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Patients presenting with >14 days lower extremity ischemia are usually considered as chronic; however, patients with subacute (>14 days and <3 months) and chronic (>3 months) occlusions often have organizing thrombus. This is not considered in current recommendations for the treatment of nonacute leg ischemia and, with the increased use of endovascular interventions, more complex lesions with long occlusions are treated percutaneously. Thrombolysis alone has been reported to successfully decrease this clot load in a significant proportion of patients with subacute occlusions, and percutaneous thrombectomy devices were suggested as a means to decrease the hemorrhagic complications associated with thrombolysis. However, distal embolization remains a problem, which these interventions are intended to prevent. In this article, we aim to review the current literature on the endovascular treatment of patients with subacute arterial occlusions, and review our experience. [Copyright &y& Elsevier]

Background: For patients with peripheral arterial disease (PAD), depression is associated with worse patency and recurrent symptoms in the treated leg, but its association with death or cardiovascular events in other vascular beds is unknown.Objective: To assess the association between depression and mortality or cardiovascular events outside the affected leg after PAD revascularization.Design: Retrospective cohort study.Subjects: Two hundred fifty-seven consecutive patients undergoing lower extremity revascularization for symptomatic PAD at a single institution between January 2000 and May 2005 were included in this study. By protocol, patients were previously screened for depression and diagnosed by the primary care provider.Measurements: The outcomes evaluated included a composite of death or major adverse cardiovascular events (MACE; coronary heart disease, contralateral PAD, or cerebrovascular event) as well as major outcome categories of death, coronary heart disease, contralateral PAD, or cerebrovascular events.Results: At revascularization, 35.0% patients had been diagnosed with depression. Those with depression were significantly younger and more likely to use tobacco. By life-table analysis, patients with depression had significantly increased risk for death/MACE, coronary heart disease, and contralateral PAD events, but not cerebrovascular events or death. By multivariate analysis, patients with depression were at significantly increased risk for death/MACE (hazard ratio [HR] = 2.05; p < .0001), contralateral PAD (HR = 2.20; p = .009), and coronary heart disease events (HR = 2.31; p = .005) but not cerebrovascular events or death.Conclusions: Depression is common among patients undergoing revascularization for symptomatic PAD. After intervention, patients with depression are at significantly increased risk for coronary heart disease events and progression of contralateral PAD. Prospective analysis is required to confirm these results. [ABSTRACT FROM AUTHOR]

Abstract: Background: The objective of this study was to compare the outcome of patients presenting with heel ulcers or gangrene (HEEL group) with those having lesions in other parts of the foot (non-HEEL group). Methods: Treatment and outcomes of all HEEL and non-HEEL patients between June 2001 and October 2006 were compared. Results: Three hundred eight patients were treated (71 HEEL and 237 non-HEEL). The HEEL group was more frequently nonambulatory, had lower albumin levels, and had gangrene. The primary amputation rate (11% vs 3%, P < .001) was higher in HEEL patients, and more endovascular interventions were also performed in the HEEL group (75% vs 55%, P = .015). The 24-month limb salvage and patency rates were similar; but survival was worse in HEEL patients. Serum albumin <3 g/dL, dialysis dependence, and gangrene were associated with limb loss in the HEEL group. Mean time to healing was 4.3 ± 3.4 months. Conclusions: Patients with ischemic heel ulcers or gangrene were more likely to undergo primary amputation; however, limb salvage rates were similar to those of non-HEEL patients after attempted salvage. Endovascular interventions currently play a significant role in the management of these patients. Gangrene, serum albumin <3 g/dL, and dialysis dependence resulted in increased limb loss in patients with ischemic heel lesions. [Copyright &y& Elsevier]

Abstract: Background: Our approach to patients with critical limb ischemia (CLI) underwent a rapid evolution from open surgery to preferential use of endovascular procedures. The goal of the current report was to evaluate the impact of this change on patients with CLI. Methods: Consecutive patients with CLI were compared between 3 periods: June 2001 to October 2002 (I) versus November 2002 to October 2003 (II) versus November 2003 to June 2005 (III). Results: A total of 275 patients (301 limbs, mean age 70 ± 11) underwent revascularization or primary major amputation (PA) for CLI (81 in I, 76 in II, 144 in III). PA decreased from 14.8%, 10.5%, and 3.5% (P < .001). Mean follow-up was 19.7 ± 13.6 months (range 0 to 57). Overall 24-month limb salvage (LS) was 60%, 69%, and 85% (P = .001), and 71%, 77%, and 88% following LS attempt (P = .017), with no difference in survival. Length of stay (LOS) decreased from 10.7 ± 12.1 (I) to 5.2 ± 6.2 days (III) (P = .001). Conclusions: Preferential use of endovascular interventions in patients presenting with CLI resulted in decreased number of PA, improved LS, and decreased LOS, without a difference in survival. [Copyright &y& Elsevier]

