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Fragmentation of outpatient care is a substantial barrier to creation and maintenance of hemodialysis access. To improve patient accessibility, satisfaction, and multidisciplinary provider communication, we created a monthly Saturday multidisciplinary vascular surgery and interventional nephrology access clinic at a tertiary care hospital in a major urban area for the complicated hemodialysis patient population. The study included patients presenting for new access creation as well as those who had previously undergone access surgery. Staffing included two to three interventional nephrologists, two to three vascular surgeons, one medical assistant, one research assistant, and one practice assistant. Patient satisfaction and perception of the clinic was measured using surveys during six of the monthly Saturday hemodialysis clinics. A total of 675 patient encounters were completed (18.2 average/clinic ±6.3 standard deviation) from August 2016 to August 2019. All patients were seen by both disciplines. The average no-show rate was 19.9% throughout the study period. Patient satisfaction in all measures was consistently high with the Saturday clinic. Providers were also assayed, and they generally valued the real-time, multidisciplinary care plan generation, and its subsequent efficient execution. Saturday multidisciplinary hemodialysis access clinics offer high provider and patient satisfaction and streamlined patient care. However, no-show rates remain relatively high for this challenging patient population.

Objective: Vascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center., Methods: We queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved., Results: There were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m 2 . The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%., Conclusions: Vascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Wound complications (WCs) after lower extremity arterial surgery (LEAS) are common, resulting in readmissions and reinterventions. Whereas diabetes and obesity are known risk factors for WCs, gender-specific variability in body fat distribution (android vs gynoid) may drive differential risks of WCs after LEAS. We analyzed the independent and synergistic effects of gender and body mass index (BMI) on WCs., Methods: We performed a retrospective review of prospectively collected data from a published, randomized, multicenter trial assessing the incidence of WCs (dehiscence, surgical site infections, seroma, and hematoma) after LEAS. Postoperative outcomes were compared between genders. A multivariable regression model assessed the impact of gender and BMI on WCs. Subanalysis focused on the synergy of gender and body habitus, groin-only incisions, and clinical outcomes., Results: There were 502 patients who underwent LEAS between October 2010 and September 2013. The cohort was elderly (67.6 ± 10.5 years), mostly male (72%), and overweight (BMI, 27.6 ± 5.7); 225 (45%) patients had a groin-only incision. In 171 patients (37.9%), a WC developed within 30 days, 85% of which were infectious in etiology. On multivariable regression, obesity (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.17-3.77), morbid obesity (OR, 2.87; 95% CI, 1.32-6.23), and female gender (OR, 1.17; 95% CI, 1.06-2.75) were independent predictors of infectious WCs at 30 days. When stratified by groin-only incision, BMI was no longer significant, but female gender (OR, 2.70; 95% CI, 1.24-5.87) was predictive of infectious WCs at 30 days. There was no synergistic effect of BMI and gender on WCs., Conclusions: WCs are common after LEAS. BMI is an independent risk factor for the development of any WC. Female gender, a potential surrogate for high hip to waist ratio body habitus, is also an independent predictor of groin WCs, suggesting the clinical importance of gynoid vs android fat distribution., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Recent initiatives to improve health care quality have focused attention on length of stay (LOS) and readmission rates for surgical patients, yet these two outcomes may be inversely related. This study was designed to elucidate the risk factors for both outcomes and to clarify the relationship between them in patients undergoing lower extremity bypass (LEB)., Methods: Peripheral arterial disease (PAD) patients who underwent LEB were identified from the 2007-2010 California State Inpatient Database. LOS and risk factors were analyzed using Poisson regression. Risk factors for 30-day readmission were analyzed using logistic regression., Results: There were 6307 patients who underwent LEB, and 1291 (20%) were readmitted. The average index LOS was 8.3 days for those who were readmitted and 5.5 days for those who were not (P < .0001) and was an independent risk factor for 30-day readmission. The significant factors with the largest effect estimates for increased LOS reflected disease severity and postoperative complications: emergency department admission; advanced PAD; postoperative pneumonia, respiratory failure, urinary tract infection, wound/graft infection, graft complication, and discharge to a nursing facility. Independent predictors of readmission, other than LOS, reflected underlying patient factors: advanced PAD, chronic lung disease, diabetes, renal failure, postoperative congestive heart failure, and discharge status. Age, Medicaid or private insurance, and low income were protective. Of the 1291 readmissions, 453 (35%) were for definitive complications., Conclusions: In patients undergoing LEB, LOS is primarily associated with the occurrence of postoperative complications, whereas 30-day readmission is largely explained by underlying patient illness. Additionally, increased LOS is an independent risk factor for readmission. These findings suggest that efforts to reduce both LOS and readmission will be complementary. Furthermore, they support the notion that both LOS and 30-day readmission rates should be risk-adjusted., (Published by Elsevier Inc.)

