthopedic injuries, and operations performed to treat vascular injuries. Risk factors for KD and concomitant injuries were compared between HE traumatic dislocations and LE dislocations in obese patients (BMI >30 kg/m2), including stratification for increasing levels of obesity.Results: Between January 1995 and April 2012, 53 patients with KD were identified. The mechanism of injury was HE in 28 (53%) and LE in 25 (47%). Of the LE KDs, 18 (72%) were related to obesity (BMI >30 kg/m2). Obese patients with LE trauma were more likely to have associated nerve injuries (50% vs 6%; P < .001), vascular injuries requiring intervention (33% vs 9%; P = .048), and vascular surgical repairs (28% vs 6%; P = .038) than patients with HE traumatic dislocations. These rates were highest in the patients with a BMI >40 kg/m2. Although all LE KDs in the obese involved an isolated extremity, the hospital lengths of stay were comparable to those with HE KDs who frequently had multisystem trauma (8.7 vs 11.4 days). During a 17-year period, LE KDs in the obese represented an increasing proportion, from 17% in 1995 to 2000 up to 53% in 2007 to 2012, and the eventual majority of all KDs at our institution (P = .024).Conclusions: LE KDs in obese patients are becoming increasingly prevalent. These patients are more likely to have nerve and vascular injuries and are more likely to undergo vascular repair than patients with HE trauma. The epidemic of obesity in the United States presents unique challenges in the identification and treatment of patients with LE KD and their associated injuries.

Predictive value of angiographic scores for the integrated management of the ischemic diabetic foot

2013-01-18

Objective: To retrospectively evaluate the agreement between the angiographic scores and the clinical outcomes after endoluminal revascularization in diabetic patients with Fontaine stage IV critical limb ischemia (CLI).Methods: Clinical and procedural data were retrospectively collected of consecutive diabetic patients with Fontaine stage IV CLI who underwent percutaneous lower limb endoluminal revascularization from January 2009 to June 2011. Pre- and postprocedural angiographic images were retrospectively reviewed to classify lower limb arterial involvement according to four systems: (1) TransAtlantic Inter-Society Consensus [TASC] I; (2) TASC II; (3) Graziani's morphologic classification; and (4) Joint Vascular Society Council calf and foot scores. Foot lesions were graded according to the University of Texas wound classification system. Clinical results (healing, nonhealing, or major amputation) were compared with baseline clinical data and angiographic results.Results: In the study period, 202 percutaneous procedures were performed, with an immediate technical success rate of 94%. Preprocedurally, the mean ± standard deviation calf and foot scores were 7.8 ± 1.6 and 7.3 ± 2.3, respectively; 132 patients (65%) were in Graziani's morphologic classes from 4 to 7; in 112 (55%) cases, TASC II was considered inapplicable, for the absence of femoropopliteal lesions; and finally, 93% of limbs were classified as TASC I type D lesions. After the procedure, mean calf and foot scores were 4.8 ± 2.3 and 5.9 ± 2.6, respectively, and 87% of cases were in Graziani's classes 1 and 2; TASC II was inapplicable in all cases, whereas 80% of cases remained TASC I type D lesions. Healing rate was 67% and major amputation rate was 4%. Among all the clinical and angiographic variables included in the analysis, only pre- and postprocedural foot scores were significantly associated to the clinical outcome (P < .05).Conclusions: Endoluminal revascularization represents a valuable treatment option in diabetic patients with CLI. TASC classifications are inadequate to describe peripheral arterial involvement in the vast majority of diabetic patients with CLI. Pre- and postprocedural foot scores represent the most significant angiographic parameters to evaluate treatment success.

Early quantitative evaluation of indocyanine green angiography in patients with critical limb ischemia

2013-01-28

Objective: Patients requiring lower extremity revascularization are increasingly complex. Traditional means of evaluating perfusion before and after revascularization are often limited by the presence of medial calcinosis, open wounds, prior toe or forefoot amputations, and infection. We evaluated the initial application of indocyanine green angiography (ICGA) to patients with severe lower extremity ischemia to develop quantitative, reproducible parameters to assess perfusion.Methods: ICGA uses a charge-coupled device camera, a laser, and intravenous contrast to visually assess skin surface perfusion. From January 2011 to April 2012, we performed ICGA within 5 days of 31 revascularization procedures in patients with Rutherford class 5 and 6 ischemia. We also compared ICGA before and after revascularization in a subset of 13 patients. We evaluated multiple, quantitative parameters to assess perfusion.Results: Twenty-four patients underwent ICGA associated with 31 revascularization procedures (26 endovascular, four open, one hybrid) for 26 lower limb wounds; 92% were diabetic and 20% were dialysis-dependent. In 50% of these patients, it was not possible to measure ankle-brachial indexes due to medial calcinosis. Paired analysis of ingress (increase in pixel strength [PxS]), ingress rate (slope of increase in PxS), curve integral (area under the curve in PxS over time), end intensity (PxS at end of study), egress (decrease in PxS from maximum), and egress rate (slope of decrease in PxS) increased significantly (P < .05) after revascularization.Conclusions: ICGA provides rapid visual and quantitative information about regional foot perfusion. We believe this is the first report describing quantification of foot perfusion before and after lower extremity revascularization for severe limb ischemia. Further study is warranted to help define the utility of this intriguing new technology to assess perfusion, response to revascularization, and potentially, to predict likelihood of wound healing.

The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome

2013-03-25

Objective: This study evaluated the effect of pedal arch quality on the amputation-free survival and patency rates of distal bypass grafts and its direct impact on the rate of healing and time to healing of tissue loss after direct angiosome revascularization in patients with critical limb ischemia (CLI).Methods: Between 2004 and 2011, patients undergoing distal bypass for CLI (Rutherford 4-6) were divided in groups taking into consideration the state of the pedal arch and direct angiosome revascularization (DAR) and non-DAR. Angiography was used to divide the pedal arch into three groups: complete pedal arch (CPA), incomplete pedal arch (IPA), and no pedal arch (NPA). The primary end points were patency rates at 12 months, amputation-free survival at 48 months, and the rate of healing and time to healing of foot tissue loss.Results: A total of 154 patients (75% men) with CLI underwent 167 infrapopliteal bypasses. Patients were a median age of 75 years (range, 46-96 years). Diabetic mellitus was present in 76%, chronic renal failure in 28%, and ischemic heart disease in 44%. The primary patency rates at 1 year in the CPA, IPA, and NPA groups were 58.4%, 54.6%, and 63.8%, respectively (P = .5168), the secondary patency rates were 86.0%, 84.7%, and 88.8%, respectively (P = .8940), and the amputation-free survival at 48 months was 67.2%, 69.7%, and 45.9%, respectively (P = .3883). Tissue loss was present in 141 of the 167 bypasses. In the CPA group, 83% of tissue loss with DAR healed compared with 92% in the non-DAR (median time to healing, 66 vs 74 days). Similarly in the IPA group, 90% with DAR healed compared with 81% in the non-DAR (median time to healing, 96 vs 86 days). In the NPA group, only 75% with DAR healed compared with 73% in the non-DAR (median time to healing, 90 vs 135 days). There was a significant difference in healing and time to healing between the CPA/IPA and NPA groups (P = .0264).Conclusions: The quality of the pedal arch did not influence the patency or the amputation-free survival rates. However, the rates for healing and time to healing were directly influenced by the quality of the pedal arch rather than the angiosome revascularized.

Feasibility and validity of self-reported walking capacity in patients with intermittent claudication

2013-02-05

Objective: The primary aim of this study was to assess if self-reported measures of walking limitation correlate better with a community-based assessment of maximum walking distance (MWD) than they do with laboratory-based tests in patients with intermittent claudication. A secondary aim was to examine the effect of prior objective testing on these correlations.Methods: Thirty-one patients completed three self-report tools (self-reported MWD; Walking Impairment Questionnaire [WIQ]; Estimation of Ambulatory Capacity by History-Questionnaire [EACH-Q]) immediately before and approximately 1 week after a series of objective tests (incremental treadmill walking test, 6-minute walk test, 1-hour global positioning system [GPS] recording of a community walk). We analyzed the feasibility of the self-report tools in terms of number of errors and their correlation (r) with objective measures.Results: The correlations of self-report tests to GPS-MWD (range, .579-.808) were consistently higher than with the treadmill test (range, .310-.584) and 6-minute walk test (range, .414-.613). The WIQ had the highest proportion of errors, both at first and second completion (58% and 42%, respectively), compared with self-reported MWD (23% and 13%, respectively) and the EACH-Q (6.5% and 13%, respectively). Correlations were improved with the second set of self-report tests (range, .310-.595 to .414-.808).Conclusions: The fact that all self-report tools correlated better with a community-based measure of MWD using GPS than with laboratory results confirms that they measure what they aim to: community-based MWD. In addition, prescription of a community walk might help patients to better estimate their walking limitation.

Initial experience with the Ventana fenestrated system for endovascular repair of juxtarenal and pararenal aortic aneurysms

Andrew Holden, Renato Mertens, Andrew Hill, Leopoldo Mariné, Daniel G. Clair — 2013-03-04

Objective: Customized fenestrated endovascular stent grafts have been investigated as an alternative to open surgery for repair of more complex juxtarenal aortic aneurysms (JAAs). The substantial time required to design and manufacture these devices has led to the desire for a standardized fenestrated endovascular system. We report the initial pilot study results of a potential “off-the-shelf” fenestrated device system to assess its initial safety and feasibility for endovascular repair of JAAs and pararenal aortic aneurysms (PAAs).Methods: Following ethics committee approvals, consenting patients were evaluated for eligibility. Patients with aneurysms abutting or including the renal artery orifices who were not candidates for standard infrarenal endograft placement because of proximal aortic neck morphology were further assessed for anatomic suitability for this “off-the-shelf” device. There were a number of anatomic requirements, the most important being a stable infra-superior mesenteric artery aortic neck length ≥15 mm. Patients are assessed in-hospital and in follow-up at 1, 6, and 12 months, and annually thereafter to 5 years for adverse events and using contrast-enhanced computed tomography angiography with Core Laboratory interpretation of renal perfusion, device integrity, migration, endoleak, and aneurysm morphology.Results: Fifteen patients (87% male) with JAAs (93%) or PAAs (6.7%) presented at mean age of 77 years (range, 66-85 years) and with mean sac diameter of 5.9 cm (range, 5.1-7.9 cm). Four Ventana fenestrated stent graft models having aligned fenestrations (three models) or offset fenestrations (one model) and renal stent grafts were successfully implanted among the patients, and all renal and visceral arteries were preserved. Mean endovascular procedure time was 108 minutes (range, 71-212 minutes) with mean contrast usage and fluoroscopy time of 254 mL (range, 67-420 mL) and 55 minutes (range, 27-104 minutes), respectively. Five patients received blood products. Mean time to hospital discharge was 3.3 days (range, 2-9 days). In follow-up to 6 months and 1 year, no rupture, conversion to open repair, migration, type I/III endoleak, or renal loss/infarcts were observed. Two late nonaneurysm-related deaths have occurred. One secondary procedure for iliac limb kinking/occlusion and one secondary procedure for renal artery stenosis have been performed.Conclusions: Early experience supports procedural and initial postprocedural safety and demonstrates proof of concept for the off-the-shelf Ventana fenestrated system for the endovascular repair of JAAs and PAAs in selected patients. Continued follow-up and expanded multicenter clinical experience is warranted.