There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events. A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year. The primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups. The TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms. TRIAL REGISTRATION: http://clinicaltrials.gov identifier: NCT03229941 [ABSTRACT FROM AUTHOR]

BACKGROUND: To examine the validity of Veterans Affair-VA risk assessment tool in predicting the perioperative and overall mortality among octogenarians. METHODS: This is a single-institution retrospective observational study, in which the clinical information of 1,618 octogenarians were extracted from the VA Surgical Quality Improvement Program database. VA risk assessment tool and ASA classification were used to predict the probability of postoperative mortality and morbidity. Multiple risk groups were compared for mortality using multiple logistic regressions. RESULTS: There were 570 survivors and 1,048 nonsurvivors. VA risk tool strongly predicted perioperative 30-day mortality in receiver operator characteristic curve analysis (area under the curve: .82 ± .02). The power of this tool, while acceptable, was less in predicting overall mortality (area under the curve: .68 ± .01). Age, dialysis, a history of congestive heart failure, functional status, transfusion, and weight loss were also associated with increased rate of death within 30 days. CONCLUSIONS: VA risk tool predicted both perioperative and overall mortality. Relatively strongpower of this tool in predicting overall mortality may be unique to this age group because of their advanced age. [ABSTRACT FROM AUTHOR]

BACKGROUND: The American Society of Anesthesiology's (ASA) 6-point physical status classification remains one of the most significant predictors of perioperative morbidity and mortality and is the most widely used risk stratification tool worldwide. Its utility is significantly limited for octogenarians, however, as the majority of these patients are classified as ASA-III. Thus, for patients aged 80 or older, we hypothesized that incorporating patients' functional status, defined by the ability to perform activities of daily living independently, would improve perioperative risk stratification. METHODS: All data were extracted from the Veterans Affairs Surgical Quality Improvement Program, a perioperative prospectively maintained computerized database. ASA-III patients were reclassified into subgroups IIIA or IIIB, with IIIA representing functionally independent patients and IIIB representing partially or fully dependent patients. Functional status was self-reported during preoperative assessments. In this database, mortality data (primary outcome) was reliably available for all patients for the duration of the 96-month follow-up period, as were other perioperative patient data. RESULTS: Seven hundred and fifty-nine (72.4%) patients were classified as ASA-IIIA, and 290 (27.6%) patients were ASA-IIIB. Thirty-day and long-term survival was significantly better in the ASA-IIIA group, irrespective of type of surgery (hazard ratio 1.87, confidence interval 1.55-2.25, p < .001). ASA-IIIB hazard ratios for mortality were greatest for orthopedic and vascular surgery patients, but a significant divergence in survival between ASA-IIIA and IIIB patients was observed in all surgical specialties. CONCLUSION: As evidenced by Kaplan-Meier and multivariate analyses, functional capacity was a significant independent predictor of mortality for ASA-III patients older than 80 years of age. [ABSTRACT FROM AUTHOR]

Background: Type or lack of insurance may affect access to care, treatment, and outcomes. We evaluated trends for surgical management of all peripheral arterial disease (PAD) in-hospital admissions by insurer status in New York State. Study Design: Statewide Planning and Research Cooperative System (SPARCS) data were obtained and cross-referenced for diagnostic and procedure codes. Data from 2001 to 2002 were averaged and used as a baseline. Change in indication, volume of admissions, procedures, and amputations were calculated for the years 2003 to 2008 and were analyzed by insurer status. Results: There were 83,949 admissions. Endovascular intervention (EVI) increased tremendously for all indications and was used equally in the insured and uninsured. Among critical limb ischemia admissions, patients with private insurance were significantly more likely to be admitted for rest pain and significantly less likely to be admitted for gangrene (p < 0.001). Admission for gangrene declined for all. As EVI increased, amputation decreased and was significantly lowest in patients with private insurance (p < 0.001). Amputation was significantly higher in Medicaid than other insured (Medicaid vs private, p < 0.001; Medicaid vs Medicare, p = 0.003), but comparable to the uninsured (p = 0.08). Age greater than 65 years and low socioeconomic class or minority status were significant risks for gangrene (p = 0.014; p < 0.001) and ultimate amputation (p = 0.05; p < 0.001). Lack of insurance may pose a similar risk. Conclusions: EVI increased tremendously and was used without disparity across insurer status. Amputation declined steadily and may have been related to increased EVI or to decreased admission for gangrene. Advanced age, low socioeconomic class or minority status, and lack of insurance negatively affect presentation and limb salvage. Universal health care may be beneficial in improving outcomes but must address root causes for delayed presentation. [ABSTRACT FROM AUTHOR]