Objective: Endovascular repair (EVAR) of abdominal aortic aneurysms is a safe alternative to open aneurysm repair (OAR) in selected patients. The aim of this study was to compare the health-related quality-of-life (HR-QoL) outcomes of patients following EVAR and OAR., Methods: A literature search of PubMed, EMBASE, and the Cochrane Library identified five randomized trials that reported on HR-QoL in EVAR and OAR for elective management of infrarenal abdominal aortic aneurysms. No consistent HR-QOL instrument was used among the studies. A meta-analysis was performed on the 36-Item Short Form (SF-36) and the EuroQol-5D (EQ-5D) HR-QoL results., Results: SF-36 general health scores were higher for EVAR at 3, 6, and 12 months postoperatively. SF-36 physical functioning scores were higher for EVAR at 6 months but this advantage was lost at 12 months. In addition, SF-36 social functioning scores were higher for EVAR at 12 months. SF-36 component summary scores were not significantly different. EVAR was associated with a better EQ-5D score at 3, 6, and 12 months, but not at 24 months of follow-up., Conclusions: EVAR was associated with better HR-QoL in some domains up to 12 months postoperatively. There is insufficient data to demonstrate a HR-QoL advantage beyond 12 months. More studies are required to examine any long-term HR-QoL advantages for either intervention., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the timing and relative frequency of common postoperative complications in a contemporary, diverse surgical population and develop a mnemonic for teaching and clinical decision support., Patients and Methods: We enrolled a cohort of general and vascular surgical patients undergoing elective, inpatient surgery in the American College of Surgeons National Surgical Quality Improvement Program database between 2005 and 2011. Index complications were noted by postoperative day (POD). Timing and incidence were compared within each day., Results: Among 614,525 patients, 51,173 (9.88%) experienced the following index complications over 30 days: pneumonia (n = 5947), urinary tract infection (n = 9459), superficial surgical site infection (sSSI) (n = 20,460), deep/organ space surgical site infection (dSSI) infection (n = 11,847), venous thromboembolism (n = 4478), kidney injury (n = 2620), and myocardial infarction (n = 1813). Median time to complication differed significantly for index complications (p < 0.0001). On POD 0, the most common complication was myocardial infarction (incidence 4.26/10,000 patient days; 95% CI: 3.75-4.78). On POD 1 and 2, pneumonia was the most common complication, with peak incidence on POD 2 (20.36; 95% CI: 19.22-21.51). On POD 3, pneumonia (16.3; 95% CI: 15.27-17.33) and urinary tract infection (15.5; 95% CI: 14.49-16.51) were significantly more common than other complications. On POD 4, the most common complication was sSSI (16.24; 95% CI: 15.20-17.28). From POD 5 to POD 30, sSSI and dSSI were the 2 most common complications. Risk of venous thromboembolism declined only slightly through POD 30., Conclusion: We propose a mnemonic for postoperative complication timing and frequency, independent of fever, as follows: Waves (myocardial infarction), Wind (pneumonia), Water (urinary tract), Wound (sSSI and dSSI), and Walking (venous thromboembolism) in the order of likelihood., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Wound complications negatively affect outcomes of lower extremity arterial reconstruction. By way of an investigator initiated clinical trial, we tested the hypothesis that a silver-eluting alginate topical surgical dressing would lower wound complication rates in patients undergoing open arterial procedures in the lower extremity., Methods: The study block-randomized 500 patients at three institutions to standard gauze or silver alginate dressings placed over incisions after leg arterial surgery. This original operating room dressing remained until gross soiling, clinical need to remove, or postoperative day 3, whichever was first. Subsequent care was at the provider's discretion. The primary end point was 30-day wound complication incidence generally based on National Surgical Quality Improvement Program guidelines. Demographic, clinical, quality of life, and economic end points were also collected. Wound closure was at the surgeon's discretion., Results: Participants (72% male) were 84% white, 45% were diabetic, 41% had critical limb ischemia, and 32% had claudication (with aneurysm, bypass revision, other). The overall 30-day wound complication incidence was 30%, with superficial surgical site infection as the most common. In intent-to-treat analysis, silver alginate had no effect on wound complications. Multivariable analysis showed that Coumadin (Bristol-Myers Squibb, Princeton, NJ; odds ratio [OR], 1.72; 95% confidence interval [CI], 1.03-2.87; P = .03), higher body mass index (OR, 1.05; 95% CI, 1.01-1.09; P = .01), and the use of no conduit/material (OR, 0.12; 95% CI, 0.82-3.59; P < .001) were independently associated with wound complications., Conclusions: The incidence of wound complications remains high in contemporary open lower extremity