Invited commentary

Ahmed M. Abou-Zamzam — 2013-05-01

Holden et al describe the initial series of patients treated with a new endovascular platform termed the Ventana by Endologix (Irvine, Calif). This investigational platform allows the treatment of aneurysms with short or absent infrarenal necks (juxtarenal or pararenal aneurysms). As surgeons have become more aggressive with endovascular aneurysm repair, the true anatomic “noncandidates” have been disappearing. Although technology has advanced to the point where iliac anatomy is rarely a contraindication to endovascular repair, the infrarenal neck is often the limiting factor.

Incidence and treatment results of Endurant endograft occlusion

2013-02-08

Objective: The Endurant endograft (Medtronic Inc, Minneapolis, Minn) is a new-generation device specifically developed to perform well in complex abdominal aortic aneurysm anatomy. Previous reports on the 1- and 2-year results of endovascular aneurysm repair (EVAR) with the Endurant endograft showed excellent outcome, including prevention of migration and type I endoleaks, but occurrence and outcome of post-EVAR occlusion have not been determined in a large multicenter patient cohort with midterm follow-up, which is the objective of this study.Methods: Data of consecutive patients treated with the Endurant from December 2007 to April 2012 in three Dutch tertiary vascular referral hospitals were prospectively gathered and retrospectively analyzed. Follow-up consisted of regular office visits, computed tomography angiography at 1 and 12 months after EVAR, and subsequently, duplex ultrasound imaging or computed tomography angiography at regular intervals. Patients with ruptured aneurysms or with earlier abdominal aortic surgery were excluded. The incidence and clinical outcome of endograft occlusions were analyzed. An expert review board assessed all cases in the search for possible causes of occlusion.Results: Included were 496 patients (87.7% male), who were a median age of 74 years (range, 68-78 years). Median follow-up was 1.7 years (range, 0-4.6 years). Twenty graft occlusions (4.0%) occurred during follow-up. Median time between primary EVAR and detection of the occlusion was 1 month, with 55% occurring ≤60 postoperative days and 90% ≤1 year. No association was found between occlusion and sex (P = .28), age (P = .96), or use of an aortouniiliac device (P = .66). Technical error was the considered cause of the occlusion in 12 patients (60%). The estimated freedom from occlusion was 98.4% at 30 days, 95.7% at 1 year, and 95.3% at 3 years. Presenting symptoms of occlusion were acute limb ischemia in 50%. Treatment was surgical (75%) or percutaneous (25%). Successful revascularization was achieved in 17 of 20 patients, but reocclusions occurred in five, resulting in a transfemoral amputation in one patient. Occlusion-related mortality was 0.6% (3 of 496).Conclusions: At a median follow-up of 1.7 years, Endurant endograft occlusion occurred in 4.0% of 496 patients. Most occlusions occurred ≤2 months after EVAR, and rarely after 1 year. A technical justification for occlusion could be found for 60% of patients. A more liberal intraoperative and early postoperative (re)intervention strategy may reduce the occlusion rates and improve outcome.

Discussion

2013-02-08

Dr Gustavo Oderich (Rochester, Minn). I would like to congratulate you on a very important paper. I think the topic is very pertinent now that we are exploring using lower-profile stents for infrarenal aneurysms. A little bit more about your methodology. Can you tell us whether you analyzed other thromboembolic events in addition to the classic end point of limb occlusion? It would be ideal for future comparisons with other devices to have more granularity on thrombus formation and changes in the ankle-brachial index. Also, have you evaluated changes such as nonocclusive thrombus formation in the limbs using repeated computed tomography (CT) scans?

The impact of hemodynamic status on outcomes of endovascular abdominal aortic aneurysm repair for rupture

2013-02-05

Objective: To date, there are no published reports comparing hemodynamically (Hd)-stable and Hd-unstable patients with ruptured abdominal aortic aneurysms (r-AAAs) undergoing endovascular aneurysm repair (EVAR). This study evaluates outcomes of EVAR for r-AAA based on patient's Hd statusMethods: From 2002 to 2011, 136 patients with r-AAAs underwent EVAR and were categorized into two groups based on systolic blood pressure (SBP) measurements before EVAR: 92 (68%) Hd-stable (SBP ≥80 mm Hg) and 44 (32%) Hd-unstable (SBP <80 mm Hg for >10 minutes). All data were prospectively entered in a database and retrospectively analyzed. Outcomes included 30-day mortality, postoperative complications, the need for secondary reinterventions, and midterm mortality. The effect of potential predictors on 30-day mortality was assessed by χ2 and logistic regression.Results: Of the 136 r-AAA patients with EVAR, the Hd-stable and Hd-unstable groups had similar comorbidities (coronary artery disease, 63% vs 59%; hypertension, 72% vs 75%; chronic obstructive pulmonary disease, 21% vs 26%; and chronic renal insufficiency, 18% vs 18%), mean AAA maximum diameter (6.6 vs 6.4 cm), need for on-the-table conversion to open surgical repair (3% vs 7%), and incidences of nonfatal complications (43% vs 38%) and secondary interventions (23% vs 25%). Preoperative computed tomography scan was available in significantly fewer Hd-unstable patients (64% vs 100%; P < .05). Compared with Hd-stable patients, the Hd-unstable patients had a significantly higher intraoperative need for aortic occlusion balloon (40% vs 6%; P < .05), mean estimated blood loss (744 vs 363 mL; P < .05), incidence of developing abdominal compartment syndrome (ACS; 29% vs 4%; P < .01), and death (33% vs 18%; P < .05). ACS was a significant predictor of death; death in all r-EVAR with ACS was significantly higher compared with all r-EVAR without ACS (10 of 17 [59%] vs 22 of 119 [18%]; P < .01).Conclusions: EVAR for r-AAA is feasible in Hd-stable and Hd-unstable patients, with a comparable incidence of conversion to open surgical repair, nonfatal complications, and secondary interventions. Hd-stable patients have reduced mortality at 30 days, whereas Hd-unstable patients require intraoperative aortic occlusion balloon more frequently, and have an increased risk for developing ACS and death.

Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England

2013-02-05

Objective: Prior studies of gender differences in abdominal aortic aneurysm (AAA) repair suggest there may be differences in presentation, suitability for endovascular aneurysm repair (EVAR), and outcomes between men and women.Methods: We used the Vascular Study Group of New England database to identify all patients undergoing EVAR or open AAA repair. We analyzed demographics, comorbidities, and procedural, and perioperative data. Results were compared using the Fisher exact test and the Student t-test. Multivariable logistic regression and Cox proportional hazards modeling were performed to identify predictors of mortality.Results: We identified 4026 patients (78% men) who underwent AAA repair (54% EVAR). Women were less likely than men to undergo EVAR for intact aneurysms (50% vs 60% of intact AAA repair; P < .001) but not for ruptured aneurysms (26% vs 20%; P = .23). Women were older (median age, 75 vs 72 years for intact; P < .001; 78 vs 73 years for rupture; P .99) repairs. Late survival was worse in women than men only for patients undergoing open repair of ruptured aneurysms (hazard ratio, 1.8; 95% confidence interval, 1.0-3.1; P = .04). After controlling for age, type of repair, urgency at presentation (ie, elective/intact vs ruptured), comorbidities, and other relevant risk factors, gender was not predictive of 30-day or 1-year mortality.Conclusions: Women with AAAs are being treated at older ages and smaller AAA diameters and are undergoing rupture repair at smaller diameters than men. Women are more likely to experience perioperative complications as a result of less favorable vascular anatomy. Age >80 years, comorbidity, presentation, and type of repair are more important predictors of mortality than gender.

Secondary interventions after elective thoracic endovascular aortic repair for degenerative aneurysms

2013-01-28

Objective: We assessed the incidence and outcomes of graft-related secondary interventions (ie, open conversion or proximal or distal extensions) after elective thoracic endovascular aortic repair (TEVAR) for aneurysmal disease.Methods: An institutional review of TEVAR for descending thoracic aortic aneurysms (DTAAs), between 2000 and 2011, was performed. Only elective TEVAR for DTAA using commercially available endografts was selected. Emergent cases, nonaneurysmal aortic pathology (ie, transection, pseudoaneurysm, dissection), and cases that used physician-modified devices were excluded. The incidence of unplanned graft-related secondary interventions was examined and outcomes were analyzed.Results: During the study period, 83 patients underwent elective TEVAR for DTAA that met the inclusion criteria. Subsequent graft-related secondary interventions were required in eight patients (10%). The mean interval to the secondary intervention was 31.8 months. Endoleak was the most common indication. Patients who required secondary interventions were significantly younger (mean age, 58 ± 12 vs 69 ± 11 years; P < .05). Operative mortality (<30 day) was zero, with one aneurysm-related late death occurring at 2 years after the secondary intervention. Factors that predisposed the need for secondary interventions were fusiform morphology of the aneurysm (P = .05) and extent of graft coverage in the proximal landing zone <3 cm (P < .05). Size of the aneurysm treated and the type of device used were not significant factors leading to secondary intervention.Conclusions: Intermediate and long-term results of elective TEVAR for DTAA demonstrate good durability, with acceptable rates of graft-related secondary interventions. Age, fusiform aneurysm morphology, and extent of proximal landing zones <3 cm were significant factors that led to subsequent secondary interventions.

Carotid-subclavian bypass and subclavian-carotid transposition in the thoracic endovascular aortic repair era

Arin L. Madenci, C. Keith Ozaki, Michael Belkin, James T. McPhee — 2013-02-05

Objective: Beyond traditional indications, subclavian revascularization is increasingly performed to allow for aortic arch debranching in the setting of thoracic endovascular aortic repair (TEVAR). Endovascular treatment options for subclavian disease have emerged, perhaps altering the patient population undergoing open revascularization. We leveraged prospectively collected American College of Surgeons (ACS)-National Surgical Quality Improvement Program (NSQIP) data to delineate evolving stroke and mortality rates after carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) in this dynamic context.Methods: The ACS-NSQIP database (2005 to 2010) was used to examine patients who underwent CSB or SCT. Patients admitted for emergency cases were excluded. Factors associated with 30-day postoperative cerebrovascular accident (CVA) or death (CVA/D) were defined using univariable and multivariable analyses.Results: CSB comprised 41% of revascularizations associated with TEVAR and 89% of isolated revascularizations. A greater proportion of TEVARs were performed in the SCT group (37.4% vs 4.9%; P < .01). The groups were similar in demographic characteristics and prevalence of comorbidities. Overall stroke, mortality, and combined CVA/D rates were 3.5% (n = 31), 3.3% (n = 29), and 5.8% (n = 51), respectively. Surgical approach did not affect outcome. The CVA/D rate was 10.2% (n = 9) for revascularization in conjunction with TEVAR and 5.3% (n = 42) for isolated reconstruction (P = .06). For patients undergoing isolated revascularization, increasing age (adjusted odds ratio, 1.06; 95% confidence interval, 1.03–1.10; P < .01), and nonindependent functional status (odds ratio, 3.49; 95% confidence interval, 1.41-8.68; P < .01) were significantly associated with CVA/D.Conclusions: In this contemporary data set, there was no significant difference in CVA/D by surgical approach. TEVAR trended toward an association with CVA/D compared with isolated subclavian reconstruction. CVA/D continues to complicate contemporary CSB and SCT, especially among elderly and nonindependent patient subsets.

