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In the last decade, there has been a dramatic increase in the number of women entering vascular surgery. Our goal was to evaluate the differences in career paths based on gender and to determine some of the factors that influence career decisions among young vascular surgeons.A 17-item web-based survey focusing on current employment status, reasons for choosing academic vs nonacademic positions, and career satisfaction was distributed to 900 members of the Society for Vascular Surgery who completed vascular surgery training in the past 10 years.A total of 199 individuals responded to the survey (22.1%). The cohort included 49 (24.6%) women and 149 (74.9%) men. The majority of the respondents were non-Hispanic white (66.3%). Sixty-four percent of all respondents were younger than 40 years. Overall, 72.9% of women had applied to academic positions after their training compared with 58.8% of men. Women were more likely to apply for and to work in an academic setting (P = .0266 and P = .0198, respectively) and cited mentorship more frequently (P = .0474) as the reason for choosing an academic practice. Women respondents were less likely to have a spouse or children (P = .0269 and P .001, respectively). More than 87.4% of all respondents were very satisfied or somewhat satisfied with their careers. However, men were more likely to be very satisfied compared with women (P = .0345).Career satisfaction remains high among young vascular surgeons. In this cohort of vascular surgery graduates, we found that women were more likely to pursue academic positions than men, with mentorship, ability to teach, and complexity of cases commonly cited as reasons for this career choice. However, whether young women stay in academia and what factors affect academic retention will need further evaluation.

ObjectivesDuplex ultrasound scanning (DUS) has benefit for intraoperative and subsequent evaluation of surgical bypasses in the lower extremities. The utility of DUS after endovascular revascularizations is not established. This study was performed to evaluate whether DUS findings after infrainguinal endovascular interventions for critical limb ischemia (CLI) were predictive of need for reintervention or amputation.MethodsTo identify the study cohort, peripheral interventions for CLI (Rutherford grades 4, 5, 6) over a 24-month period (2006-2007) were reviewed. DUS findings were considered indicative of hemodynamic stenosis if the peak systolic velocity (PSV) was ≥180 cm/s or the PSV velocity ratio was ≥2.0. Demographic, clinical, procedural, and outcomes were examined. SVS and TASC II classifications and reporting standards were used. Arteriograms were reviewed and treated segments were categorized as patent (

Objective Screening for abdominal aortic aneurysms (AAA) significantly reduces aneurysm-related death. In January 2007, the Federal government enacted Medicare coverage guideline to screen persons at risk for the presence of an AAA, the Screen for Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act. The purpose of this study is to evaluate the efficacy and costs of a large scale screening effort for identifying AAAs in patients in clinical practice. Methods A regional veterans affairs mandate for screening for AAA was implemented in February 2007. Data were extracted through the Northern California Veterans Affairs (VA) Service Network to identify veteran males 65-75 years of age who ever smoked at least 100 cigarettes during their lifetime. An AAA was defined as an aortic diameter 3.0 cm or greater. A Decision Support Systems software (LumiData, Minneapolis, Minn) package tracked true costs of conducting a large AAA screening protocol in the Northern California VA Health Care System. Results A total of 2918 patients (average age, 71 ± 6 years) were screened for AAA over a 1-year period from February 2007 to February 2008. An AAA was diagnosed in 5.1% (148/2918) of patients. Two hundred ninety patients out of the 2918 (9.9%) were inappropriately screened. The aneurysm distribution was as follows: 83% (123/148) of the aneurysms were 3.0-4.4 cm, 13% (19/148) were 4.5-5.5 cm, and 4.1% (6/148) were greater than 5.5 cm. Incidental findings of isolated iliac artery aneurysms were found in 0.1% (3/2918) of patients. The cost of AAA screening per patient is $53. Conclusion The results of a large AAA screening effort in clinical practice reflect the results reported in the major clinical trials at a reasonable cost. The identification of large iliac artery aneurysms in the screening has not been previously reported.

Albeit uncommon, delayed renal dysfunction after endovascular abdominal aortic aneurysm repair (EVAR) can be attributed to proximal stent graft migration or unrecognized partial renal artery coverage. We report two patients who were found to have renal artery occlusion 1 week after EVAR with Zenith (Cook, Bloomington, Ind) infrarenal devices despite patent bilateral renal arteries shown on completion angiograms. Both patients presented with prolonged symptoms of acute renal failure, and uremic encephalopathy developed in one. Both patients were successfully treated with renal artery stenting, which led to symptom resolution and recovery of renal function. Our cases highlight that although postoperative renal occlusion after EVAR is rare, a high index of suspicion and urgent intervention are warranted because renal salvage can be achieved after prolonged ischemic insult.