arterial surgery. Under the study conditions, a silver-eluting alginate dressing showed no effect on the incidence of wound complications., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Although mortality after elective abdominal aortic aneurysm (AAA) repair has steadily declined, operative mortality for a ruptured AAA (rAAA) remains high. Repair of rAAA at hospitals with a higher elective aneurysm workload has been associated with lower mortality rates irrespective of the mode of treatment. This study sought to determine the association between surgeon specialization and outcomes after rAAA repair., Methods: The American College of Surgeons National Surgical Quality Improvement Project database from 2005 to 2010 was used to examine the 30-day mortality and morbidity outcomes of patients undergoing rAAA repair by vascular and general surgeons. Multivariable logistic regression analysis was performed for each death and morbidity, adjusting for all independently predictive preoperative risk factors. Survival curves were compared using the log-rank test., Results: We identified 1893 repairs of rAAAs, of which 1767 (96.1%) were performed by vascular surgeons and 72 (3.9%) were performed by general surgeons. There were no significant differences between patients operated on by general vs vascular surgeons in preoperative risk factors or method of repair. Overall 30-day mortality was 34.3% (649 of 1893). After risk adjustment, mortality was significantly lower in the vascular surgery group compared with the general surgery group (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.30-0.86; P = .011). The risk of returning to the operating room (OR, 0.58; 95% CI, 0.35-0.97; P = .038), renal failure (OR, 0.54; 95% CI, 0.31-0.95; P = .034), and a cardiac complication (OR, 0.53; 95% CI, 0.28-0.99; P = .047) were all significantly less in the vascular surgery group., Conclusions: Despite similar preoperative risk factors profiles, patients who were operated on by vascular surgeons had lower mortality, less frequent returns to the operating room, and decreased incidences of postoperative renal failure and cardiac events. These data add weight to the case for further centralization of vascular services., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Open surgical reconstruction for supra-aortic trunk occlusive disease persists despite advances in endovascular therapy. Although extrathoracic reconstructions developed as a safer alternative to transthoracic reconstructions, contemporary national data evaluating relative rates of operative outcomes are lacking., Methods: With use of the National Surgical Quality Improvement Program (2005-2011), patients who underwent transthoracic or extrathoracic reconstruction were evaluated. Patients with nonocclusive indications were excluded. The primary outcome was a composite end point of stroke/myocardial infarction (MI)/death. Secondary outcomes were 30-day postoperative complications. Univariate and multivariable regression analyses were performed., Results: Overall, 83 patients (10.7%) underwent transthoracic reconstructions and 692 patients (89.3%) underwent extrathoracic reconstructions. Vascular surgeons performed most transthoracic (96%) and extrathoracic (97%) reconstructions. The most common extrathoracic reconstructions were carotid-subclavian bypass (68%), carotid-carotid bypass (14%), and subclavian transposition (7%). Less commonly, axillary-axillary bypass (6%), subclavian-axillary bypass (2%), subclavian-subclavian bypass (1%), and carotid transposition (1%) were performed. At the time of operation, 10% (transthoracic reconstructions) and 8% (extrathoracic reconstructions) of patients had a concurrent carotid endarterectomy (P < .60). Analysis of more than 20 characteristics showed that the groups did not differ significantly. The two groups had similar rates of postoperative stroke (1.2% in the transthoracic reconstruction group vs 2.2% in the extrathoracic reconstruction group; P > .99), MI (0% vs 1.3%; P = .61), death (2.4% vs 1.3%; P = .33), and stroke/MI/death (3.6% vs 3.8%; P > .99). Transthoracic reconstruction patients had longer hospital stays (6.3 days vs 4.0 days; P < .0002), received more transfusions (8.4% vs 2.5%; P < .0096), and had higher rates of postoperative sepsis (3.6% vs 0.3%; P < .01) and venous thromboembolic complications (3.6% vs 0.4%; P < .02). After adjustment for other factors, including surgical approach, stroke/MI/death was significantly associated with postoperative pneumonia (odds ratio [OR], 26.0; 95% confidence interval [CI], 6.29-108.28; P < .0001), postoperative ventilator dependence (OR, 12.45; 95% CI, 2.74-56.48; P = .001), and postoperative return to the operating room (OR, 4.75; 95% CI, 1.67-13.54; P = .004)., Conclusions: At U.S. hospitals, extrathoracic reconstruction is the more common reconstruction for supra-aortic trunk occlusive disease. Both approaches carry acceptably low rates of death, MI, and stroke. Transthoracic reconstruction results in more resource utilization because of its postoperative complications and greater complexity., (Copyright © 2014 Society for Vascular Surgery. All rights reserved.)