Abstract: Background: Management of patients with an abdominal aortic aneurysm (AAA) and malignancy is challenging. We aimed to define the coincidence of AAA and lung cancer and to determine a treatment strategy. Methods: The outcomes for patients diagnosed with AAA and lung cancer between 1991 and 2004 at our institution were reviewed retrospectively. Results: We identified 75 patients with both lesions among 1,096 AAA and 1,875 lung cancer patients. Survival correlated with cancer stage; only 3 deaths were directly attributable to the patient''s AAA. Of 59 patients who did not have AAA repair at the time of cancer diagnosis, 12 were repaired. Twenty-seven of those 59 patients had a 5.0-cm or larger AAA; only 1 patient with a 7.5-cm AAA had a rupture 5 months after thoracotomy and died. Conclusions: The co-existence of AAA and lung cancer is not rare; prognosis is poor and largely determined by the lung cancer stage. Open or endovascular repair of AAA rarely is justified in patients with advanced disease unless the AAA is symptomatic or large (>7 cm). Treatment for AAAs greater than 5.5 cm should be based on stage, histology, and patient comorbidities. [Copyright &y& Elsevier]

Objective: Poor glycemic control in the perioperative period has been reported to be associated with early and late major adverse limb events (MALEs). However, these studies were mostly from large databases or lacked long-term outcomes. We examined the long-term effects of high hemoglobin A1c (HbA1c) level on patency, MALE, limb salvage (LS) and survival after lower extremity revascularization procedures in patients with diabetes., Methods: Patients with diabetes who underwent revascularization for Rutherford class 3 to 6 ischemia between May 2002 and December 2018 were identified. Patients with an HbA1c of ≤7% were compared with those with an HbA1c of >7% for patency, MALE, survival, LS, and amputation-free survival., Results: Of 706 patients, 699 had HbA1c data (775 limbs), with 311 (357 limbs) in the HbA1c ≤7% and 388 (418 limbs) in the HbA1c >7% groups. Patients with an HbA1c of >7% were younger (69.9 ± 10.2 years vs 71.7 ± 9.5 years; P = .011), had higher lipid levels, insulin use (70% vs 49%; P < .01), American Society of Anesthesiologists classification of 4, and had a lower prevalence of chronic kidney disease (32% v s41%; P = .023). Patients with an HbA1c of >7% were more likely to present with chronic limb-threatening ischemia (CLTI) (79% vs 72%; P = .019) and undergo infrapopliteal interventions (49% vs 42%; P = .005), with no difference in anatomical complexity (TransAtlantic Inter Society Consensus class C/D, 75% vs 77%; P = .72) or type of revascularization (24% vs 18% open, 66% vs 70% endovascular, 10% vs 12% hybrid; P = .236). Patency and freedom from MALE were significantly lower in patients with an HbA1c of >7% for infrainguinal revascularizations, whereas amputation-free survival and overall survival were similar. In patients with chronic limb-threatening ischemia, LS rates at 5 years were significantly lower in patients undergoing open revascularization (HbA1c > 7%: 64% ± 6% vs HbA1c < 7%:86% ± 5%; P = .020), whereas it was similar after endovascular interventions (HbA1c > 7%:79% ± 4% vs HbA1c < 7%:77% ± 3%; P = .631). Seventy patients with an HbA1c of >7% lost limbs vs 38 patients with an HbA1c of ≤7% (P = .007). In multivariate analysis, HbA1c was associated significantly with primary patency. HbA1c, insulin use, level of intervention, and angiotensin-converting enzyme inhibitor use were associated with MALE., Conclusions: A perioperative HbA1c of >7% is associated with poorer patency rates and increased MALE, especially at the infrainguinal level revascularization in patients with diabetes, with no significant impact on survival. LS is impacted after open, but not after endovascular revascularization., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Objective: BEST-CLI, an international randomised trial, compared an initial strategy of bypass surgery with endovascular treatment in chronic limb threatening ischaemia (CLTI). In this substudy, overall amputation rates and risk of major amputation as an initial or subsequent outcome were evaluated., Methods: A total of 1 830 patients were randomised to receive surgical or endovascular treatment in two parallel cohorts: patients with adequate single segment great saphenous vein (SSGSV) (n = 1 434) were assigned to cohort 1; and patients without adequate SSGSV (n = 396) were assigned to cohort 2. Differences in time to first event and number of amputations were evaluated., Results: In cohort 1, there were 410 (45.6%) total amputation events in the surgical group vs. 490 (54.4%) in the endovascular group (p = .001) during a mean follow up of 2.7 years. Approximately one in three patients underwent minor amputation after index revascularisation: 31.5% of the surgical group vs. 34.9% in the endovascular group (p = .17). Subsequent major amputation was required significantly less often in the surgical group compared with the endovascular group (15.0% vs. 25.6%; p = .002). The first amputation was major in 5.6% of patients in the surgical group and 6.0% in the endovascular group (p = .72). Major amputation was required in 10.3% (74/718) of patients in the surgical group and 14.9% (107/716) in the endovascular group (p = .008). In cohort 2, there were 199 amputation events in 132 patients (33.3%) during a mean follow up of 1.6 years: 95 (47.7%) in the surgical group vs. 104 (52.3%) in the endovascular group (p = .49). Major amputation