Objective This study examined the medical and surgical management and outcomes of patients with aortic endograft infection after abdominal endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR). Methods Patients diagnosed with infected aortic endografts after EVAR/TEVAR between January 1, 2004, and January 1, 2014, were reviewed using a standardized, multi-institutional database. Demographic, comorbidity, medical management, surgical, and outcomes data were included. Results An aortic endograft infection was diagnosed in 206 patients (EVAR, n = 180; TEVAR, n = 26) at a mean 22 months after implant. Clinical findings at presentation included pain (66%), fever/chills (66%), and aortic fistula (27%). Ultimately, 197 patients underwent surgical management after a mean of 153 days. In situ aortic replacement was performed in 186 patients (90%) using cryopreserved allograft in 54, neoaortoiliac system in 21, prosthetic in 111 (83% soaked in antibiotic), and 11 patients underwent axillary-(bi)femoral bypass. Graft cultures were primarily polymicrobial (35%) and gram-positive (22%). Mean hospital length of stay was 23 days, with perioperative 30-day morbidity of 35% and mortality of 11%. Of the nine patients managed only medically, four of five TEVAR patients died after mean of 56 days and two of four EVAR patients died; both deaths were graft-related (mean follow-up, 4 months). Nineteen replacement grafts were explanted after a mean of 540 days and were most commonly associated with prosthetic graft material not soaked in antibiotic and extra-anatomic bypass. Mean follow-up was 21 months, with life-table survival of 70%, 65%, 61%, 56%, and 51% at 1, 2, 3, 4, and 5 years, respectively. Conclusions Aortic endograft infection can be eradicated by excision and in situ or extra-anatomic replacement but is often associated with early postoperative morbidity and mortality and occasionally with a need for late removal for reinfection. Prosthetic graft replacement after explanation is associated with higher reinfection and graft-related complications and decreased survival compared with autogenous reconstruction.

Orificial occlusive lesion involving the aortic arch vessels is commonly treated with balloon-expandable stent placement. Stenting of such a lesion typically involves an initial aortogram to precisely identify the vessel origin, followed by deployment of a balloon-expandable stent to cover the ostial lesion. We report a simple technique of an antegrade femoral guidewire placement along the outer curvature of the aortic arch to facilitate the identification of the origin of aortic arch vessels. This enhanced ostial visualization enables a precise positioning and deployment of a balloon-expandable stent in aortic arch vessels. This dual guidewire technique facilitates the visual identification of arch vessel origin and reduces potential contrast requirement, which provides procedural benefit in patients with renal insufficiency or contrast allergy.

ObjectiveCurrently, there are no well-established duplex ultrasound (DUS) criteria for the evaluation of the mesenteric arteries after stenting for occlusive disease. Previous studies suggested DUS velocity criteria in the native superior mesenteric artery (SMA) overestimate stenosis in stented arteries, but most studies have not evaluated DUS imaging after SMA stenting longitudinally. This study was undertaken to determine the accuracy of DUS after mesenteric artery revascularization and, in particular, to evaluate the utility of DUS imaging for the detection of in-stent stenosis (ISS) of the SMA.MethodsA retrospective record review was performed for all patients who underwent SMA stenting for chronic mesenteric ischemia at a single institution from January 2004 to May 2011.ResultsMesenteric artery occlusive disease resulted in 24 patients undergoing mesenteric stenting of the SMA alone (n = 20) or the SMA and celiac artery simultaneously (n = 3). The mean ± standard deviation peak systolic velocity (PSV) in 13 prestent DUS images of the SMA was 464 ± 130 cm/s. Prestenting angiography revealed an average SMA stenosis of 79% ± 14%. After stenting, completion angiography in each case revealed .05). Follow-up SMA DUS imaging showed an average PSV of 335 ± 138 cm/s at 0.9 ± 1.5 months, 360 ± 143 cm/s at 4.8 ±2.6 months, and 389 ± 95 cm/s at 14.4 ± 5.1 months. A significant difference existed between the prestent and the first poststent mean SMA PSV (P < .05), but no significant difference existed between each poststenting interval. Eight reinterventions for SMA ISS were performed, with a mean elevated in-stent SMA PSV of 505 ± 74 vs 341 ± 145 cm/s in patients who did not undergo reintervention. Angiography before the eight reinterventions demonstrated an average SMA ISS of 53% ± 25%. In-stent SMA PSV decreased from 505 ± 74 to 398 ± 108 cm/s after the reintervention (P < .05).ConclusionsConsistent with other reports, our data demonstrate the PSV in successfully stented SMAs remains higher than the PSV threshold of 275 cm/s used for the diagnosis of high-grade native SMA stenosis. In addition, in-stent SMA PSVs did not significantly change over DUS surveillance for patients who did not undergo reintervention. Thus, obtaining a baseline DUS early after mesenteric stenting should be considered to compare future surveillance DUS. An increase above this baseline or an in-stent SMA PSV approaching 500 cm/s should be considered suspicious for ISS, but larger prospective studies will be required to validate these preliminary findings.