Progress in management of malperfusion syndrome from type B dissections

2013-02-04

Objective: Malperfusion syndrome is a known predictor of poor outcomes in acute type B dissection. We describe our experience with revascularization in the acute setting.Methods: Patients undergoing intervention for ischemia complicated acute type B dissection between November 1999 and March 2011 were reviewed. Details of presenting condition, surgical intervention, and postoperative course were collected. Descriptive and inferential statistical analyses included survival and freedom from reintervention using Cox proportional hazards models.Results: A total of 61 patients were identified with malperfusion in at least one territory, including spinal cord 7/61 (12%), mesenteric 37/61 (61%), renal 45/61 (73%), and lower extremity 38/61 (62%). Thoracic stent grafts were placed in all patients, and 41% of patients required adjunctive branch vessel stenting. After intervention, resolution of the ischemia was reported in 57/61 (93%) of patients. The 30-day/in-hospital mortality was 21.3%. The 6-month, 1-year, and 5-year survival was 75% (95% CI, 65%-87%), 71% (95% CI, 61%-84%), and 56% (95% CI, 43%-74%), respectively. The 6-month, 1-year, and 5-year freedom from reintervention was 84% (95% CI, 75%-95%), 76% (95% CI, 65%-90%), and 42% (95% CI, 24%-76%), respectively. Territory of ischemia was not independently associated with mortality, but placement of a stent graft proximal to the subclavian artery was associated with poor outcome hazard ratio 2.91 (95% CI, 1.09-8.11; P = .034).Conclusions: Malperfusion in any territory at the time of presentation in patients with type B dissections can be treated with endovascular intervention with acceptable outcomes. Opposed to branch vessel intervention alone, increased aortic intervention with regard to proximal coverage may signify more serious disease is associated with worse outcome.

Discussion

2013-02-04

Dr Edward Woo (Philadelphia, Pa). Tim, I had a question for you. There is a pretty high complication rate of renal failure. Were most of these patients who came in with renal ischemia as well, or was this secondary to the procedure?

Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition

2013-02-27

Objective: The aim of the study was to determine whether type II endoleak (T2E) after endovascular repair of abdominal aorta (EVAR) is a benign condition (ie, not associated with growth, reintervention, rupture, or death).Methods: Data from patients who underwent EVAR for atherosclerotic infrarenal aortic aneurysms between June 1995 and May 2010 in the Vascular Surgery Department of Henri Mondor Hospital were prospectively collected. Data from patients presenting with at least one T2E on computed tomography scan during their follow-up were compared with those with no T2E. Three subcategories of T2E were studied according to time of occurrence (early or late), persistence (persistent or transient), and recurrence (recurrent or not recurrent).Results: Seven hundred patients were included with follow-up ranging from 1 month to 15 years (median, 31.3 months; range, 12.4-61.4); 201 (28.9%) had at least one T2E. Patients with T2Es were significantly older (P < .001), female (P = .015), had larger aneurysms (P = .019), and patent lumbar arteries (P = .003). Patients without T2Es had a higher incidence of current smoking (P < .001) and chronic obstructive pulmonary disease (P < .005). Multivariate analysis showed risk of T2E was increased in older patients (odds ratio [OR], 1.04; confidence interval [CI], 95% 1.02-1.06; P < .001) and in those with patent lumbar arteries (OR, 1.70; CI, 95% 1.16-2.50; P = .007), and was reduced in active smokers (OR, 0.16 CI, 95% 0.04-0.71; P = .015) or patients with coronary artery disease (OR, 0.65; CI, 95% 0.45-0.92; P = .016). Patients with T2Es had more complications (death, rupture, reintervention, or conversion) (P < .001) and greater aneurysm sac enlargement (>5 mm upon follow-up) (P < .001). Multivariate analysis showed T2E was a risk factor for aneurysm diameter growth >5 mm; this risk was increased if T2E persisted more than 6 months (hazard ratio [HR], 3.16; CI, 95% 2.55-6.03; P < .001), was recurrent (HR, 1.88; CI, 95% 1.18-3.01; P = .008), or associated with a type I or III endoleak (HR, 1.96; CI, 95% 1.41-2.73; P < .001). Recurrent T2E was associated with a higher rate of reintervention (P = .04) and conversion to open surgery (P = .028).Conclusions: Not all T2Es are benign. Recurrent as well as persistent T2Es are prone to life-threatening complications.

Invited commentary

Bengt Lindblad — 2013-05-01

In this issue of the Journal of Vascular Surgery, El Batti and coworkers report on the not-always-benign outcome of type II endoleak after endovascular aneurysm repair (EVAR) in 700 patients, of whom 201 patients had type II endoleaks. This is an important problem. Today, there is no consensus on the handling of type II endoleaks, and recent reviews agree at least on one issue—the lack of hard facts on how to handle type II endoleaks.

Results of elective and emergency endovascular repairs of popliteal artery aneurysms

2013-02-04

Objective: Endovascular repair has emerged as a treatment option for popliteal artery aneurysms. Our goal was to analyze outcomes of elective and emergency endovascular popliteal artery aneurysm repair (EVPAR).Methods: This was a retrospective review of clinical data of patients treated with EVPAR at our institution between 2004 and 2010. Stent-related complications, patency, outcome limb salvage, and survival were evaluated and analyzed.Results: EVPAR was performed in 31 limbs of 25 patients (mean age, 81 years; range, 65-89 years). Repair was elective in 19 limbs (61%) and emergent in 12 (39%). One aneurysm ruptured and 11 presented with acute thrombosis. All 11 underwent thrombolysis before EVPAR. Patients were implanted with a mean of 2.1 Viabahn stent grafts (range, 1-4). Ten procedures (32%) were performed percutaneously and 21 by femoral cutdown. Technical success was 97%. Overall 30-day mortality was 6.4%, with 0% in the elective group, and 16.7% in the emergent group (P = .14). Early complications included graft thrombosis in two limbs (6.4%) and hematoma in four (13%), all after percutaneous repair. Myocardial infarction and thrombolysis-associated intracranial hemorrhage occurred in one patient each (3.2%). The 30-day primary and secondary patencies were 93.6% and 96.7%, respectively, and were 100% in the elective group and 83.3% and 91.6%, respectively, for the emergent group. Mean follow-up was 21.3 months (range, 1-75 months). Primary patency at 1 year was 86% (95% for elective, 69% for emergent; P = .56), secondary patency at the same time was 91% (elective, 100%; emergent, 91%). One-year limb salvage was 97%. Two-year survival was 91% for the elective group and 73% for the emergent group (P = .15). Five stent occlusions were encountered after 30 days, four in the elective group. Four underwent successful reintervention, two had bypass, and two had thrombolysis, followed by angioplasty. The fifth patient was asymptomatic and nonambulatory and remains under observation. Stent graft infolding occurred in one limb (3.2%), with no clinical sequelae. No stent migration or separation was observed. One stent fracture was noted in an asymptomatic patient. Three (10%) type II endoleaks were detected but none had aneurysm expansion. One (3.2%) type I endoleak was treated percutaneously with placement of an additional stent graft. Overall, major adverse events, including death, graft occlusion with or without reoperation, or reoperation for endoleak or stent infolding occurred after 11 procedures (35.5%). On univariate analysis, no factors predicted stent failure, including runoff, antiplatelet therapy, emergency repair, number of stents implanted, heparin bonding of the stent, or degree of stent oversizing.Conclusions: These results support elective EVPAR in anatomically suitable patients with increased risk for open repair; however, major adverse events after EVPAR, mainly after emergency repairs, are frequent. A prospective randomized multicenter study to justify EVPAR in the emergent setting is warranted.

Evolving treatment of popliteal artery aneurysms

2013-02-01

Background: Over the past decade, the treatment of popliteal aneurysms has evolved at our institution from sole operative intervention during the initial part of the study period, to combined surgical and endovascular treatment, and finally to endovascular-centered management in more recent years.Methods: This is a retrospective review of all patients with popliteal aneurysms treated at our institution from 2001 to 2011. Data collection included the indication for intervention, treatment details, interventional patency, limb salvage, perioperative outcome, and midterm survival.Results: Eighty-eight aneurysms (72 patients) were treated during this period. Indications for intervention included symptomatic presentations in 53% (n = 47) and asymptomatic in 47% (n = 41). Treatment included endovascular exclusion in 24, surgical repair in 63 (14 posterior approach and 49 medial approach with bypass and exclusion), and primary amputation in one patient. Nine aneurysms (10.2%) received catheter-directed thrombolysis. Demographics were similar between the two treatment cohorts, except for age with endovascular stenting patients being significantly older (76.0 vs 66.0 years; P = .002). The mean length of stay was 3.9 days vs 9.5 days (P < .001), favoring endovascular treatment. There were no perioperative (30-day) deaths in the endovascular group and one in the surgical cohort. The mean patency follow-up was 21.2 vs 28.3 months. Primary patency did not differ between endovascular and surgically treated patients at 1 year (92.9% vs 83.3%; P = .26) and 3 years (63.7% vs 77.8%; P = .93). No limbs were lost in the endovascular group during the follow-up period of 22.4 months, and one late limb loss occurred in the surgical cohort (mean follow-up, 29.2 months). Endovascular patients had a midterm survival rate of 65% (mean follow-up, 33.9 months), whereas surgical patients experienced a survival rate of 80.8% (mean follow-up, 42.9 months; P = .22).Conclusions: Endovascular treatment of popliteal aneurysms provides similar short-term patency to that of the traditional gold standard approach with surgical bypass, with shorter hospitalizations in both symptomatic and asymptomatic patients. Further long-term follow-up is required to compare these two treatment modalities for durability to determine the optimal popliteal aneurysm management.

Selective coverage of the left subclavian artery without revascularization in patients with bilateral patent vertebrobasilar junctions during thoracic endovascular aortic repair

2013-01-28

Objective: The primary purpose of the current study was to evaluate the safety and effectiveness of selective coverage of the left subclavian artery (LSCA) without revascularization during thoracic endovascular aortic repair (TEVAR) in patients with bilateral patent vertebrobasilar junctions. The secondary purpose was to assess morphologic change of the vertebral artery (VA) after the procedure.Methods: Among 126 patients who underwent TEVAR between 2006 and 2011, 29 patients requiring LSCA coverage without preemptive revascularization were retrospectively analyzed in this study. The patients were a mean age of 63.1 years (range, 45-84 years). The mean follow-up period was 19.9 months (range, 1-63 months). Bilateral patent vertebrobasilar junctions were evaluated by contrast-enhanced computed tomography (CT), time-of flight magnetic resonance angiography, or conventional angiography. Neurologic complications, such as spinal cord ischemia (SCI) or cerebrovascular accidents, were analyzed. Preprocedural and postprocedural changes in VAs were evaluated on follow-up contrast-enhanced CT.Results: The overall 30-day mortality was 6.9% (2 of 29). None of the patients had SCI or a stroke of posterior circulation alone. Cerebrovascular accidents from embolic infarctions occurred in two patients (7.4%). Transient left arm ischemic symptoms were present in five patients (18.5%), but none required secondary interventions. Delayed development of type I endoleak occurred due to stent deformity in one patient, who underwent surgery. One patient required reintervention after the 10-month follow-up contrast-enhanced CT showed a pseudoaneurysm had developed at the distal margin of the previously placed stent graft. Hypertrophy of the right VA after TEVAR was seen in seven of 27 patients (25.9%); two patients showed bilateral hypertrophy of VAs.Conclusions: LSCA coverage without revascularization can be safely performed during TEVAR in patients with bilateral patent vertebrobasilar junctions. Hypertrophy of the right VA was noted in 25.9% of patients after LSCA coverage.