was required in 15.2% (30/197) of patients in the surgical group and 14.1% (28/199) in the endovascular group (p = .74)., Conclusion: In patients with CLTI, surgical bypass with SSGSV was more effective than endovascular treatment in preventing major amputations, mainly due to a decrease in major amputations subsequent to minor amputations., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: Our study aims to examine the role of multi-disciplinary surgical pause committees (MDSPC) in perioperative planning to reduce adverse postoperative events and mortality rates., Summary Background Data: Frail patients could benefit from preoperative MDSPCs when utilizing risk-benefit ratios for the proposed surgical plan. We examined whether MDSPCs improved clinical outcomes by developing individualized care plans and stratifying patients based on their level of frailty and ability to overcome external stressors., Methods: We retrospectively collected patient information after MDSPC evaluation, at our medical center for 12 years since 2011. Patient's frailty risk assessment index (RAI) scores were calculated, and survival status was updated. MDSPCs plans were put into the following categories: proceed with the planned surgery (G1), proceed after medical optimization (G2), reduce invasiveness of surgery or anesthesia plan (G3), or adopt a non-surgical approach (G4). Chi-square and independent t-tests were used for categorical and numerical data, respectively. Survival analysis for 30-day (primary endpoint), one-year, and overall mortality rates used Kaplan-Meier. The alpha was set at 0.05., Results: Clinical information was accessed from 12 women and 382 men. The average age was 71±11 years. 87.3% of planned surgical operations were stratified as ASA class III and IV. RAI scores were 36.4±9.6 (G1), similar to 37.4±10.8 (G2) but lower than 41.4±9.3 (G3) and 44.2±9.7 (G4) (P<0.001). Average survival duration was 35 months (G1), 35 months (G2), both significantly longer than 20 months (G3) and 18 months (G4) (P<0.001)., Conclusion: Medical optimization improved overall survival and reduced death within 30 days and one year to be comparable to G1. Additionally, reducing the surgical invasiveness only improved survival advantage for six months, after which it was comparable to those in G4 with the worst outcome. RAI scoring is an excellent tool to predict the outcome of surgery, and it was used successfully in critically ill patients., Competing Interests: Disclosures: The authors involved have no financial, consultant, institutional, or other relationship conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This prospective, longitudinal, pragmatic study describes at home treatment with a proprietary advanced pneumatic compression device (APCD) for patients with lower extremity lymphedema (LED)., Methods: Following institutiona review board approval, four participating Veterans Affairs centers enrolled LED patients from 2016 to 2022. The primary outcome measures were health-related quality of life (HR-QoL) questionnaires (lymphedema quality of life-leg and the generic SF-36v2) obtained at baseline and 12, 24, and 52 weeks. The secondary outcome measures were limb circumference, cellulitis events, skin quality, and compliance with APCD and other compression therapies., Results: Because a portion of the trial was conducted during the coronavirus disease 2019 pandemic, 179 patients had 52 weeks of follow-up, and 143 had complete measurements at all time points. The baseline characteristics were a mean age of 66.9 ± 10.8 years, 91% were men, and the mean body mass index was 33.8 ± 6.9 kg/m 2 . LED was bilateral in 92.2% of the patients. Chronic venous insufficiency or phlebolymphedema was the most common etiology of LED (112 patients; 62.6%), followed by trauma or surgery (20 patients; 11.2%). Cancer treatment as a cause was low (4 patients; 2.3%). Patients were classified as having International Society for Lymphology (ISL) stage I (68.4%), II (27.6%), or III (4.1%). Of the primary outcome measures, significant improvements were observed in all lymphedema quality of life-leg domains of function, appearance, symptoms, and emotion and the overall score after 12 weeks of treatment (P < .0001) and through 52 weeks of follow-up. The SF-36v2 demonstrated significant improvement in three domains at 12 weeks and in the six domains of physical function, bodily pain, physical component (P < .0001), social functioning (P = .0181), role-physical (P < .0005), and mental health (P < .0334) at 52 weeks. An SF-36v2 score <40 indicates a substantial reduction in HR-QoL in LED patients compared with U.S. norms. Regarding the secondary outcome measures at 52 weeks, compared with baseline, the mean limb girth decreased by 1.4 cm (P < .0001). The maximal reduction in mean limb girth was 1.9 cm (6.0%) at 12 weeks in ISL stage II and III limbs. New episodes of cellulitis in patients with previous episodes (21.4% vs 6.1%, P = .001) were reduced. The 75% of patients with skin hyperpigmentation at baseline decreased to 40% (P < .01) at 52 weeks. At 52 weeks, compliance, defined as use for 5 to 7 days per week, was reported for the APCD by 72% and for elastic stockings by 74%., Conclusions: This longitudinal study of Veterans Affairs patients with LED demonstrated improved generic and disease-specific HR-QoL through 52 weeks with at home use of an APCD. Limb girth, cellulitis episodes, and skin discoloration were reduced, with excellent compliance., Competing Interests: Disclosures None., (Published by Elsevier Inc.)