Background: Patients with critical limb ischemia (CLI) often undergo revascularization before amputation. The exact relationship between multiple procedures and increased risk of amputation is unclear. We sought to determine the increased risk of amputation for each additional revascularization., Methods: The 2007-2009 California State Inpatient Database (SID) was used to identify a cohort of CLI patients undergoing revascularization and conduct a time-to-event analysis for patients undergoing one or more revascularization procedures. One-year estimates were generated with Kaplan-Meier curves and compared with the log-rank test. The Wei-Lin-Weissfeld (WLW) marginal proportional hazards model was used to assess independent effects of number of revascularization procedures on amputation and death., Results: A total of 11,190 patients with CLI underwent revascularization between July 2007 and December 2009. Their mean age was 71.0 years (interquartile range 62-80 years) and 6255 (55.9%) were male. Over half the subjects (55.2%) were smokers and there was a high burden of comorbidities in the cohort. One-year estimates of amputation by number of revascularizations (1: 23.3%; 2: 27.1%; 3: 30.3%; 4: 26.7%; 5(+): 28.6%; P < 0.001) and death (1: 18.7%; 2: 21.1%; 3: 26.3%; 4: 23.6%; 5+: 32.1%; P = 0.012) increased significantly as procedures increased. In the WLW model for amputation, the hazard increased significantly for patients with 2 revascularization versus 1 (HR = 1.22; 95% CI 1.09-1.37; P = 0.001) and 3 revascularizations versus 2 (HR = 1.33; 95% CI 1.10-1.62; P = 0.004). In the multivariable WLW models for death, the increase in revascularization procedures for 2 compared with 1 (HR = 1.18; 95% CI 1.04-1.34; P = 0.010) was significant., Conclusions: The risk of amputation increases with each additional revascularization procedure. These findings hold true for both percutaneous transluminal angioplasty only and lower extremity bypass only subsets. In addition, increased revascularization procedures appear to result in an increased risk of death. We advocate for continued communication between clinicians and patients on the true risks and benefits of additional revascularization procedures., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Brief preoperative dietary interventions emphasizing reduced calorie and protein intake will decrease perioperative morbidity and mortality associated with vascular operative procedures by modulating maladaptive response to operative stress., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Thirty-day unplanned readmission after lower extremity bypass represents a large cost burden and is a logical target for cost-containment strategies. We undertook this study to evaluate factors associated with unplanned readmission after lower extremity bypass., Methods: This is a retrospective analysis from a prospective institutional registry. All lower extremity bypasses for occlusive disease from January 1995 to July 2011 were included. The primary end point was 30-day unplanned readmission. Secondary end points included graft patency and limb salvage., Results: Of 1543 lower extremity bypasses performed, 84.5% were for critical limb ischemia and 15.5% were patients with intermittent claudication. Twenty-seven patients (1.7%) died in-house and were excluded from further analysis. Of 1516 lower extremity bypasses analyzed, 42 (2.8%) were in patients with a planned readmission within 30 days, and 349 (23.0%), in patients with an unplanned readmission. Most unplanned readmissions were wound related (62.9%). By multivariable analysis, preoperative predictive factors for unplanned readmission were dialysis dependence (odds ratio [OR], 1.73; P = .004), tissue loss indication (OR, 1.62; P = .0004), and history of congestive heart failure (OR, 1.43; P = .03). Postoperative predictors included distal inflow source (OR, 1.38; P = .016), in-hospital wound infection (OR, 8.30; P < .0001), in-hospital graft failure (OR, 3.20; P < .0001), and myocardial infarction (OR, 1.96; P < .04). Neither index length of stay nor discharge disposition independently predicted unplanned readmission. Unplanned readmission was associated with loss of assisted primary patency (hazard ratio, 1.39; 95% confidence interval, 1.08-1.80; P = .01) and long-term limb loss (hazard ratio, 1.68; 95% confidence interval, 1.23-2.29; P = .001)., Conclusions: Thirty-day unplanned readmission is a frequent occurrence after lower extremity bypass (23.0%). Stratifying patients by risk factors associated with unplanned readmission is essential for quality improvement and equitable resource allocation when disease-specific bundling