The impact of Centers for Medicare and Medicaid Services high-risk criteria on outcome after carotid endarterectomy and carotid artery stenting in the SVS Vascular Registry

2013-02-13

Objective: The Centers for Medicare and Medicaid Services (CMS) require high-risk (HR) criteria for carotid artery stenting (CAS) reimbursement. The impact of these criteria on outcomes after carotid endarterectomy (CEA) and CAS remains uncertain. Additionally, if these HR criteria are associated with more adverse events after CAS, then existing comparative effectiveness analysis of CEA vs CAS may be biased. We sought to elucidate this using data from the SVS Vascular Registry.Methods: We analyzed 10,107 patients undergoing CEA (6370) and CAS (3737), stratified by CMS HR criteria. The primary endpoint was composite death, stroke, and myocardial infarction (MI) (major adverse cardiovascular event [MACE]) at 30 days. We compared baseline characteristics and outcomes using univariate and multivariable analyses.Results: CAS patients were more likely to have preoperative stroke (26% vs 21%) or transient ischemic attack (23% vs 19%) than CEA. Although age ≥80 years was similar, CAS patients were more likely to have all other HR criteria. For CEA, HR patients had higher MACEs than normal risk in both symptomatic (7.3% vs 4.6%; P < .01) and asymptomatic patients (5% vs 2.2%; P < .0001). For CAS, HR status was not associated with a significant increase in MACE for symptomatic (9.1% vs 6.2%; P = .24) or asymptomatic patients (5.4% vs 4.2%; P = .61). All CAS patients had MACE rates similar to HR CEA. After multivariable risk adjustment, CAS had higher rates than CEA for MACE (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.0-1.5), death (OR, 1.5; 95% CI, 1.0-2.2), and stroke (OR, 1.3; 95% CI,1.0-1.7), whereas there was no difference in MI (OR, 0.8; 95% CI, 0.6-1.3). Among CEA patients, age ≥80 (OR, 1.4; 95% CI, 1.02-1.8), congestive heart failure (OR, 1.7; 95% CI, 1.03-2.8), EF <30% (OR, 3.5; 95% CI, 1.6-7.7), angina (OR, 3.9; 95% CI, 1.6-9.9), contralateral occlusion (OR, 3.2; 95% CI, 2.1-4.7), and high anatomic lesion (OR, 2.7; 95% CI, 1.33-5.6) predicted MACE. Among CAS patients, recent MI (OR, 3.2; 95% CI, 1.5-7.0) was predictive, and radiation (OR, 0.6; 95% CI, 0.4-0.8) and restenosis (OR, 0.5; 95% CI, 0.3-0.96) were protective for MACE.Conclusions: Although CMS HR criteria can successfully discriminate a group of patients at HR for adverse events after CEA, certain CMS HR criteria are more important than others. However, CEA appears safer for the majority of patients with carotid disease. Among patients undergoing CAS, non-HR status may be limited to restenosis and radiation.

Race as a predictor of morbidity, mortality, and neurologic events after carotid endarterectomy

2013-02-01

Objective: Racial disparities in the outcomes of patients undergoing carotid endarterectomy (CEA) have been reported. We sought to examine the contemporary relationship between race and outcomes and to report postdischarge events after CEA.Methods: The American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were reviewed to identify all CEAs performed from 2005 to 2010 by vascular surgeons. The influence of race on outcomes was examined. Multivariate analysis was performed using variables found to be significant on bivariate analysis. The primary outcomes were stroke and mortality. Secondary outcomes were other 30-day complications, including postdischarge events.Results: CEA was performed on 29,114 white patients (95.7%) and on 1316 black patients (4.3%); the overall stroke and mortality rates were 1.65% and 0.7%, respectively. The stroke rate was 1.6% for whites and 2.5% blacks (P = .009). The 30-day mortality rate was 0.7% for whites and 1.4% for blacks (P = .002). There was a longer operating time (P < .001) and total length of stay (P < .001), more postoperative pneumonias (P = .049), unplanned intubations (P < .001), ventilator dependence (P < .001), cardiac arrests (P < .001), bleeding requiring transfusions (P = .024), and reoperations within 30 days (P = .021) among black patients. Multivariate logistic regression modeling identified black race as an independent risk factor for 30-day mortality (odds ratio, 1.9; P = .007). Black patients also had a greater proportion of in-hospital deaths than white patients (73.7% vs 43.1%; P = .01). There was no between-group difference in the rate of postdischarge strokes. Thirty-six percent of all strokes occurred after discharge at a mean of 8.3 days, and 54.3% of deaths occurred after discharge at a mean of 11 days.Conclusions: Black race is an independent risk factor for 30-day mortality after CEA. A significant proportion of strokes and deaths occur after discharge in both racial groups evaluated.

Impact of postoperative nadir hemoglobin and blood transfusion on outcomes after operations for atherosclerotic vascular disease

2013-02-05

Objective: Controversy surrounds the topic of transfusion policy after noncardiac operations. This study assessed the combined impact of postoperative nadir hemoglobin (nHb) levels and blood transfusion on adverse events after open surgical intervention in patients who undergo operative intervention for atherosclerotic vascular disease.Methods: Consecutive patients who underwent peripheral arterial disease (PAD)-related operations were balanced on baseline characteristics by inverse weighting on propensity score calculated as their probability to have nHb greater than 10 gm/dL on the basis of operation type, demographics, and comorbidities, including the revised cardiac risk index. A multivariate generalized estimating equation analysis was performed to investigate associations between nHb, transfusion, and a composite outcome of perioperative death and myocardial infarction. Logistic and Cox proportional hazards regressions were used to assess the impact of nHb and transfusion on respiratory and wound complications; and a composite end point (CE) of death, myocardial infarction during a 2-year follow-up. Level of statistical significance was set at alpha of 0.0125 to adjust for the increased probability of type I error attributable to multiple comparisons.Results: The analysis cohort included 880 patients (1074 operations). After adjusting for nHb level, the number of units transfused was not associated with the perioperative occurrence of the CE (odds ratio [OR], 1.13; P = .025). Adjusted for the number of units transfused, nHb had no impact on the perioperative CE (OR, 0.62; P = .22). An interaction term between transfusion and nHb level remained nonsignificant (P = .312), indicating that the impact of blood transfusion was the same regardless of the nHb level. Perioperative respiratory complications were more likely in patients receiving transfusions (OR, 1.22; P = .009), and perioperative wound infections were less common in patients with nHb >10 gm/dL (OR, 0.65; P = .01). During an average follow-up of 24 months, transfused patients were more likely to develop the CE (hazard ratio [HR], 1.15, P = .009), whereas nHb level did not impact the long-term adverse event rate (HR, 0.78; P = .373). The above associations persisted even after adjusting the Cox regression model for the occurrence of perioperative cardiac events.Conclusions: Although nHb less than 10 gm/dL is not associated with death or ACS after PAD-related operations, maintaining nHb greater than 10 gm/dL appears to decrease the risk of wound infection. Blood transfusion is associated with increased risk of perioperative respiratory complications. Until a randomized trial settles this issue definitively, a restrictive transfusion strategy is justified in patients undergoing operations for atherosclerotic vascular disease.

Discussion

2013-02-05

Dr Ronald Fairman (Philadelphia, Pa). My first question is, did you look at the timing of transfusion and did that have an impact on your results, whether the transfusions were administered only during the surgery as opposed to the early postoperative or late postoperative periods?

Variation in smoking cessation after vascular operations

2013-02-01

Objective: Smoking is the most important modifiable risk factor for patients with vascular disease. The purpose of this study was to examine smoking cessation rates after vascular procedures and delineate factors predictive of postoperative smoking cessation.Methods: The Vascular Study Group of New England registry was used to analyze smoking status preoperatively and at 1 year after carotid endarterectomy, carotid artery stenting, lower extremity bypass, and open and endovascular abdominal aortic aneurysm repair between 2003 and 2009. Of 10,734 surviving patients after one of these procedures, 1755 (16%) were lost to follow-up and 1172 (11%) lacked documentation of their smoking status at follow-up. The remaining 7807 patients (73%) were available for analysis. Patient factors independently associated with smoking cessation were determined using multivariate analysis. The relative contribution of patient and procedure factors including treatment center were measured by χ-pie analysis. Variation between treatment centers was further evaluated by calculating expected rates of cessation and by analysis of means. Vascular Study Group of New England surgeons were surveyed regarding their smoking cessation techniques (85% response rate).Results: At the time of their procedure, 2606 of 7807 patients (33%) were self-reported current smokers. Of these, 1177 (45%) quit within the first year of surgery, with significant variation by procedure type (open abdominal aortic aneurysm repair, 50%; endovascular repair, 49%; lower extremity bypass, 46%; carotid endarterectomy, 43%; carotid artery stenting, 27%). In addition to higher smoking cessation rates with more invasive procedures, age >70 years (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.30-2.76; P < .001) and dialysis dependence (OR, 2.38; 95% CI, 1.04-5.43; P = .04) were independently associated with smoking cessation, whereas hypertension (OR, 1.23; 95% CI, 1.00-1.51; P = .051) demonstrated a trend toward significance. Treatment center was the greatest contributor to smoking cessation, and there was broad variation in smoking cessation rates, from 28% to 62%, between treatment centers. Cessation rates were higher than expected in three centers and significantly lower than expected in two centers. Among survey respondents, 78% offered pharmacologic therapy or referral to a smoking cessation specialist, or both. The smoking cessation rate for patients of these surgeons was 48% compared with 33% in those who did not offer medications or referral (P < .001).Conclusions: Patients frequently quit smoking after vascular surgery, and multiple patient-related and procedure-related factors contribute to cessation. However, we note significant influence of treatment center on cessation as well as broad variation in cessation rates between treatment centers. This variation indicates an opportunity for vascular surgeons to impact smoking cessation at the time of surgery.

Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome

2013-02-04

Objective: This study evaluated the early effectiveness of isolated pectoralis minor tenotomy (PMT) in the surgical treatment of selected patients with neurogenic thoracic outlet syndrome (NTOS) compared with supraclavicular decompression (SCD; as scalenectomy, neurolysis, and first rib resection) plus PMT (SCD+PMT).Methods: Data were obtained for 200 patients undergoing operative treatment for disabling NTOS between 2008 and 2011. Isolated PMT was offered to 57 patients with physical examination findings limited to the subcoracoid space, and SCD+PMT was offered to 143 with scalene triangle and subcoracoid findings. Functional outcomes were assessed before and 3 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) survey and related instruments.Results: There were no significant differences (P > .05) between PMT and SCD+PMT patients with respect to age (overall, 37 ± 1 years), sex (73% women), side affected (52% right, 14% bilateral), or the frequency of various NTOS symptoms, but fewer PMT patients had a bony anomaly (0% vs 18%; P < .01) or a history of injury (35% vs 61%; P < .01). Mean preoperative DASH scores were similar between PMT and SCD+PMT groups (49.9 ± 3.6 vs 50.8 ± 1.6), but previous use of opiate pain medications was higher in PMT patients (47% vs 20%; P = .0004). PMT was conducted as an outpatient procedure, whereas the mean hospital stay after SCD+PMT was 4.8 ± 0.1 days, with two patients (1%) requiring early reoperations for persistent lymph leaks. Mean DASH scores 3 months after surgery were significantly improved after isolated PMT (29.6 ± 4.2; P < .01) and SCD+PMT (41.5 ± 2.2; P < .01), but the mean extent of improvement in DASH scores was not significantly different in PMT (32% ± 9%) vs SCD+PMT (19% ± 5%). There were also no significant differences in the proportion of PMT vs SCD+PMT patients demonstrating improvement in functional outcome measures (75% vs 72%) or in overall use of opiate medications (35% vs 27%).Conclusions: Isolated PMT is a low-risk outpatient procedure that is effective for the treatment of selected patients with disabling NTOS, with early outcomes similar to SCD+PMT. These findings emphasize the importance of recognizing subcoracoid brachial plexus compression as part of the spectrum of NTOS and support the role of PMT in surgical management.