ObjectiveGhrelin, a novel growth hormone–releasing peptide, is implicated to play a protective role in cardiovascular tissues. However, it is not clear whether ghrelin protects vascular tissues from injury secondary to risk factors such as homocysteine (Hcy). This study investigated the effect and potential mechanisms of ghrelin on Hcy-induced endothelial dysfunction.MethodsPorcine coronary artery rings were incubated for 24 hours with ghrelin (100 ng/mL), Hcy (50 μM), or ghrelin plus Hcy. Endothelial vasomotor function was evaluated using the myograph tension model. The response to the thromboxane A2analog U46619, bradykinin, and sodium nitroprusside was analyzed. Endothelial nitric oxide synthase (eNOS) expression was determined using real-time polymerase chain reaction and immunohistochemistry staining, and superoxide anion production was documented lucigenin-enhanced chemiluminescence analysis. Human coronary artery endothelial cells (HCAECs) were treated with different concentrations of Hcy, ghrelin, or antighrelin receptor antibody for 24 hours, and eNOS protein levels were determined by Western blot analysis.ResultsMaximal contraction with U46619 and endothelium-independent vasorelaxation with sodium nitroprusside were not different among the four groups. However, endothelium-dependent vasorelaxation with bradykinin (10−6 M) was significantly reduced by 34% with Hcy compared with controls (P < .05). The addition of ghrelin to Hcy had a protective effect, with 61.6% relaxation, which was similar to controls (64.7%). Homocysteine significantly reduced eNOS expression, whereas ghrelin cotreatment effectively restored eNOS expression to the control levels. Superoxide anion levels, which were increased by 100% with Hcy, returned to control levels with ghrelin cotreatment. Ghrelin also effectively blocked the Hcy-induced decrease of eNOS protein levels in HCAECs in a concentration-dependent manner. Antighrelin receptor antibody effectively inhibited the effect of ghrelin.ConclusionGhrelin has a protective effect in the porcine coronary artery by blocking Hcy-induced endothelial dysfunction, improving eNOS expression, and reducing oxidative stress. Ghrelin also shows a protective effect on HCACEs from the Hcy-induced decrease in eNOS protein levels. The effect of ghrelin is receptor-dependent. Thus, ghrelin administration may have beneficial effects in the treatment of vascular disease in patients with hyperhomocysteinemia.Clinical RelevanceHomocysteine is an independent risk factor for atherosclerosis and other vascular lesions. It causes endothelial dysfunction and oxidative stress. Ghrelin, a novel growth hormone–releasing peptide, is implicated to play a protective role in cardiovascular tissues. This study investigated the effect and potential mechanisms of ghrelin on Hcy-induced endothelial dysfunction. The results showed that ghrelin has a protective effect in the porcine coronary artery and human coronary artery endothelial cells by blocking Hcy-induced endothelial dysfunction, improving endothelial nitric oxide synthase expression, and reducing oxidative stress. Ghrelin administration may have beneficial effects in the treatment of vascular disease in patients with hyperhomocysteinemia.

ObjectiveRecent results after endovascular abdominal aortic aneurysm repair (EVAR) have brought into question its value in patients deemed at high-risk for surgical intervention. The Department of Veteran Affairs (VA) National Surgical Quality Improvement Program (NSQIP) is the largest prospectively collected and validated United States surgical database representing current clinical practice. The purpose of our study was to evaluate outcomes after elective EVAR performed in high-risk veterans.MethodsUsing NSQIP data from 123 participating VA hospitals, we retrospectively evaluated patients who underwent elective aneurysm repair from May 2001 to December 2004. High-risk criteria were used to identify a cohort for analysis (EVAR, n = 788; open, n = 1580). High-risk criteria analyzed included age ≥60 years, American Society of Anesthesiology (ASA) classification 3 or 4, and the comorbidity variables of history of cardiac, respiratory, or hepatic disease, cardiac revascularization, renal insufficiency, and low serum albumin level. Our primary end points were 30-day and 1-year all-cause mortality, and we evaluated a secondary end point of perioperative complications. Statistical analysis included univariate analysis and multivariate modeling.ResultsVeterans who were classified as high-risk underwent elective EVAR with significantly lower 30-day (3.4% vs 5.2%, P = .047) and 1-year all-cause mortality (9.5% vs 12.4%, P = .038) than patients having open repair. EVAR was associated with a decrease in 30-day postoperative mortality (adjusted odds ratio [OR], 0.65; 95% confidence interval [CI], 0.42 to 1.03; P = .067) as well as 1-year mortality (adjusted OR, 0.68; 95% CI, 0.51 to 0.91; P = .0094) despite the presence of severe comorbid conditions. The risk of perioperative complications was significantly lower after EVAR (16.2% vs 31.0%; P < .0001; adjusted OR, 0.41; 95% CI, 0.33 to 0.52; P < .0001). A subset analysis of higher-risk patients (ASA 4 and the above comorbidity variables) still demonstrated an acceptable 30-day mortality rate.ConclusionIn veterans deemed high-risk for surgical therapy, outcomes after elective EVAR are excellent, and the procedure is relatively safe in this special patient population. Our retrospective data demonstrate that patients with considerable medical comorbidities and infrarenal abdominal aortic aneurysms benefit from and should be considered for primary EVAR.