strategies are being derived., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Single-segment great saphenous vein (SSGSV) remains the conduit of choice for femoral to below-knee popliteal (F-BK) surgical revascularization. The purpose of this study was to determine the optimal conduit in patients with inadequate SSGSV., Methods: This was a retrospective review of a prospectively maintained vascular registry. Patients underwent F-BK bypass with alternative vein (AV; arm vein, spliced GSV, or composite vein) or prosthetic conduit (PC)., Results: From January 1995 to June 2010, 83 patients had unusable SSGSV for F-BK popliteal reconstruction. Thirty-three patients had an AV conduit and 50 had PC. The AV group was a lower median age than the PC group (69 vs 75 years). The two groups were otherwise similar in comorbid conditions of diabetes mellitus (57.6% vs 58.0%; P > .99), smoking (15.2% vs 32.0%; P = .12), and hemodialysis (3% vs 12%; P = .23). The groups were similar in baseline characteristics such as limb salvage as indication (93.9% vs 86.0%; P = .31), mean runoff score (5.2 vs 4.6; P = .39), and prior ipsilateral bypass attempts (18.2% vs 18.0%; P > .99). The AV and PC groups were also similar in 30-day mortality (6.1% vs 4.0%; P > .99) and wound infection rates (6.1% vs 6.0%; P > .99). PC patients were more likely to be discharged on Coumadin (Bristol-Myers Squibb, Princeton, NJ) than AV patients (62.0% vs 27.3%; P = .002). Seventeen of the 50 PC patients (34%) had a distal anastomotic vein cuff. A log-rank test comparison of 5-year outcomes for the AV and PC groups found no significant difference in primary patency (55.3% ± 9.9% vs 51.9% ± 10.8%; P = .82), assisted primary patency (68.8% ± 9.6% vs 54.0% ± 11.0%; P = .45), secondary patency (68.4% ± 9.6% vs 63.7% ± 10.4% for PC; P = .82), or limb salvage rates (96.2% ± 3.8% vs 81.1% ± 8.1%; P = .19). Multivariable analysis demonstrated no association between conduit type and loss of patency or limb. The factors most predictive of primary patency loss were limb salvage as the indication for surgery (hazard ratio [HR], 4.23; 95% confidence interval [CI], 1.65-10.9; P = .003) and current hemodialysis (HR, 3.51; 95% CI, 1.08-11.4; P = .037). The most predictive factor of limb loss was current hemodialysis (HR, 7.02; 95% CI, 1.13-43.4; P = .036)., Conclusions: For patients with inadequate SSGSV, PCs, with varying degrees of medical and surgical adjuncts, appear comparable to AV sources in graft patency for below-knee popliteal bypass targets. This observation is tempered by the small cohort sample size of this single-institutional analysis. Critical limb ischemia as the operative indication and current hemodialysis predict impaired patency, and hemodialysis is associated with limb loss., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Patient selection and techniques for the operative management of abdominal aortic aneurysms (AAAs) continue to evolve. We sought to examine trends in open surgical repair (OSR) over a 15-year period in which endovascular aneurysm repair (EVAR) has become increasingly prevalent., Methods: Patients undergoing elective repair of infra- and pararenal AAAs were identified through our center's prospective vascular surgery registry during two time periods: 1995 to 2004 (era 1) and 2004 to 2010 (era 2). Data collected included comorbidities, demographics, and operative characteristics., Results: A total of 1,188 elective AAAs were repaired during the study period, including 828 (70%) OSRs and 360 (30%) EVARs. The proportion of OSRs requiring suprarenal cross-clamping increased from 14.2% during era 1 to approximately 50% by the end of era 2. Compared with era 1, increases were seen in the unadjusted mortality rates during era 2 for OSR with infrarenal clamping (from 0.62% to 1.73%) and OSR with suprarenal clamping (from 1.22% to 3.98%); after adjusting for other variables, however, no significant temporal trends were seen. Similarly, no significant change in major complication rate was seen after adjusting for other factors. The incidence of major comorbidities among the OSR group was largely unchanged between the two eras., Conclusions: OSR of AAAs has become increasingly complex, with the increased utilization of EVAR. Despite this complexity, risk-adjusted outcomes may remain good in high-volume centers., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Major amputation is often selected over infrainguinal bypass in patients with severe systemic comorbidities because it is assumed to have lower perioperative risks, yet this assumption is unproven and largely unexamined., Methods: The 2005 to 2008 National Surgical Quality