Computer modeling for the prediction of thoracic aortic stent graft collapse

Salvatore Pasta, Jae-Sung Cho, Onur Dur, Kerem Pekkan, David A. Vorp — 2013-01-14

Objective: To assess the biomechanical implications of excessive stent protrusion into the aortic arch in relation to thoracic aortic stent graft (TASG) collapse by simulating the structural load and quantifying the fluid dynamics on the TASG wall protrusion extended into a model arch.Methods: One-way coupled fluid-solid interaction analyses were performed to investigate the flow-induced hemodynamic and structural loads exerted on the proximal protrusion of the TASG and aortic wall reconstructed from a patient who underwent traumatic thoracic aortic injury repair. Mechanical properties of a Gore TAG thoracic endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz) were assessed via experimental radial compression testing and incorporated into the computational modeling. The TASG wall protrusion geometry was characterized by the protrusion extension (PE) and by the angle (θ) between the TASG and the lesser curvature of the aorta. The effect of θ was explored with the following four models with PE fixed at 1.1 cm: θ = 10 degrees, 20 degrees, 30 degrees, and 40 degrees. The effect of PE was evaluated with the following four models with θ fixed at 10 degrees: PE = 1.1 cm, 1.4 cm, 1.7 cm and 2.0 cm.Results: The presence of TASG wall protrusion into the aortic arch resulted in the formation of swirling, complex flow regions in the proximal luminal surface of the endograft. High PE values (PE = 2.0 cm) led to a markedly reduced left subclavian flow rate (0.27 L/min), low systolic perfusion pressure (98 mm Hg), and peak systolic TASG diameter reduction (2 mm). The transmural pressure load across the TASG was maximum for the model with the highest PE and θ, 15.2 mm Hg for the model with PE = 2.0 cm and θ = 10 degrees, and 11.6 mm Hg for PE = 1.1 cm and θ = 40 degrees.Conclusions: The findings of this study suggest that increased PE imparts an apparent risk of distal end-organ malperfusion and proximal hypertension and that both increased PE and θ lead to a markedly increased transmural pressure across the TASG wall, a load that would portend TASG collapse. Patient-specific computational modeling may allow for identification of patients with high risk of TASG collapse and guide preventive intervention.Clinical Relevance: A potentially devastating complication that may occur after endovascular repair of traumatic thoracic aortic injuries is stent graft collapse. Although usually asymptomatic, stent graft collapse may be accompanied by adverse hemodynamic consequences. Numerous anatomic and device-related factors contribute to the development of collapse, but predictive factors have not yet been clearly defined. In the present study, we assessed the relevant hemodynamics and solid mechanics underlying stent graft collapse using a computational fluid-structure interaction framework of stent graft malapposition. Our findings suggest that both increased stent graft angle and extension into the aortic arch lead to a markedly increased transmural pressure across the stent graft wall, portending collapse. Patient-specific computational modeling may allow for identification of patients at high risk for collapse and aid in planning for an additional, prophylactic intervention to avert its occurrence.

Transglutaminase type 2 in human abdominal aortic aneurysm is a potential factor in the stabilization of extracellular matrix

Sung Shin, Yong-Pil Cho, Heungman Jun, Hojong Park, Hea Nam Hong, Tae-Won Kwon — 2013-03-27

Objective: The aim of this study was to evaluate transglutaminase type 2 (TG2) expression in human abdominal aortic aneurysm (AAA) tissue and to elucidate a potential role of TG2 in AAA formation. TG2, which is a Ca2+-dependent cross-linking enzyme, has been proven important for stabilizing the extracellular matrix. However, there is no evidence of the effect of TG2 on AAA formation in a human model.Methods: Aortic wall tissues were obtained during surgery in AAA patients (n = 38) and in patients with aortoiliac occlusive disease (Control; n = 4) in the Asan Medical Center from March 2011 to February 2012. In each AAA patient, the aortic neck (Neck) and maximally dilated portion (Max) of the aneurysm were sampled for analysis. TG2 expression was evaluated using immunohistochemistry and Western blotting. In addition, ex vivo experiments of isolated AAA tissue culture with the TG2 inhibitor cystamine and recombinant human TG2 were performed.Results: Among 38 AAA patients, 11 had ruptured (contained or free) AAAs. The mean maximal diameter of AAAs was 6.09 ± 1.46 cm. TG2 expressions of Max were significantly increased compared with those of Control (1.7-fold increase of Control; P = .00). Compared with Control, the intensities of tissue necrosis factor-α, matrix metalloproteinase (MMP)-2, MMP-9, and tissue inhibitors of metalloproteinase-2 were significantly upregulated in Max (1.7-fold, 1.5-fold, 1.3-fold, and 1.6-fold increases of Control; P = .00, P = .004, P = .046, and P = .007, respectively). Furthermore, double immunofluorescent staining showed that colocalization of TG2/transforming growth factor-β or TG2/fibronectin was prominent in Max compared with those of Neck or Control. In addition, MMP-2 intensity was upregulated in ruptured AAAs compared with unruptured AAAs, with marginal significance (P = .078). Ex vivo experiments showed that protein expressions of tissue necrosis factor-α, MMP-2, and MMP-9 in cultured AAA tissue were decreased by recombinant human TG2 but were increased by exogenous cystamine.Conclusions: The TG2 expression in the maximally dilated portion of AAAs was enhanced compared with that of nondilated aorta. It is suggested that TG2 has a potential effect in stabilization of extracellular matrix by inhibition of proinflammatory cytokines and MMPs or by interaction with fibronectin and transforming growth factor-β.Clinical Relevance: Transglutaminase type 2 (TG2), which is a Ca2+-dependent cross-linking enzyme, has been known be to important in stabilizing the extracellular matrix. In a rat abdominal aortic aneurysm (AAA) model, TG2 has a protective effect on AAA formation, whereas there has been no evidence of the effect of TG2 on AAA formation in a human model. This is the first study to suggest that TG2 has a potential effect in the stabilization of extracellular matrix in a human model. It is expected that our results may serve as the foundation to develop a preventive remedy for AAA.

Role of hemodynamic forces in the ex vivo arterialization of human saphenous veins

2013-01-25

Background: Human saphenous vein grafts are one of the salvage bypass conduits when endovascular procedures are not feasible or fail. Understanding the remodeling process that venous grafts undergo during exposure to arterial conditions is crucial to improve their patency, which is often compromised by intimal hyperplasia. The precise role of hemodynamic forces such as shear stress and arterial pressure in this remodeling is not fully characterized. The aim of this study was to determine the involvement of arterial shear stress and pressure on vein wall remodeling and to unravel the underlying molecular mechanisms.Methods: An ex vivo vein support system was modified for chronic (up to 1 week), pulsatile perfusion of human saphenous veins under controlled conditions that permitted the separate control of arterial shear stress and different arterial pressure (7 mm Hg or 70 mm Hg).Results: Veins perfused for 7 days under high pressure (70 mm Hg) underwent significant development of a neointima compared with veins exposed to low pressure (7 mm Hg). These structural changes were associated with altered expression of several molecular markers. Exposure to an arterial shear stress under low pressure increased the expression of matrix metalloproteinase (MMP)-2 and MMP-9 and tissue inhibitor of metalloproteinase (TIMP)-1 at the transcript, protein, and activity levels. This increase was enhanced by high pressure, which also increased TIMP-2 protein expression despite decreased levels of the cognate transcript. In contrast, the expression of plasminogen activator inhibitor-1 increased with shear stress but was not modified by pressure. Levels of the venous marker Eph-B4 were decreased under arterial shear stress, and levels of the arterial marker Ephrin-B2 were downregulated under high-pressure conditions.Conclusions: This model is a valuable tool to identify the role of hemodynamic forces and to decipher the molecular mechanisms leading to failure of human saphenous vein grafts. Under ex vivo conditions, arterial perfusion is sufficient to activate the remodeling of human veins, a change that is associated with the loss of specific vein markers. Elevation of pressure generates intimal hyperplasia, even though veins do not acquire arterial markers.Clinical Relevance: The pathological remodeling of the venous wall, which leads to stenosis and ultimately graft failure, is the main limiting factor of human saphenous vein graft bypass. This remodeling is due to the hemodynamic adaptation of the vein to the arterial environment and cannot be prevented by conventional therapy. To develop a more targeted therapy, a better understanding of the molecular mechanisms involved in intimal hyperplasia is essential, which requires the development of ex vivo models of chronic perfusion of human veins.

Transrenal E-XL stenting to resolve or prevent type Ia endoleak in the case of severe neck angulation during endovascular abdominal aortic aneurysm repair

2013-02-04

During endovascular abdominal aortic aneurysm repair, a severely angulated neck can make proximal sealing of endografts challenging, and the occurrence of a type Ia endoleak can complicate the procedure. We describe an original adjunctive procedure involving transrenal placement of a self-expanding nitinol stent (E-XL aortic stent; Jotec GmbH, Hechingen, Germany) to remodel the proximal aortic neck and treat or prevent type Ia endoleaks in the case of severe angulation of the proximal neck.

Repair of bilateral true aneurysms of the dorsalis pedis artery

Marta Ballesteros-Pomar, Nuria Sanz-Pastor, Fernando Vaquero-Morillo — 2013-01-10

Aneurysms of peripheral arteries are infrequent, with an incidence <1%. Dorsalis pedis artery (DPA) aneurysms are extremely rare, and most of them are pseudoaneurysms secondary to trauma or iatrogenic injuries. We report the first case of simultaneous (synchronous) bilateral DPA true aneurysms and how we repaired them. We review the literature on DPA true aneurysms and focus on the surgical management.

“Sandal strap” trauma and atherosclerosis are dual pathologies leading to bilateral true aneurysms of the dorsalis pedis arteries

Miranda Sonntag, Neil Hopper, Antony R. Graham — 2013-01-10

True aneurysm of the dorsalis pedis artery is rare. To our best knowledge, only 19 cases have been reported in the literature with one case of bilateral involvement. We describe an unusual case of simultaneous, bilateral true aneurysms of the dorsalis pedis arteries due to chronic mild trauma from dorsally positioned sandal straps with secondary atherosclerotic change. This is the first such case reported. Symptomatic aneurysms are at risk for thrombosis or embolization, and surgical management is recommended. In our case, both aneurysms were resected and repaired with interposition graft of saphenous vein. The patient was symptom free at 6-month follow-up.

Bilateral retroesophageal course of the carotid arteries

Dimitrios Virvilis, George Koullias, Nicos Labropoulos — 2013-05-01

Many variations in the anatomy of the carotid artery are described in the literature. There are few case reports of hypoplasia or the retropharyngeal course of the internal carotid artery. We describe the unique case of a 72-year-old woman with bilateral complete retroesophageal common carotid arteries and concomitant hypoplasia of the right carotid system. Anatomical detection of such a variation is critical because the misidentification of a retroesophageal carotid artery carries the risk of potential injury during orotracheal intubation and oropharyngeal procedures.

Endovascular recanalization of the superior mesenteric artery in the context of mesenteric bypass graft infection

2013-01-18

Mesenteric prosthetic graft infection is a rare and challenging clinical scenario. A patient is described who developed recurrent abdominal pain after occlusion of an iliomesenteric prosthetic bypass. Endovascular recanalization of the native superior mesenteric artery, which had been occluded for more than 10 years, was accomplished using axillofemoral through-wire access and a steerable guiding catheter. The infected prosthetic was then explanted and his graft-enteric fistula repaired. Technical and strategic considerations are discussed.

