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Christine Lim,1 Yasaman Kavousi,2 Ying Wei Lum,2 Paul J Christo1 1Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins University School of Medicine, Baltimore, MD, USACorrespondence: Paul J Christo Email pchristo@jhmi.eduAbstract: Neurogenic thoracic outlet syndrome (NTOS) represents a disorder believed to involve compression of one or more neurovascular elements as they exit the thoracic outlet. This comprehensive literature review will focus on the occurrence, classification, etiology, clinical presentation, diagnostic measures, and both nonoperative and operative therapies for NTOS. NTOS represents the most common subtype of thoracic outlet syndrome and can significantly impair quality of life. Botulinum toxin injection into the anterior scalene muscle, or even the middle scalene or pectoralis minor muscles, can reduce the symptoms of this syndrome. The best available evidence for botulinum toxin therapy to the cervicothoracic muscles supports the value of this treatment for reducing pain in the affected extremity, and for an approximate duration of 2 months or more. Surgical approaches and newer minimally invasive surgical approaches offer high rates of improvement in select centers.Keywords: thoracic outlet syndrome, neurogenic thoracic outlet syndrome, anterior scalene muscle, brachial plexus, compression neuropathy

Background: This study investigated the outcomes before and after initiation of a postoperative care pathway for carotid endarterectomy (CEA) patients., Methods: A CEA pathway was developed with stakeholders. We compared in-hospital outcomes and charges (USD) for patients undergoing CEA 18 months before (11/2019-04/2021) vs. after (05/2021-11/2022) implementation., Results: 149 patients (mean age 70.2 ​± ​10.9 years, 60.4 ​% male, 75.7 ​% white) underwent CEA (83 pre-initiative, 66 post-initiative). There was significant reduction in intensive care unit (ICU) care (90.4 ​% vs.46.2 ​%; P ​< ​0.001) but no changes in stroke (3.6 ​% vs. 0 ​%), death (0 ​% vs. 0 ​%), or median length-of stay (1.0 vs. 1.0 days) following implementation (all, P ​> ​0.12). After risk adjustment, the pathway was associated with charge reductions of $1631/patient/day (95%CI -$3,008, -$254)., Conclusions: Initiation of a CEA pathway was associated with lower ICU rates and reduction in hospital charges without compromising patient outcomes., Competing Interests: Declaration of competing interest CWH reports consulting relationships with Cook Medical LLC, W.L. Gore, and Silk Road Medical that are unrelated to this work. The remaining authors have no conflicts of interest for this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: Vascular injuries require urgent repair to minimize loss of limb and life. Standard revascularization relies on autologous vein or synthetic grafts, but alternative options are needed when adequate vein is not feasible and when clinical conditions preclude safe use of synthetic materials., Objective: To evaluate the performance of the acellular tissue engineered vessel (ATEV) in the repair of arterial injuries., Design, Setting, and Participants: Two open-label, single-arm, nonrandomized clinical trials, including 1 prospective civilian study (CLN-PRO-V005 [V005]) and 1 retrospective observational study in a war zone (CLN-PRO-V017 [V017]), were conducted from September 2018 to January 2024 (follow-up ongoing) at 19 level 1 trauma centers in the US and Israel and 5 frontline hospitals in Ukraine. Patients had vascular injury, no autologous vein available for emergent revascularization, and risk factors for wound infection. Data were analyzed from September 2023 to January 2024., Intervention: The ATEV is a bioengineered vascular conduit grown from human vascular cells, available off the shelf, and implantable without immunosuppression., Main Outcomes and Measures: Primary patency at day 30 was the primary outcome. Secondary outcomes included limb salvage, graft infection, and patient survival. A systematic literature review identified synthetic graft benchmarks in the treatment of arterial trauma for the same end points., Results: The V005 and V017 studies evaluated 69 and 17 patients, respectively, and included 51 in V005 and 16 