Improvement Project (NSQIP) database was used to identify all patients undergoing either infrainguinal bypass or major amputation using procedural codes. Patients with systemic or local infections were excluded. A subset of high-risk patients were then defined as American Society of Anesthesiologists (ASA) class 4 or 5, or ASA class 3 with renal failure, dyspnea at rest, ventilator dependence, recent congestive heart failure, or recent myocardial infarct. Propensity score matching was used to obtain two high-risk patient groups matched for preoperative characteristics., Results: No significant differences in demographic, preoperative, or anesthetic variables were found between the matched, high-risk amputation or bypass groups (792 and 780 patients, respectively). Bypass was associated with a lower 30-day postoperative mortality than amputation (6.54% vs 9.97%; P = .0147). Amputation was associated with higher rates of pulmonary embolism (0.9% vs 0% for amputation vs bypass groups, respectively; P = .009) and urinary tract infection (5.2% vs 2.7%; P = .01), while bypass was associated with higher rates of return to the operating room (14.1% vs 27.6%; P < .001) and a trend toward higher postoperative transfusion requirements (0.9% vs 2.1%; P = .054). The postoperative time to discharge did not differ between the two groups., Conclusion: The decision to perform an infrainguinal bypass or amputation should depend on well-established predictors of graft patency and functional success rather than presumptions about different perioperative risks between the two procedures., (Copyright © 2011. Published by Mosby, Inc.)

Large databases can be a rich source of clinical and administrative information on broad populations. These datasets are characterized by demographic and clinical data for over 1000 patients from multiple institutions. Since they are often collected and funded for other purposes, their use for secondary analysis increases their utility at relatively low costs. Advantages of large databases as a source include the very large numbers of available patients and their related medical information. Disadvantages include lack of detailed clinical information and absence of causal descriptions. Researchers working with large databases should also be mindful of data structure design and inherent limitations to large databases, such as treatment bias and systemic sampling errors. Withstanding these limitations, several important studies have been published in vascular care using large databases. They represent timely, "real-world" analyses of questions that may be too difficult or costly to address using prospective randomized methods. Large databases will be an increasingly important analytical resource as we focus on improving national health care efficacy in the setting of limited resources.

Disparities in health care are well documented for several racial, ethnic, and gender groups. In peripheral arterial disease, differences in prevalence, treatment selection, treatment outcomes, and resulting quality of life have negative effects on some minority groups and women. It may be easy to document disparities, but it is harder to understand their underlying causes. Are there biologic differences between members of racial and ethnic groups that influence disease presentation and outcomes? Or is the socioeconomic environment that surrounds them the true driver of observed differences? This article reviews the evidence for racial and gender disparities in vascular surgery and presents some potential mechanisms that may explain the disparities., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Limb salvage, operative mortality and short and long term graft patency have long been important variables for assessment of infrainguinal arterial reconstructions. More recently it is now appreciated that patient and society oriented measures of outcomes in determining the effectiveness of any surgical procedure are also important. In particular, the impact of an intervention on a patient's overall quality of life (QOL) and whether it is cost effective in achieving improvement of QOL are questions of increasing importance from the patient's perspective and from the perspective of those who must make difficult health policy decisions. This chapter reviews the cost effectiveness and impact of infrainguinal bypass on patient perceived quality of life in patients with intermittent claudication and patients with critical limb ischemia. The data are not robust but suggest favorable impact of infrainguinal bypass in terms of both QOL and cost effectiveness in both patients with intermittent claudication and critical limb ischemia.