Fibromuscular dysplasia with multiple visceral artery involvement

Natarajan Sekar, Rajendran Shankar — 2013-05-01

A 19-year-old female presented with episodic abdominal pain not related to food intake. She had occasional vomiting but had no gastrointestinal bleed. Routine ultrasound examination picked up aneurysm of the superior mesenteric artery (SMA). Computed tomography angiogram showed stenosis of the origin of the SMA and multiple aneurysms involving the proximal SMA. A large collateral artery also showed aneurysm at its origin. The celiac artery and hepatic arteries were not visualized. Splenic artery was reconstituted through gastroepiploic artery. Multiple collaterals from the phrenic and mammary arteries were seen to supply the liver. Inferior mesenteric artery was dilated, and a large marginal artery was seen joining the superior mesenteric artery. Right renal artery showed mild irregularity at the proximal part ().

Profunda femoris artery aneurysm causing local deep venous thrombosis

David Connor, Michael Sharp, Sriram Rajagopalan — 2013-05-01

Aneurysms of the profunda femoris artery (PFA) are uncommon. We present a patient with a PFA aneurysm resulting in a deep venous thrombosis (DVT) of the femoral vein due to extrinsic compression.

Local drug delivery to prevent restenosis

2013-05-01

Introduction: Despite significant advances in vascular biology, bioengineering, and pharmacology, restenosis remains a limitation to the overall efficacy of vascular reconstructions, both percutaneous and open. Although the pathophysiology of intimal hyperplasia is complex, a number of drugs and molecular tools have been identified that can prevent restenosis. Moreover, the focal nature of this process lends itself to treatment with local drug administration. This article provides a broad overview of current and future techniques for local drug delivery that have been developed to prevent restenosis after vascular interventions.Methods: A systematic electronic literature search using PubMed was performed for all accessible published articles through September 2012. In an effort to remain current, additional searches were performed for abstracts presented at relevant societal meetings, filed patents, clinical trials, and funded National Institutes of Health awards.Results: The efficacy of local drug delivery has been demonstrated in the coronary circulation with the current clinical use of drug-eluting stents. Until recently, however, drug-eluting stents were not found to be efficacious in the peripheral circulation. Further pursuit of intraluminal devices has led to the development of balloon-based technologies, with a recent surge in trials involving drug-eluting balloons. Early data appear encouraging, particularly for treatment of superficial femoral artery lesions, and several devices have recently received the Conformité Européene mark in Europe. Investigators have also explored the periadventitial application of biomaterials containing antirestenotic drugs, an approach that could be particularly useful for surgical bypass or endarterectomy. In the past, systemic drug delivery has been unsuccessful; however, there has been recent exploration of intravenous delivery of drugs designed specifically to target injured or reconstructed arteries. Our review revealed a multitude of additional interesting strategies, including >65 new patents issued during the past 2 years for approaches to local drug delivery focused on preventing restenosis.Conclusions: Restenosis after intraluminal or open vascular reconstruction remains an important clinical problem. Success in the coronary circulation has not translated into solutions for the peripheral arteries. However, our literature review reveals a number of promising approaches, including drug-eluting balloons, periadventitial drug delivery, and targeted systemic therapies. These and other innovations suggest that the future is bright and that a solution for preventing restenosis in peripheral vessels will soon be at hand.

Too small to fail: The prisoner's dilemma

Bauer E. Sumpio — 2013-05-01

Standing before you at this moment, I am overwhelmed with a sense of pride and gratitude at the honor of being your President. I would like to thank the membership for the opportunity to serve, as I consider leadership of this society one of the highest honors of my professional career. It has been a wonderful and memorable journey since I attended my first meeting 25 years ago in Bretton Woods, New Hampshire. Although many of my predecessors have taken this opportunity to reflect on surgical achievements, past and future, that will not be my topic today. Part of what I will emphasize today is the importance of both adaptation and cooperation.

Rationale, scope, and 20-year experience of vascular surgical training with lifelike pulsatile flow models

2013-05-01

Vascular surgical training currently has to cope with various challenges, including restrictions on work hours, significant reduction of open surgical training cases in many countries, an increasing diversity of open and endovascular procedures, and distinct expectations by trainees. Even more important, patients and the public no longer accept a “learning by doing” training philosophy that leaves the learning curve on the patient's side. The Vascular International (VI) Foundation and School aims to overcome these obstacles by training conventional vascular and endovascular techniques before they are applied on patients. To achieve largely realistic training conditions, lifelike pulsatile models with exchangeable synthetic arterial inlays were created to practice carotid endarterectomy and patch plasty, open abdominal aortic aneurysm surgery, and peripheral bypass surgery, as well as for endovascular procedures, including endovascular aneurysm repair, thoracic endovascular aortic repair, peripheral balloon dilatation, and stenting. All models are equipped with a small pressure pump inside to create pulsatile flow conditions with variable peak pressures of ∼90 mm Hg. The VI course schedule consists of a series of 2-hour modules teaching different open or endovascular procedures step-by-step in a standardized fashion. Trainees practice in pairs with continuous supervision and intensive advice provided by highly experienced vascular surgical trainers (trainer-to-trainee ratio is 1:4). Several evaluations of these courses show that tutor-assisted training on lifelike models in an educational-centered and motivated environment is associated with a significant increase of general and specific vascular surgical technical competence within a short period of time. Future studies should evaluate whether these benefits positively influence the future learning curve of vascular surgical trainees and clarify to what extent sophisticated models are useful to assess the level of technical skills of vascular surgical residents at national or international board examinations. This article gives an overview of our experiences of >20 years of practical training of beginners and advanced vascular surgeons using lifelike pulsatile vascular surgical training models.

Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome

Danfeng Xu, Yi Gao, Jie Chen, Junkai Wang, Jianqing Ye, Yushan Liu — 2013-01-25

Nutcracker syndrome is a rare entity caused by extrinsic compression on the left renal vein (LRV) crossing between the superior mesenteric artery and the aorta. This article reports the treatment of two cases of nutcracker syndrome using laparoscopic inferior mesenteric-gonadal vein bypass, knowing that this treatment option would avoid renal reperfusion injury and LRV hypertension. In addition, it is easier to operate compared with laparoscopic splenorenal venous bypass and laparoscopic transposition of LRV into the inferior vena cava.

The role of completion imaging following carotid artery endarterectomy

Jean-Baptiste Ricco, Fabrice Schneider, Giulio Illuminati, Russell H. Samson — 2013-05-01

A variety of completion imaging methods can be used during carotid endarterectomy to recognize technical errors or intrinsic abnormalities such as mural thrombus or platelet aggregation, but none of these methods has achieved wide acceptance, and their ability to improve the outcome of the operation remains a matter of controversy.It is unclear if completion imaging is routinely necessary and which abnormalities require re-exploration. Proponents of routine completion imaging argue that identification of these abnormalities will allow their immediate correction and avoid a perioperative stroke. However, much of the evidence in favor of this argument is incidental, and many experienced vascular surgeons who perform carotid endarterectomy do not use any completion imaging technique and report equally good outcomes using a careful surgical protocol. Furthermore, certain postoperative strokes, including intracerebral hemorrhage and hyperperfusion syndrome, are unrelated to the surgical technique and cannot be prevented by completion imaging.This controversial subject is now open to discussion, and our debaters have been given the task to clarify the evidence to justify their preferred option for completion imaging during carotid endarterectomy.

Editors' commentary

Thomas L. Forbes, Jean-Baptiste Ricco — 2013-05-01

Although many aspects of carotid endarterectomy (CEA) surgery have been well analyzed with robust clinical studies, the role of completion imaging remains unclear. Randomized controlled trials are lacking in this regard, and those studies that have reviewed this issue tend to lack sufficient numbers of patients or an appropriate comparative group. Additionally, some causes of postoperative neurologic events, including hyperperfusion syndrome, hypotension, and intracerebral hemorrhage, are not necessarily directly related to technical skill and not visible to the standard methods of post-CEA imaging. Into this knowledge breach step our debaters.

Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Program in England

Meryl Davis, Mike Harris, Jonothan J. Earnshaw — 2013-03-25

The National Health Service Abdominal Aortic Aneurysm Screening Program (NAAASP) has been introduced after research and analysis of data from a number of randomized trials and existing local screening programs in England that showed a reduction in aneurysm-related mortality when men aged ≥65 years were offered ultrasound screening. The evidence was assessed by the United Kingdom National Screening Committee against a set of internationally recognized criteria that confirmed that screening all men aged ≥65 years saves lives. The introduction of abdominal aortic aneurysm (AAA) screening to men aged 65 years is estimated to reduce premature death from ruptured AAAs by up to 50% over the next 10 years. This article describes the AAA screening program in England, its ongoing implementation and current challenges, and outcomes in the first 150,000 men.

Predictive value of angiographic scores for the integrated management of the ischemic diabetic foot

Sean P. Roddy — 2013-05-01

Reimbursement for radiology testing is divided into two parts: professional and technical. The professional component is paid for the official physician interpretation of the diagnostic imaging. The technical component compensates for the overhead required to perform the service based on expenses such as monthly space rental, utilities, the actual imaging equipment (eg, ultrasound machine or fluoroscopic unit), disposables (eg, ultrasound gel, catheters, stents, balloons, and contrast), technician and/or nursing salary, and picture archiving and communication system (also known as PACS) image storage. If a test is performed in the hospital where the facility owns the equipment and pays the staff, the interpreting physician would typically bill with a -26 modifier appended to the CPT code. This signifies that the physician is requesting compensation only for professional component. “Global” reimbursement is the sum of both the technical and professional elements. When the equipment is owned by a medical practice in an office setting and a member of that group also interprets the imaging data, billing of the imaging service would not have a modifier attached in the insurance claim; this is termed billing global. Examples include vascular laboratories and angiography suites located in the physician office.

Evidence for a Strong Genetic Influence on Carotid Plaque Characteristics: An International Twin Study

A.D. Tarnoki, C. Baracchini, D.L. Tarnoki — 2013-05-01

Heritability of ultrasound plaque characteristics is high. Only a few studies have even partially investigated genetic determinants of carotid plaque characteristics. The San Antonio Family Heart Study found moderate (23%-28%) heritability of the presence of carotid plaques (Hunt KJ et al, Stroke 2002;33:2775-80). The Erasmus Rucphen Family (ERF) study used a carotid plaque score to quantify common carotid artery carotid bifurcation and internal carotid artery plaque and found 28% heritability of the carotid plaque (Sayed-Tabatabaei FA et al, Stroke 2005;36:2351-6). It is also known that underlying atherosclerotic phenotypes associated with carotid plaque formation (intima-media thickness, arterial stiffness) can also exhibit moderate heritability. However, genetic determinants related directly to carotid plaque characteristics are not clear. The authors sought to study the heritability of carotid plaque characteristics in a twin population. Twin studies more reliably estimate relative contribution of genes to phenotypic traits than can be determined with a “family study” design. There were 192 monozygotic and 83 dizygotic adult twin pairs (age 49 ± 15 years) from Italy, Hungary, and the United States who underwent B-mode and color Doppler ultrasound imaging of their bilateral common, internal, and external carotid arteries. Age-, sex-, and country-adjusted heritability was 78% for the presence of carotid plaque (95% confidence interval [CI] 55%-90%), 74% for plaque echogenicity (95% CI, 38%-87%), and 69% for plaque size (area in mm2 in longitudinal plane; <50 percentile or >50 percentile; 95% CI, 16%-86%). Adjusted heritability for plaque sidedness was 74% (95% CI, 25%-90%). Heritability was 74% for plaque numerosity (95% CI, 26%-86%) and 68% (95% CI, 40%-84%) and 66% (95% CI, 32%-90%), respectively, for presence of plaque in the carotid bulb and proximal internal carotid artery. No role for shared environmental factors was found. The remaining variants (22%-34%) were attributed to unique environmental factors. Controlling for relative covariates did not change the results of the study significantly.