in V017 with noniatrogenic arterial injuries of the extremities. The majority were male (V005, 38 [74.5%]; V017, 16 [100%]), the mean (SD) ages were similar (V005, 33.5 [13.6] years; V017, 34.2 [9.0] years), and the mean (SD) Injury Severity Scores were similar (V005, 20.8 [10.5]; V017, 20.1 [18.9]). Penetrating injuries dominated (V005, 29 patients [56.9%]; V017, 14 patients [87.5%]). At day 30 for the V005 and V017 trials, respectively, ATEV primary patency was 84.3% (95% CI, 72.0%-91.8%) and 93.8% (95% CI, 71.7%-98.9%); secondary patency was 90.2% (95% CI, 79.0%-95.7%) and 93.8% (95% CI, 71.7%-98.9%); amputation rate was 9.8% (95% CI, 4.3%-21.0%) and 0% (95% CI, 0.0%-19.4%); ATEV infection rate was 2.0% (95% CI, 0.4%-10.3%) and 0% (95% CI, 0.0%-19.4%); and death rate was 5.9% (95% CI, 2.0%-15.9%) and 0% (95% CI, 0.0%-19.4%) (no deaths attributed to the ATEV). Day 30 synthetic graft benchmarks were as follows: secondary patency, 78.9%; amputation, 24.3%; infection, 8.4%; and death, 3.4%., Conclusions and Relevance: Results of 2 single-arm trials in civilian and real-world military settings suggest that the ATEV provides benefits in terms of patency, limb salvage, and infection resistance. Comparing ATEV outcomes with synthetic graft benchmarks demonstrates improved outcomes in the treatment of acute vascular injuries of the extremities., Trial Registration: ClinicalTrials.gov Identifiers: NCT03005418, NCT05873959.

Objective: Surgical decompression via transaxillary first rib resection (TFRR) is often performed in patients presenting with venous thoracic outlet syndrome (VTOS). We aimed to evaluate the outcomes of TFRR based on chronicity of completely occluded axillosubclavian veins in VTOS., Methods: We performed a retrospective institutional review of all patients who underwent TFRR for VTOS and had a completely occluded axillosubclavian vein between 2003 and 2022. Patients were categorized into three groups based on the time of inciting VTOS event to TFRR acuity of their venous occlusion: <4 weeks, 4 to 12 weeks, and >12 weeks. We evaluated the association of TFRR timing with 1-year outcomes, including patency and symptomatic improvement. We used the χ 2 test to compare baseline characteristics and postoperative outcomes., Results: Overall, 103 patients underwent TFRR for VTOS with a completely occluded axillosubclavian vein (median age, 30.0 years; 42.7% female; 8.8% non-White), of whom 28 had occlusion at <4 weeks, 36 had occlusion at 4 to 12 weeks, and 39 had occlusion at >12 weeks. Postoperative venogram performed 2 to 3 weeks after TFRR demonstrated that 78.6% in the <4 weeks group, 72.2% in the 4- to 12-weeks group, and 61.5% in the >12 weeks group had some degree of recanalization (P = .76). Postoperative balloon angioplasty was successfully performed in 60 patients with stenosed or occluded axillosubclavian vein at the time of postoperative venogram. At the 10- to 14-month follow-up, 79.2% of the <4 weeks group, 73.3% of the 4- to 12-weeks group, and 73.3% of the >12 weeks group had patent axillosubclavian veins based on duplex ultrasound examination (P = .86). Among patients who underwent postoperative balloon angioplasty, 80.0%, 85.0% and 100% in the <4 weeks, 4- to 12-weeks, and >12 weeks groups respectively demonstrated patency at 10 to 14 months (P = .31). Symptomatic improvement was reported in 95.7% in the <4 weeks group, 96.7% in the 4- to 12-weeks group, and 93.5% in the >12 weeks group (P = .84)., Conclusions: TFRR offers excellent postoperative outcomes for patients with symptomatic VTOS, even in cases of completely occluded axillosubclavian veins, regardless of the chronicity of the occlusion. By 14 months, 95.2% of patients experienced symptomatic improvement, and 75% attained venous patency., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Performing surgery for renal cell carcinoma (RCC) in patients with horseshoe kidneys presents unique anatomic challenges. The complexities of clinical decision-making and technical challenges are further compounded by the presence of both IVC tumor thrombus extension and metastatic disease., Case Presentation: We encountered the unique case of a 66-year-old woman with a horseshoe kidney who presented with a 14cm mass in her right kidney with