Objectives: Gender and ethnicity are factors affecting the incidence and severity of vascular disease as well as subsequent treatment outcomes. Although well studied in other fields, balanced enrollment of patients with relevant demographic characteristics in vascular surgery randomized controlled trials (RCTs) is not well known. This study describes the reporting of gender and ethnicity data in vascular surgery RCTs and analyzes whether these studies adequately represent our diverse patient population., Methods: We conducted a retrospective review of United States-based RCTs from 1983 through 2007 for three broadly defined vascular procedures: aortic aneurysm repair (AAR), carotid revascularization (CR), and lower extremity revascularization (LER). Included studies were examined for gender and ethnicity data, study parameters, funding source, and geographic region. The Nationwide Inpatient Sample (NIS) database was analyzed to obtain group-specific procedure frequency as an estimate of procedure frequency in the general population., Results: We reviewed 77 studies, and 52 met our inclusion criteria. Only 85% reported gender, and 21% reported ethnicity. Reporting of ethnicity was strongly associated with larger (>280 participants), multicenter, government-funded trials (P < .001 for all). Women are disproportionately under-represented in RCTs for all procedure categories (AAR, 9.0% vs 21.5%; CR, 30.0% vs 42.9%; LER, 22.4% vs 41.3%). Minorities are under-represented in AAR studies (6.0% vs 10.7%) and CR studies (6.9% vs 9.5%) but are over-represented in LER studies (26.0% vs 21.8%, P < .001 for all)., Conclusions: Minority ethnicity and female gender are under-reported and under-represented in vascular surgery RCTs, particularly in small, non-government-funded and single-center trials. The generalizability of some trial results may not be applicable to these populations. Greater effort to enroll a balanced study population in RCTs may yield more broadly applicable results.

Introduction: Recent evidence suggests disparities exist among racial groups with peripheral arterial disease (PAD). Hispanics (HI) are the fastest growing demographic in the United States, but little outcome data is available for this population. Therefore, we undertook this study to compare the results of autogenous infrainguinal bypass grafting in HI to Caucasians (CA) and African Americans (AA)., Methods: This was a comparative cohort study of prospectively collected registry data of infrainguinal bypass performed at a tertiary center. Patient demographics and comorbidities, operative indications, bypass graft characteristics, and postoperative courses were analyzed. Cumulative patency rates, limb salvage, mortality, and factors associated with these outcomes were determined using Kaplan-Meier analysis and Cox proportional hazards models., Results: From January 1, 1985, through December 31, 2007, 1646 consecutive patients (1408 CA, 57 HI, and 181 AA) underwent 1646 autogenous infrainguinal reconstructions. HI and AA were younger and more often diabetic than CA but HI had less chronic renal insufficiency (CRI) and dialysis-dependence than AA. AA, but not HI, more commonly underwent bypass for critical limb ischemia (CLI) in comparison to CA (AA 90% vs CA 80%, P < .0001; HI 86%). HI and AA bypass grafts had inflow and outflow distal to that in CA. Perioperative mortality (2.3%) and morbidity were similar between groups. Five-year primary patency (+/- standard error [SE]) was significantly lower in HI compared to CA and similar to that in AA (HI 54% +/- 7% vs CA 69% +/- 1%, P = .02; AA 58% +/- 4%). Cox proportional hazard modeling showed high-risk conduit, age <65, CLI, female gender, and AA race were risk factors for failure of primary patency. Secondary patency of HI grafts, unlike AA, was not different than that in CA. Five-year limb salvage (+/- SE) was significantly lower in HI compared to CA and similar to that in AA (HI 80% +/- 6% vs CA 91% +/- 1%, P = .004; AA 83% +/- 3%). Hispanic ethnicity, CLI, high-risk conduit, age <65, CRI, female gender, and diabetes were significant predictors of limb loss., Conclusion: Autogenous infrainguinal bypass surgery in HI is associated with primary patency and limb salvage inferior to that of CA and similar to that of AA, despite HI rates of CLI equivalent to CA and HI comorbidities less severe than AA. HI ethnicity was an independent predictor of limb loss. Our data provides evidence of outcome disparities in HI treated aggressively for their PAD. Further investigation with regard to biologic and social factors is required to delineate the reasons for these inferior outcomes in HI patients.