Current Prevalence of Abdominal Aortic Aneurysm in 70-Year-Old Women

S. Svensjo, M. Bjorck, A. Wanhainen — 2013-05-01

Screening 70-year-old women who do not smoke is likely to be ineffective in discovering abdominal aortic aneurysm (AAA). Ultrasound screening of older men for AAA is an evidence-based method to reduce aneurysm-related and all-cause mortality. The only randomized study including women, however, demonstrated no reduction in mortality with aortic aneurysm screening (Scott RA et al, Br J Surg 2005;89:283-5). A modeling study, however, suggests screening woman could be cost-effective given the observed higher rupture rates of AAA in women and increased longevity among women compared with men (Wanhainen A et al, J Vasc Surg 2006;43:908-14). The Society for Vascular Surgery recommends aneurysm screening among older women with a family history of AAA or who have smoked (Chaikof EL et al. J Vasc Surg 2009;50(Suppl):S2-49). The U.S. Preventative Services Task Force, however, found no evidence of benefit in screening women, regardless of risk factors (U.S. Preventative Task Force, Ann Intern Med 2005;142:198-202). However, people also may be healthier now, and with delayed aneurysm development, than at the time screening for AAAs was first evaluated. The aim of this study was therefore to determine the prevalence of AAA and risk factors in a contemporary well-defined population of 70-year-old women. The study targeted 70-year-old women because previous investigations suggested AAAs present later in life in women than in men (Katz DJ et al, J Vasc Surg 1997;25:561-8). The 70-year-old women were identified through the Swedish National Population Registry in two neighboring counties of Uppsala and Dalarna and were invited to a free ultrasound examination of the abdominal aorta. An aorta >30 mm in diameter was defined as an AAA. Of the 6925 women who were invited, 5140 (74.2%) accepted the invitation for screening and 19 AAAs (0.4%) were detected (95% confidence interval [CI], 0.2%-0.5%). In the invited cohort, 12 women (0.2%; 95% CI, 0.1%-0.3%) had undergone previous AAA repair (11) or had a known AAA under surveillance (one). The total prevalence of AAA was therefore estimated at 0.5% (0.4%-0.7%). Of 19 women with screen-detected AAAs, 18 (95%) had a history of smoking compared with a smoking history of 44.2% of those with a normal aorta (odds ratio, 20.29; 95% CI, 2.7-152.65). Prevalence of AAA was 0.03% (0%-0.1%) among never smokers, 0.4% (0.2%-0.8%) among former smokers, and 2.1% (1.0%-3.7%) among current smokers.

Final Follow-up of the Multicentre Aneurysm Screening Study (MASS) Randomized Trial of Abdominal Aortic Aneurysm Screening

2013-05-01

Screening for abdominal aortic aneurysms (AAA) results in a reduction of all-cause mortality out to 13 years of follow-up. The UK Multicenter Aneurysm Screening Study (MASS) is the largest randomized trial of screening vs no screening of AAAs to reduce aneurysm and all-cause mortality. Previous results from MASS were published after 10 years of follow-up (Thompson SG et al, BMJ 2009;338;b2307). At that time, there was some increase in rupture of AAA among those initially screened as normal. However, this increase had no impact on overall proportionate AAA-related mortality. The 15-year results of the UK Chichester trial suggested a possible substantial increase in ruptured AAAs during follow-up (Ashton HA et al, Br J Surg 2007;94:696-701). Significant numbers of AAA ruptures in those initially screened as normal could result in a long-term reduction of benefits in AAA mortality implied by a normal initial screening study. This latest publication from the MASS trial investigators examined further follow-up in the MASS trial participants with respect to potential benefits of all-cause mortality and late AAA rupture in those initially screened as normal. The MASS trial was a population-based sample of men aged 65 to 74 years who were randomized to an invitation for ultrasound screening (invited group) for AAA or to a control group that was not offered screening. Patients with an abdominal aorta >3 cm detected at the initial study underwent surveillance and were offered surgery after predefined criteria had been met. Cause-specific mortality data were analyzed using Cox regression techniques. The study enrolled 67,770 men. Over 13 years, 224 AAA-related deaths occurred in the invited group and 381 in the control group. This was a relative risk reduction of 42% in the invited group compared with the control group (hazard ratio, 0.58; 95% confidence interval, 0.49-0.69). Relative risk reduction did not vary by baseline age or center, and there was no evidence of an effect on other causes of death. There was an overall reduction in all-cause mortality of 3% (1%-5%). Benefit was greater in earlier years of follow-up and decreased with longer follow-up, with a risk reduction of 48% from randomization to 10 years and 20% from 10 to 14 years. During the 13-year interval, nonfatal AAA ruptures were halved in the invited group (49 in the invited group vs 95 in the control group). After a normal first scan, 59 ruptured AAAs occurred, and 80% of these were fatal. Ruptured AAA after a normal first scan had a marked increase after 8 years of follow-up. Among the measured baseline aortic diameters, about half of those initially screened as normal and subsequently having ruptured AAA were in the initial screening range of aortic diameters of 2.5 to 2.9 cm.

Causes and Implications of Readmission After Abdominal Aortic Aneurysm Repair

D.Y. Greenblatt, C.C. Greenburg, A. Kind — 2013-05-01

Early readmission is common after abdominal aortic aneurysm (AAA) repair. Almost one in five hospitalized Medicare patients are readmitted ≤30 days of discharge. The costs are enormous, >$17.4 billion per year (Jencks SF et al, N Engl J Med 2009;360:1418-28). In addition, vascular surgical procedures are among the most common procedures leading to readmission, with Medicare readmission rates for vascular patients approaching 24%. The Medicare Payment Advisory Commission has identified vascular procedures as one of seven categories that are particularly likely to lead to preventable readmissions. On a per-patient basis, vascular surgery-related readmissions are also the most costly (Hackbarth G et al, Report to the Congress: Promoting Greater Efficiently in Medicare. Memphis, TN: Books LLC; 2007). Vascular procedures are set to be added to the Center for Medicare and Medicaid Services (CMS) tracking of hospital risk-adjusted 30-day readmission rates for selected medical conditions. Because CMS is set to reduce Medicare reimbursements to hospitals with higher-than-predicted readmission rates, it is important to systematically study vascular surgery-specific readmissions. In this study, the authors described the frequency, causes, predictors, and consequences of 30-day readmission after AAA repair in a Medicare population. Elective AAA repairs over a 2-year period from the CMS chronic conditions warehouse, a 5% national sample of Medicare beneficiaries, were studied. There were 2481 patients who underwent AAA repair, comprising 1502 endovascular aneurysm repairs (EVAR) and 749 open aneurysm repairs. The 30-day readmission rates were equivalent for EVAR (13.3%) and open repair (12.8%). Wound complication was the most common reason for readmission after both procedures. The relative frequency of other causes differed (ie, bowel obstruction after open repair and graft complication after EVAR). A multivariate analysis showed preoperative comorbidities had a modest effect on readmission. However, postoperative factors, including serious complications leading to a prolonged hospital stay and a discharge destination other than home, had a profound influence on the probability of readmission. The 1-year mortality was 23.4% in readmitted patients vs 4.5% in those not readmitted (P < .001). In-hospital mortality for patients readmitted from a skilled nursing facility was 9.8%.

21st-Century Hazards of Smoking and Benefits of Cessation in the United States

P. Jha, C. Ramasundarahettige, V. Landsman — 2013-05-01

Compared with those who have never smoked, smokers lose at least one decade of life expectancy. If smokers quit before the age of 40 years, this reduces the risk of death associated with continued smoking by ∼90%.

The 21st Century Hazards of Smoking and Benefits of Stopping: A Prospective Study of One Million Women in the UK

K. Pirie, R. Peto, G.K. Reeves — 2013-05-01

Two-thirds of all deaths of smokers in their 50s, 60s, and 70s are caused by smoking. There are substantial hazards of smoking until age 40 years, where hazards of continuing beyond 40 years are 10 times greater. Stopping smoking before age 40 avoids >90% of excess mortality caused by continued smoking. Stopping before age 30 avoids >97% of excess mortality by continued smoking.

Aortic Pathology Determines Midterm Outcome After Endovascular Repair of the Thoracic Aorta. Report from the Medtronic Thoracic Endovascular Registry (MOTHER) Database

B. Patterson, P. Holt, C. Nienaber — 2013-05-01

Midterm outcomes of endovascular repair of the thoracic aorta (TEVAR) are determined by presenting pathology, mode of hospital admission, and associated comorbidities. For endovascular repair of the abdominal aorta, the early mortality advantage is lost after 2 to 3 years as a result of late aortic rupture (Greenhalgh RM et al, N Engl J Med 2010;362:1863-71). The authors indicate there is concern that a similar “catch-up” phenomenon may also affect TEVAR. The thoracic aorta has many different pathologies. To help determine whether TEVAR offers a durable solution to prevent aortic-related death, it seems reasonable to examine whether outcome of TEVAR is pathology-specific. The authors in this report built a database from five prospective studies and a single-institutional series. Perioperative adverse events were calculated as well as midterm death and reintervention rates for TEVAR. Multivariable analysis, logistical regression modeling, and Kaplan-Meier survival curves were used. There were 1110 patients in the database. Of these, 670 had thoracic aortic aneurysm, 195 had chronic type B dissection, and 114 had acute type B aortic dissection. Elective mortality was 3% in patients with chronic dissection and 5% in patients with aneurysm. Multivariate analysis indicated age, mode of admission, American Society of Anesthesiologists grade, and pathology were independent predictors of 30-day death (P < .05). All-cause mortality was 8, 4.9, and 3.2 deaths per 100 patient-years for thoracic aortic aneurysm, acute type B dissection, and chronic type B dissection, respectively. Rates of aortic-related death were 0.6, 1.2, and 0.4 deaths per 100 patient-years for thoracic aortic aneurysm, acute type B aortic dissection, and chronic type B aortic dissection, respectively. Freedom from aortic reintervention at 6 years was 84% in the thoracic aortic aneurysm group, 71% in the chronic type B aortic dissection group, and 46% in the acute type B aortic dissection group. The most common cause for reintervention in the thoracic aortic aneurysm group was endoleak (most commonly type 1,) and malperfusion was the most common reason for reintervention in both dissection groups.