Objective: The objective of this study was to help guide inferior vena cava (IVC) filter choices by better understanding the retrieval characteristics, complications, and total costs between two commonly used IVC filters., Methods: All patients who underwent retrieval or attempted retrieval of Denali (Bard Peripheral Vascular) or Option (Argon Medical Devices) IVC filters were identified between March 2016 and October 2021 at a single tertiary care center. Those with imaging studies that permitted evaluation of filter placement, presence or degree of tilt, and/or hooking of the filter into the IVC wall were included in the present study. Filter retrieval success, number of attempts, use of advanced techniques, and fluoroscopy and procedural times were recorded and compared between the two filters., Results: A total of 87 patients presented for retrieval of 52 Denali and 35 Option Elite filters during the study period. Denali filters were more likely to be successfully retrieved at the first attempt (94% vs 77%; P = .019). The procedural and fluoroscopy times were shorter for Denali filters (29 minutes vs 63 minutes [P < .001] and 7 minutes vs 25 minutes [P < .001], respectively). Denali filters were less likely to be significantly tilted (≥15 ○ ) at retrieval (12% vs 29%; P < .001) or to have the filter hook embedded in the IVC wall (6% vs 40%; P < .001). Tilting of the filter of ≥15 ○ had no significant effects on the retrieval success rate (no tilt or tilt <15 ○ vs tilt of ≥15 ○ : 98% vs 100%; P = .58). In contrast, filter hook penetration into the IVC wall significantly reduced successful recovery (41% vs 99%; P < .001)., Conclusions: The findings from this study suggest that although the filter designs are similar, a benefit exists in the ease of retrievability of the Denali over the Option filter. We found that tilting and hooking of the filter in the IVC wall occurred significantly more with the Option filter. These factors likely made retrieval more difficult and contributed to the longer procedure and fluoroscopy times., Competing Interests: Disclosures None., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Optimizing medical management and risk factor modification are underused strategies in patients with chronic limb-threatening ischemia (CLTI), despite evidence of improved outcomes. The Vascular Quality Initiative (VQI) registry is a tool to improve quality of vascular care. In this study, we used the VQI to evaluate trends in medical management in patients with CLTI undergoing peripheral vascular interventions (PVI), and the impact of changes in management on overall survival (OS), amputation-free survival (AFS), and limb salvage (LS)., Methods: Patients undergoing index PVI for CLTI between 2012 and 2016, with ≥24 months of follow-up were identified from the national VQI registry. Patient details including smoking status and medication use, OS, LS, and AFS were analyzed with linear-by-linear association, t test, and logistic regression., Results: There were 12,370 PVI completed in 11,466 patients. There was a significant increase in infrapopliteal interventions (from 29.8% to 39.0%; P < .001) and PVI performed for tissue loss (from 59.1% to 66.5%; P < .001). The percentage of current smokers at time of PVI decreased (from 36.2% to 30.7%; P = .036). At discharge, statins were initiated in 25%, aspirin in 45%, and P2Y12 therapy in 58% of patients not receiving these medications before PVI. Over the course of follow-up, dual antiplatelet therapy (DAPT) (from 41.1% to 48.0%; P < .001), angiotensin-converting enzyme (ACE) inhibitor (from 46.2% to 51.3%; P < .001), and statin (from 70.4% to 77.5%; P < .001) use increased. Combined DAPT, ACE inhibitor and statin use increased from 33.6% to 39.6% (P ≤ .001). Significant improvement in 24-month OS and AFS was noted (OS, from 90.9% to 93.7% [P = .002]: AFS, from 81.2% to 83.1% [P = .046]), but not LS (from 89.6% to 89.0%; P = .83). Combined therapy with P2Y12 inhibitors, statins and ACE inhibitors was an independent predictor of improved OS (hazard ratio, 0.61; 95% confidence interval, 0.39-0.96; P = .034). DAPT was independent predictor of improved LS (hazard ratio, 0.83; 95% confidence interval, 0.79-0.87; P < .007)., Conclusions: Antiplatelet, ACE inhibitor, and statin use increased over the study period and was associated with improved OS and AFS. LS trends did not change significantly over time, possibly owing to the inclusion of patients with a greater disease burden or inadequate medical management. Medical management, although improved, remained far from optimal and represents an area for continued development., (Copyright © 2023 Society for Vascular Surgery. All rights reserved.)