Background: Infrainguinal bypass (IB) surgery is an effective means of improving arterial circulation to the lower extremity for patients with critical limb ischemia (CLI). However, wound complications (WC) of the surgical incision following IB can impart significant morbidity., Methods: A retrospective analysis of WC from the 1404 patients enrolled in a multicenter clinical trial of vein bypass grafting for CLI was performed. Univariate and multivariable regression models were used to determine WC predictors and associated outcomes, including graft patency, limb salvage, quality of life (QoL), resource utilization (RU), and mortality., Results: A total of 543 (39%) patients developed a reported WC within 30 days of surgery, with infections (284, 52%) and hematoma/hemorrhage (121, 22%) being the most common type. Postoperative anticoagulation (odds ratio [OR], 1.554; 95% confidence interval [CI] 1.202 to 2.009; P = .0008) and female gender (OR, 1.376; 95% CI, 1.076 to 1.757; P = .0108) were independent factors associated with WC. Primary, primary-assisted, and secondary graft patency rates were not influenced by the presence of WC; though, patients with WC were at increased risk for limb loss (hazard ratio [HR], 1.511; 95% CI 1.096 to 2.079; P = .0116) and higher mortality (HR, 1.449; 95% CI 1.098 to 1.912; P = .0089). WC was not significantly associated with lower QoL at 3 months (4.67 vs 4.79, P = .1947) and 12 months (5.02 vs 5.13, P = .2806). However, the subset of patients with serious WC (SWC) demonstrated significantly lower QoL at 3 months compared with patients without WC, (4.43 vs 4.79, respectively, P = .0166), though this difference was not seen at 12 months (4.94 vs 5.13, P = .2411). Patients with WC had higher RU than patients who did not have WC. Mean index length of hospital stay (LOS) was 2.3 days longer, mean cumulative 1-year LOS was 8.1 days longer, and mean number of hospitalizations was 0.5 occurrences greater for patients with WC compared with patients without WC (all P < .0001)., Conclusions: WC is a frequent complication of IB for CLI, associated with increased risk for major amputation, mortality, and greater RU. Further detailed investigation into the link between female gender and oral anticoagulation use with WC may help identify causes of WC and perhaps prevent or lessen their occurrence.

Objectives: We sought to determine the long-term results of revision procedures performed for repair of stenotic lesions in infrainguinal vein bypass grafts., Methods: A retrospective review of 188 vein grafts, from a total series of 1260 bypasses, undergoing revision of stenotic lesions between January 1, 1987, and December 31, 2002, at Brigham & Women's Hospital was undertaken. Lesions were identified by recurrence of symptoms, change in examination findings, or with routine duplex ultrasound graft surveillance. Demographic and medical risk factors, and surgical variables were analyzed with respect to patency outcomes after the initial graft revision, with descriptive statistics, logistic regression, and life table analysis. Primary and secondary patency rates were determined from the time of graft revision., Results: Patients included 108 men (57%) and 80 women (42%) who underwent revision at a mean age of 67.8 years. One hundred thirty grafts required only a single revision, whereas 58 required subsequent additional revisions. Revision procedures included 99 vein patches (52.7%), 23 jump grafts (12.2%), 23 interposition grafts (12.2%), 8 transpositions to new outflow vessels (4.3%), and 35 balloon angioplasty procedures (18.6%). During a mean follow-up of 1535 days, 5-year primary patency rate was 49.3% +/- 4.5% (SE) and 5-year secondary patency rate was 80.3% +/- 3.6%. There was no difference in patency rate for different revision procedures, type of vein graft, indication for the original procedure, or for patients with diabetes mellitus or renal disease. The overall limb salvage rate was 83.2% +/- 3.5% 5 years after graft revision. With COX proportional hazard analysis of time to failure of the revision procedure, the outflow level of the original bypass and the time of revision proved to be an important predictor of durability of the graft revision. Revision of popliteal bypass grafts resulted in a 60% 5-year primary patency rate, whereas revision of tibial grafts resulted in a 42% 5-year primary patency rate (P = .004; hazard ratio [HR], 2.06). Five-year secondary patency rates were 90% and 76%, respectively (P = .009; HR = 3.43). The timing of the graft revision proved an additional predictor. Grafts revised within 6 months of the index operation had lower primary patency than those with later revisions (42.9% vs 80.7%, respectively; HR = 1.754; P = .0152)., Conclusions: Vein graft revisions offer durable patency and limb salvage rates after repair of stenotic infrainguinal bypass grafts. Vigilant ongoing surveillance is essential, because 30.9% of revised grafts will develop additional lesions that will require repair. Tibial level bypass grafts that require early repeat intervention to treat graft stenosis are at particular risk for development of subsequent lesions.