Selective D-Dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis: A Randomized Trial

L.A. Linkins, S.M. Bates, E. Lang — 2013-05-01

For patients with a first episode of suspected deep vein thrombosis (DVT), selected D-dimer testing is more efficient than having everyone undergo D-dimer testing. D-dimer is a sensitive but not a specific test for the diagnosis of DVT. In effect, this means that a negative result (D-dimer level <0.5 μg/mL) excludes the diagnosis of DVT but a positive result (≥0.5 μg/mL) indicates additional testing, generally venous ultrasound imaging, is required. The authors postulate that it may be possible to improve the tradeoff between D-dimer sensitivity and specificity by varying the threshold distinguishing a negative from positive test result on the basis of the patient's clinical probability of having DVT. They further postulate that because the prevalence of DVT is low in patients with low clinical pretest probability (C-PTP), use of a higher, less sensitive threshold could exclude DVT in more patients without significantly increasing the number of missed diagnoses. The authors therefore designed this study to determine whether using a selective D-dimer testing strategy based on C-PTP for DVT is safe and potentially reduces diagnostic testing compared with use of a single D-dimer threshold for all patients. This was a randomized multicentered controlled trial that took place in five Canadian hospitals. Patients were allocated using a central automated system. Study adjudicators and ultrasonographers, but not other study personnel, were blinded to patient allocation. The study included consecutive patients with a first episode of suspected DVT. There were two basic trial groups. Those with selected testing (n = 860) were defined as having D-dimer testing for outpatients with low or moderate C-PTP (DVT was excluded at D-dimer levels <1.0 μg/mL [low C-PTP] or with a D-dimer level <0.5 μg/mL with moderate C-PTP). Venous ultrasonography without In the non-selected testing group D-dimer testing was performed for outpatients with high C-PTP and for in-patients, or for those assigned uniform testing (n = 863), defined as D-dimer testing for all participants (DVT excluded at D-dimer levels <0.5 μg/mL). The primary study end point was the proportion of patients not diagnosed with DVT during initial testing who had an episode of symptomatic venous thromboembolism (VTE) during 3 months of follow-up and the proportion of patients undergoing D-dimer testing and ultrasound imaging. The incidence of new symptomatic VTE at 3 months in those initially judged negative for DVT was 0.5% in both study groups (difference, 0.0 percentage points; 95% confidence interval [CI] −0.8 to 0.8 percentage points). In the selected testing group, the proportion of patients who required D-dimer testing was reduced by 21.8% (95% CI, 19.1%-24.8%). Selective testing reduced the proportion that required ultrasonography by 7.6% (95% CI, 2.9%-12.2%) overall, and by 21.0% (95% CI, 14.2%-27.6%) in outpatients with low C-PTP.

Comparison of Open and Endovascular Treatments of Post-carotid Endarterectomy Restenosis

2013-05-01

To compare early and long term results of open and endovascular treatment of post-carotid endarterectomy (CEA) restenosis in a single centre experience. From January 2005 to December 2011, ninety-nine consecutive interventions for primary severe post-CEA restenosis were performed: in 41 cases (41%, Group 1) open repair was carried out, whereas the remaining 58 patients (59%, group 2) underwent an endovascular treatment. Data concerning these interventions were prospectively collected in a dedicated database containing main pre, intra and postoperative variables.

Iliac Conduits for Endovascular Repair of Aortic Pathologies

N. Tsilimparis, A. Dayama, S. Perez, J.J. Ricotta — 2013-05-01

Challenging iliac access during thoracic endovascular aortic repair (TEVAR) is associated with a higher risk of access site complications such as injury or rupture of the iliac vessels. As a result, the use of iliac conduits is frequently used to facilitate access during TEVAR. This report evaluates the effect of iliac conduits on TEVAR outcomes.

Volume Estimation of the Aortic Sac after EVAR Using 3-D Ultrasound – A Novel, Accurate and Promising Technique

2013-05-01

Volume estimation is more sensitive than diameter measurement for detection of aneurysm growth after endovascular aneurysm repair (EVAR), but this has only been confirmed on three-dimensional, reconstructed computer tomography (3-D CT). The potential of 3-D ultrasound (3-D US) for volume estimation in EVAR surveillance is unknown.

Endograft Repair of Complicated Acute Type B Aortic Dissections

2013-05-01

This study aims to assess patient outcomes and aortic remodelling following coverage of the proximal entry tear with an endograft in complicated acute type B aortic dissections (caTBADs).

Regarding “Expanding the use of simulation in open vascular surgical training”

Raghvinder Pal Singh Gambhir — 2013-05-01

John Wolfe and Vikas Pandey must be complemented for trying once again to highlight the need for structured simulator training in open vascular surgery, because increasingly, the number of open procedures being performed is falling and the time available for training is dwindling from >100 hours to 48 hours per week. John has been at the forefront of vascular surgical training, not only in the United Kingdom but also in Europe and India. Having designed the “St Mary's Boot,” he also knows that bench simulation can never match the actual procedure. Trainers over the years have overcome the problem by breaking the open procedures into components and having trainees acquire the requisite skills, such as arterial anastomosis, in the skills laboratories.

Reply

John Wolfe — 2013-05-01

We share your concerns regarding the European Working Time Directive, and these concerns are shared by the Royal College of Surgeons who are doing their best to alter these regulations for surgical trainees.

Regarding “Application of robotic telemanipulation system in vascular interventional surgery”

2013-05-01

In recent years, robot technology has made rapid development in medical and surgical applications, and the development of computer technology and remote communication technology has promoted the development of telemedicine. Its advantage lies in the breakthrough of the space limitations of conventional surgery and enhances the capacity expansion of medical experts. The vascular interventional robot (VIR) has become a promising technology and has produced a prototype that has been used in animal experiments. On the basis of the successful application of the VIR, we used the VIR-2 to explore remote cerebral angiography surgery between Beijing, China, and Kagawa, Japan, and provide a basis for further clinical applications.

Editorial Board

2013-05-01

Information for authors

Anton N. Sidawy, Bruce A. Perler — 2013-05-01

Complete information for authors and editorial policies are available in the January and July issues, at our Web site www.jvascsurg.org, or at our Editorial Manager Web site at jvs.editorialmanager.com. An abbreviated checklist for manuscript submission follows. Manuscripts that are accepted for publication become the property of the Journal of Vascular Surgery®, which is copyrighted by the Society for Vascular Surgery®. They may not be published or reproduced in whole or in part without the written permission of the author(s) and the Journal.

Information for readers

2013-05-01

Communications regarding original articles and editorial management should be addressed to Anton N. Sidawy, MD, and Bruce A. Perler, MD, Editors, Journal of Vascular Surgery, 633N. St. Clair, 22nd Floor, Chicago, IL 60611; telephone: 312-334-2317; fax: 312-334-2320; e-mail: JVASCSURG@vascularsociety.org. Information for authors appears in the January and July issues, at www.jvascsurg.org, and at jvs.editorialmanager.com. Authors should consult this document before submitting manuscripts to this Journal. Address business communications to Journal Publisher, Elsevier Inc, 360 Park Avenue South, New York, NY 10010-1710. For Events of Interest, contact Andrew O'Brien, Journal Manager, at a.obrien@elsevier.com. Visit our Web site at www.jvascsurg.org

Events of interest

2013-05-01

News items of interest to the vascular surgeon must be received at least 8 weeks before the desired month of publication. Announcements published at no charge include those received from a sponsoring society of this Journal, those courses and conferences sponsored by state, regional, national, or international vascular surgical organizations, and university-sponsored continuing medical education courses. All other news items selected for publication carry a charge of $60.00 US for each insertion, and the fee must accompany the request to publish. Send announcements and payment, payable to this Journal, to Issue Management, Elsevier Inc., 1600 John F. Kennedy Boulevard, Suite 1800, Philadelphia, PA, 19103.

Journal of Vascular Surgery

A single nucleotide polymorphism in the p27Kip1 gene is associated with primary patency of lower extremity vein bypass grafts

The Comprehensive Risk Assessment for Bypass (CRAB) facilitates efficient perioperative risk assessment for patients with critical limb ischemia

Invited commentary

Changing presentation of knee dislocation and vascular injury from high-energy trauma to low-energy falls in the morbidly obese

Predictive value of angiographic scores for the integrated management of the ischemic diabetic foot

Early quantitative evaluation of indocyanine green angiography in patients with critical limb ischemia

The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome

Feasibility and validity of self-reported walking capacity in patients with intermittent claudication

Initial experience with the Ventana fenestrated system for endovascular repair of juxtarenal and pararenal aortic aneurysms

Invited commentary

Incidence and treatment results of Endurant endograft occlusion

Discussion

The impact of hemodynamic status on outcomes of endovascular abdominal aortic aneurysm repair for rupture

Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England

Secondary interventions after elective thoracic endovascular aortic repair for degenerative aneurysms

Carotid-subclavian bypass and subclavian-carotid transposition in the thoracic endovascular aortic repair era

Progress in management of malperfusion syndrome from type B dissections

Discussion

Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition

Invited commentary

Results of elective and emergency endovascular repairs of popliteal artery aneurysms

Evolving treatment of popliteal artery aneurysms

Selective coverage of the left subclavian artery without revascularization in patients with bilateral patent vertebrobasilar junctions during thoracic endovascular aortic repair

The impact of Centers for Medicare and Medicaid Services high-risk criteria on outcome after carotid endarterectomy and carotid artery stenting in the SVS Vascular Registry

Race as a predictor of morbidity, mortality, and neurologic events after carotid endarterectomy

Impact of postoperative nadir hemoglobin and blood transfusion on outcomes after operations for atherosclerotic vascular disease

Discussion

Variation in smoking cessation after vascular operations

Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome

Computer modeling for the prediction of thoracic aortic stent graft collapse

Transglutaminase type 2 in human abdominal aortic aneurysm is a potential factor in the stabilization of extracellular matrix

Role of hemodynamic forces in the ex vivo arterialization of human saphenous veins

Transrenal E-XL stenting to resolve or prevent type Ia endoleak in the case of severe neck angulation during endovascular abdominal aortic aneurysm repair

Repair of bilateral true aneurysms of the dorsalis pedis artery

“Sandal strap” trauma and atherosclerosis are dual pathologies leading to bilateral true aneurysms of the dorsalis pedis arteries

Bilateral retroesophageal course of the carotid arteries

Endovascular recanalization of the superior mesenteric artery in the context of mesenteric bypass graft infection

Fibromuscular dysplasia with multiple visceral artery involvement

Profunda femoris artery aneurysm causing local deep venous thrombosis

Local drug delivery to prevent restenosis

Too small to fail: The prisoner's dilemma

Rationale, scope, and 20-year experience of vascular surgical training with lifelike pulsatile flow models

Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome

The role of completion imaging following carotid artery endarterectomy

Editors' commentary

Implementation of the National Health Service Abdominal Aortic Aneurysm Screening Program in England

Predictive value of angiographic scores for the integrated management of the ischemic diabetic foot

Evidence for a Strong Genetic Influence on Carotid Plaque Characteristics: An International Twin Study

Current Prevalence of Abdominal Aortic Aneurysm in 70-Year-Old Women

Final Follow-up of the Multicentre Aneurysm Screening Study (MASS) Randomized Trial of Abdominal Aortic Aneurysm Screening

Causes and Implications of Readmission After Abdominal Aortic Aneurysm Repair

21st-Century Hazards of Smoking and Benefits of Cessation in the United States

The 21st Century Hazards of Smoking and Benefits of Stopping: A Prospective Study of One Million Women in the UK

Aortic Pathology Determines Midterm Outcome After Endovascular Repair of the Thoracic Aorta. Report from the Medtronic Thoracic Endovascular Registry (MOTHER) Database

Selective D-Dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis: A Randomized Trial

Comparison of Open and Endovascular Treatments of Post-carotid Endarterectomy Restenosis

Iliac Conduits for Endovascular Repair of Aortic Pathologies

Volume Estimation of the Aortic Sac after EVAR Using 3-D Ultrasound – A Novel, Accurate and Promising Technique

Endograft Repair of Complicated Acute Type B Aortic Dissections

Regarding “Expanding the use of simulation in open vascular surgical training”

Reply

Regarding “Application of robotic telemanipulation system in vascular interventional surgery”

Editorial Board

Contents

Information for authors

Information for readers

Events of interest