Background: Statin therapy is recommended in all patients with peripheral arterial disease (PAD). Its impact on reduction in mortality has been well-documented, yet effect on limb-specific outcomes has been less conclusive. Differences among PAD subgroups or variability of statin use may contribute to the inconsistent findings. We evaluated statin use in patients who underwent peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI) and its impact on overall survival (OS), amputation-free survival (AFS) and limb salvage (LS)., Methods: The national Vascular Quality Initiative was queried for the index PVI for CLTI during the period 2010-2016; follow-up (FU) through 2020. Demographics, comorbidities, operative details, and FU status were recorded. Patients were categorized as E-Statin: statin use pre-PVI through discharge (D/C) and FU or N-Statin: No statins pre-PVI, at D/C or any time during FU. The propensity score matched model (PSM) was constructed. Groups were compared using chi-square, Kaplan-Meier survival and Cox regression analysis., Results: There were 9,089 index PVI in 8,402 patients; E-Statin: 7149 index PVI in 6,591 patients; and N-Statin: 1940 index PVI in 1811 patients. The mean age was 69 ± 12 years and 58% were male. Statin use was associated with improved 3-year OS-E Statin: 92.9% ± 0.9 versus N Statin: 91.1% ± 2.2%; P = 0.003; hazard ratio (HR): Exp (B) (95% confidence interval): 0.66 (0.44-0.99); P = 0.047 and remained significant following PSM: E Statin: 95.1% ± 0.2% versus 90.8% ± 0.3%; P = 0.02; HR: 0.50 (0.27-0.92); P = 0.025. No significant differences in 3-year LS or AFS were noted between the prematched groups; LS: E Statin: 83.7% ± 0.8 versus N Statin: 84.0% ± 1.7%; P = 0.89; HR: 1.09 (0.88-1.35); P = 0.44; AFS-E Statin: 77.2% ± 1.1% versus 76.1% ± 2.5%; P = 0.17; HR: 0.97 (0.79-1.18); P = 0.74. or following PSM: AFS: 80.2% ± 2.8% vs. 74.7% ± 3.9%; P = 0.53, HR: 0.92 (0.72-1.19); P = 0.54; LS 85.3% ± 1.9% vs. 83.5% ± 2.6%; P = 0.51, HR: 1.08 (0.83-1.4); P = 0.57. Statins significantly improved LS among those with renal failure: 67.8% ± 2.6% vs. 59.7% ± 4.4%; P = 0.003; HR: 56 (0.40-0.79); P = 0.001., Conclusions: Statins are independently associated with improved OS in patients who undergo PVI for CLTI and should be considered for all barring intolerance. Statin use was associated with improved LS in patients with end-stage renal disease. Additional research is needed in this area, particularly, the impact of statin therapy in high-risk CLTI subgroups., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Patients can choose between open repair and endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). However, the factors associated with patient preference for one repair type over another are not well-characterized. Here we assess the factors associated with preference of choice for open or endovascular AAA repair among veterans exposed to a decision aid to help with choosing surgical treatment., Methods: Across 12 Veterans Affairs hospitals, veterans received a decision aid covering domains including patient information sources and understanding preference. Veterans were then given a series of surveys at different timepoints examining their preferences for open versus endovascular AAA repair. Questions from the preference survey were used in analyses of patient preference. Results were analyzed using χ 2 tests. A logistic regression analysis was performed to assess factors associated with preference for open repair or preference for EVAR., Results: A total of 126 veterans received a decision aid informing them of their treatment choices, after which 121 completed all preference survey questions; five veterans completed only part of the instruments. Overall, veterans who preferred open repair were typically younger (70 years vs 73 years; P = .02), with similar rates of common comorbidities (coronary disease 16% vs 28%; P = .21), and similar aneurysms compared with those who preferred EVAR (6.0 cm vs 5.7 cm; P = .50). Veterans in both preference categories (28% of veterans preferring EVAR, 48% of veterans preferring open repair) reported taking their doctor's advice as the top box response for the single most important factor influencing their decision. When comparing the tradeoff between less invasive surgery and higher risk of long-term complications, more than one-half of veterans preferring EVAR reported invasiveness as more important compared with approximately 1 in 10 of those preferring open repair (53% vs 12%; P < .001). Shorter recovery was an important factor for the EVAR group (74%) and not important in the open repair group (76%) (P = .5). In multivariable analyses, valuing a short hospital stay (odds ratio, 12.4; 95% confidence interval, 1.13-135.70) and valuing a shorter recovery (odds ratio, 15.72; 95% confidence interval, 1.03-240.20) were associated with a greater odds of preference for EVAR, whereas finding these characteristics not important was associated with a greater odds of preference for open repair., Conclusions: When faced with the decision of open repair versus EVAR, veterans who valued a shorter hospital stay and a shorter recovery were more likely to prefer EVAR, whereas those more concerned about long-term complications preferred an open repair. Veterans typically value the advice of their surgeon over their own beliefs and preferences. These findings need to be considered by surgeons as they guide their patients to a shared decision., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Antiplatelet therapy is recommended in patients with peripheral arterial disease to reduce cardiovascular risk and improve outcomes. However, issues including the drug of choice and use of dual antiplatelet therapy (DAPT) vs monotherapy remain unclear. This study aims to compare the impact of aspirin (ASA) monotherapy, P2Y12 monotherapy, and DAPT on limb salvage (LS), amputation-free survival (AFS), and overall survival (OS) in patients undergoing lower extremity peripheral endovascular intervention (PVI) for chronic limb-threatening ischemia (CLTI)., Methods: The Vascular Quality Initiative PVI registry was used to identify index procedures completed for CLTI between March 1, 2010 and September 30, 2017. Patients were categorized by antiplatelet use at the time of last follow-up. Patients not on antiplatelet therapy were compared with ASA, P2Y12 monotherapy, and DAPT. Propensity score-matched samples were created for direct ASA vs P2Y12 and P2Y12 vs DAPT comparisons; veracity was confirmed by χ 2 and Hosmer-Lemeshow tests. Kaplan-Meier and Cox regression were performed for OS, AFS, and LS., Results: A total of 12,433 index PVI were completed for CLTI in 11,503 subjects in the pre-matched sample. Antiplatelet use at follow-up was: 12% none, 31% ASA, 14% P2Y12, and 43% DAPT. Median follow-up was 1389 days. P2Y12 monotherapy was associated with improved outcomes as compared with ASA monotherapy, OS (87.8% vs 85.5%l P = .026; Cox hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.68-0.98; P = .03), AFS (79.6% vs 74.8%; P < .001; Cox HR, 0.75; 95% CI, 0.65-0.86; P < .001) and LS (89.5% vs 86.8%; P = .013; Cox HR, 0.74; 95% CI, 0.60-0.91; P = .004). P2Y12 monotherapy and DAPT had comparable OS (87.8% vs 88.9%; P = .62; Cox HR, 0.94; 95% CI, 0.77-1.14; P = .50), AFS (79.6% vs 81.5%; P = .33; Cox HR, 0.92; 95% CI, 0.78-1.07; P = .28), and LS (91.7% vs 89.4; P = .03; Cox HR, 0.80; 95% CI, 0.64-1.00; P = .06)., Conclusions: P2Y12 monotherapy was associated with superior OS, AFS, and LS as compared with ASA monotherapy, and comparable OS, LS, and AFS with DAPT in patients undergoing PVI for CLTI. P2Y12 monotherapy may be considered over ASA monotherapy and DAPT in patients with CLTI, especially in patients with high bleeding risk., (Copyright © 2022. Published by Elsevier Inc.)

Objective: The objective of the present study was to evaluate radiation safety practices, radiation training, and radiation exposure among senior vascular residents and fellows in Accreditation Council for Graduate Medical Education-accredited programs across the United States., Methods: Anonymous surveys were sent to all Accreditation Council for Graduate Medical Education program directors to be distributed to postgraduate year 4 to 7 vascular trainees for completion. The survey questions focused on program type (single vs multiple hospital site), familiarity with their radiation officer, formal radiation training, frequency of radiation feedback, use of safety equipment, and adherence to as low as reasonably achievable principles., Results: A total of 95 trainees responded (27% response rate). Of the 95 trainees, 49 (51.6%) had reported they had never met their radiation safety officer, 74 (77.9%) reported they had received formal radiation safety education, 50 (53%) reported receiving feedback regarding their monthly radiation exposure, and 24 (25%) reported never having received such feedback. All the findings were more common among the multiple hospital site program respondents., Conclusions: It should be of significant concern that such a high number of trainees have been exceeding radiation exposure limits. Programs should strive to reduce radiation exposure through formal training, provision of safety equipment, modeling by attendings of adherence to as low as reasonably achievable principles, and timely feedback on radiation exposure., (Copyright © 2022 Society for Vascular Surgery. All rights reserved.)

Background: Evaluate outcomes following urinary catheter (UC) versus no urinary catheter (NUC) insertion in elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA)., Methods: Retrospective record review of all elective EVAR at a university affiliated medical center over a 5-year period. Statistical analysis included Chi Sq, Independent Student t Test., Results: Six surgeons performed 272 elective EVAR. Three surgeons preferred selective insertion of indwelling UC, such that 86 (32%) EVAR were completed without indwelling urinary catheters (NUC). Differences between NUC versus UC included; male: (86% vs. 70%; P = 0.004), CAD: (45% vs. 33%; p = 0.046), conscious sedation: (36% vs. 8%; P < 0.001), bilateral percutaneous EVAR (PEVAR): (100% vs. 90%; P = 0.01), within Proglide TM IFU guidelines (87% vs 75%; P = .05), major adverse operative event (MAOE): (3.5% vs. 10%; P = 0.05) and mean operative time (185 ± 73 vs. 140 ± 37; P < 0.001). Intra-operative catheterization was never required among NUC. Postoperative adverse urinary events (AUE) were more common among UC (11.4% vs. 8.1%; P = 0.41); with longer times to straight catheterization/reinsertion (1575 ± 987 vs, 522 ± 269 min; P = 0.015) and lower likelihood of eligibility for same day discharge (SDD); (41% vs. 59%; P = 0.008). Ineligibility for SDD was due to AUE in 18% of UC patients., Conclusion: Selective preoperative UC insertion should be considered for EVAR, with particular consideration to no preoperative catheterization in men meeting Proglide IFU. Adverse urinary events occurred less frequently among NUC and were identified/ treated earlier. Moreover, AUEs were the most common reason for potential SDD ineligibility among UC patients. Selective policies may facilitate SDD., (Copyright © 2021. Published by Elsevier Inc.)

Background: Angiotensin-converting enzyme Inhibitors and Angiotensin II Receptor Blockers (ACEI/ARB) reduce the risk of cardiovascular events and mortality in patients with peripheral arterial disease (PAD). However, their effect on limb-specific outcomes is unclear. The objective of this study is to assess the effect of ACEI/ARB on patency and limb salvage in patients undergoing interventions for critical limb ischemia (CLI)., Methods: Patients undergoing infrainguinal revascularization for CLI (Rutherford 4-6) between 06/2001 and 12/2014 were retrospectively identified. Primary Patency (PP), Secondary Patency (SP), Limb Salvage (LS), major adverse cardiac events (MACE), and survival rates were calculated using Kaplan-Meier. Multivariate analysis was performed using Cox regression., Results: A total of 755 limbs in 611 patients (311 ACEI/ARB, 300 No ACEI/ARB) were identified. Hypertension (86% vs. 70%, P < 0.001), diabetes (68% vs. 55%, P = 0.001) and statin use (61% vs. 45%, P < 0.001) were significantly greater in the ACEI/ARB group. Interventions were performed mostly for tissue loss (83% ACEI/ARB vs. 84% No ACEI/ARB, P = 0.73). Comparing ACEI/ARB versus No ACEI/ARB, in femoropopliteal interventions, 60-month PP (54% vs. 55%, P = 0.47), SP (76% vs. 75%, P = 0.83) and LS (84% vs. 87%, P = 0.36) were not significantly different. In infrapopliteal interventions, 60-month PP (45% vs. 46%, P = 0.66) and SP (62% vs. 75%, P = 0.96) were not significantly different. LS was significantly greater in ACEI/ARB (75%), as compared to No ACEI/ARB (61%) (P = 0.005). Cox regression identified diabetes (HR 2.4 (1.4-4.1), P = 0.002), ESRD (HR 3.5 (2.1-5.7), P < 0.001), hypertension (HR 0.4 (0.2-0.6), P < 0.001), and ACEI/ARB (HR 0.6 (0.4-0.9), P = 0.03), as factors independently associated with LS after infrapopliteal interventions. Freedom from MACE (ACEI/ARB 37% vs. 32%, P = 0.82) and overall survival (ACEI/ARB 42% vs. 35% No ACEI/ARB, P = 0.84) were not significantly different., Conclusions: ACEI/ARB is associated with improved limb salvage in CLI patients undergoing infrapopliteal interventions, but not after femoropopliteal interventions. ACEI/ARB had no impact on patency rates. They were also associated with a trend toward improved survival and freedom from MACE. Our findings suggest that the use of ACEI/ARB may improve outcomes in the high-risk CLI patient population., (Copyright © 2019. Published by Elsevier Inc.)

Pre-emptive, nonselective perigraft embolization of abdominal aortic aneurysm sac to reduce the risk of type II endoleak has been previously reported with a percutaneous technique using contralateral access with resheathing for coiling. The approach has been modified to simplify the procedure and to eliminate unnecessary sheath exchanges., (© 2019 The Authors.)