level II tumor thrombus extension into the IVC, retroperitoneal lymphadenopathy, and pulmonary nodules that were biopsy-proven to be consistent with metastatic clear cell RCC (cT3aN1M1). She was treated with combination immune checkpoint inhibition (ICI) and targeted therapy upfront. Given her durable response to systemic therapy, we elected to perform a consolidative cytoreductive nephrectomy for residual ypT3aN0 disease, and she has since remained disease-free radiographically. Using step-by-step illustrative photographs obtained intraoperatively, we detail our surgical approach and highlight technical pearls to manage similar cases of advanced RCC arising from horseshoe kidneys., Conclusion: We present a complex case of metastatic RCC with IVC tumor thrombus arising from a horseshoe kidney. We share our clinical and technical approach to overcoming the medical and surgical challenges inherent to her case. The optimal role and timing of cytoreductive nephrectomy relative to ICI administration continue to evolve based on both tumor- and patient-related factors. Indeed, we favor a multidisciplinary approach to optimize patient outcomes.

Background: Long-term follow-up (LTFU) following carotid revascularization is important for post-surgical care, stroke risk optimization and post-market surveillance of new technologies., Methods: We instituted a quality improvement project to improve LTFU rates for carotid revascularizations (primary outcome) by scheduling perioperative and one-year follow-up appointments at time of surgery discharge. A temporal trends analysis (Q1 2019 through Q1 2022), multivariable regression, and interrupted time series (ITS) were performed to compare pre-post intervention LTFU rates., Results: 269 consecutive patients were included (151 pre-intervention, 118 post-intervention; mean 71 ​± ​12 years-old, 39% female, 77% White). The overall LTFU rate improved (64.9%-78.8%; P ​= ​0.013) after the intervention. After controlling for patient factors, procedures performed after the intervention were associated with increased odds of being seen for 1-year follow-up (OR: 2.2 95%CI: 1.2-4.0). Quarterly ITS analysis corroborated this relationship (P ​= ​0.01)., Conclusions: Time-of-surgery appointment creation and automated patient reminders can improve LTFU rates following carotid revascularizations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Thoracic outlet syndrome (TOS) is a rare anatomic condition caused by compression of neurovascular structures as they traverse the thoracic outlet. Depending on the primary structure affected by this spatial narrowing, patients present with one of three types of TOS-venous TOS, arterial TOS, or neurogenic TOS. Compression of the subclavian vein, subclavian artery, or brachial plexus leads to a constellation of symptoms, including venous thrombosis, with associated discomfort and swelling; upper extremity ischemia; and chronic pain due to brachial plexopathy. Standard textbooks have reported a predominance of females patients in the TOS population, with females comprising 70%. However, there have been few comparative studies of sex differences in presentation, treatment, and outcomes for the various types of TOS., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Previous studies have reported an association of Black race with worse carotid revascularization outcomes, but rarely include socioeconomic status as a confounding covariate. We aimed to assess the association of race and ethnicity with in-hospital and long-term outcomes following carotid revascularization before and after accounting for socioeconomic status., Methods: We identified non-Hispanic Black and non-Hispanic white patients who underwent carotid endarterectomy, transfemoral carotid stenting, or transcarotid artery revascularization between 2003 and 2022 in the Vascular Quality Initiative. Primary outcomes were in-hospital stroke/death and long-term stroke/death. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of race with perioperative and long-term outcomes after adjusting for baseline characteristics using a sequential model approach without and with consideration of Area Deprivation Index (ADI), a validated composite marker of socioeconomic status., Results: Of 201,395 patients, 5.1% (n = 10,195) were non-Hispanic Black, and 94.9% (n = 191,200) were non-Hispanic white. Mean follow-up time was 3.4±0.01 years. A disproportionately high percentage of Black patients were living in more socioeconomically deprived neighborhoods relative to their white counterparts (67.5% vs 54.2%; P < .001). After adjusting for demographic, comorbidity, and disease characteristics, Black race was associated with greater odds of in-hospital (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.10-1.40) and long-term stroke/death (adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.23). These associations did not substantially change after additionally adjusting for ADI; Black race was persistently associated with greater odds of in-hospital (aOR, 1.23; 95% CI, 1.09-1.39) and long-term stroke/death (aHR, 1.12; 95% CI, 1.03-1.21). Patients living in the most deprived neighborhoods were at greater risk of long-term stroke/death compared with patients living in the least deprived neighborhoods (aHR, 1.19; 95% CI, 1.05-1.35)., Conclusions: Non-Hispanic Black race is associated with worse in-hospital and long-term outcomes following carotid revascularization despite accounting for neighborhood socioeconomic deprivation. There appears to be unrecognized gaps in care that prevent Black patients from experiencing equitable outcomes following carotid artery revascularization., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: At present, no data are available to support the use of tibial interventions in the treatment of claudication. We characterized the practice patterns surrounding tibial peripheral vascular interventions (PVIs) for patients with claudication in the United States., Methods: Using 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients who underwent an index PVI for claudication. Patients with any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt or delivery of tibial revascularization during an index PVI for claudication, defined as tibial PVI with or without concomitant femoropopliteal PVI. Univariable comparisons and multivariable hierarchical logistic regression were used to assess the patient and physician characteristics associated with the use of tibial PVI for claudication., Results: Of 59,930 Medicare patients who underwent an index PVI for claudication between 2017 and 2019, 16,594 (27.7%) underwent a tibial PVI (isolated tibial PVI, 38.5%; tibial PVI with concomitant femoropopliteal PVI, 61.5%). Of the 1542 physicians included in our analysis, the median physician-level tibial PVI rate was 20.0% (interquartile range, 9.1%-37.5%). Hierarchical logistic regression suggested that patient-level characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR], 1.23), increasing age (aOR, 1.30-1.96), Black race (aOR, 1.47), Hispanic ethnicity (aOR, 1.86), diabetes (aOR, 1.36), no history of hypertension (aOR, 1.12), and never-smoking status (aOR, 1.64; P < .05 for all). Physician-level characteristics associated with tibial PVI for claudication included early-career status (aOR, 2.97), practice location in the West (aOR, 1.75), high-volume PVI practice (aOR, 1.87), majority of practice in an ambulatory surgery center or office-based laboratory setting (aOR, 2.37), and physician specialty. The odds of vascular surgeons performing tibial PVI were significantly lower compared with radiologists (aOR, 2.98) and cardiologists (aOR, 1.67; P < .05 for all). The average Medicare reimbursement per patient was dramatically higher for physicians performing high rates of tibial PVI (quartile 4 vs quartile 1-3, $12,023.96 vs $692.31 per patient; P < .001)., Conclusions: Tibial PVI for claudication was performed more often by nonvascular surgeons in high-volume practices and high-reimbursement settings. Thus, a critical need exists to reevaluate the indications, education, and reimbursement policies surrounding these procedures., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome. However, NTOS has remained difficult to diagnose and treat successfully. The purpose of the present study was to generate a predictive clinical calculator for postoperative outcomes after first rib resection (FRR) for NTOS., Methods: We performed a retrospective review of patients who had undergone FRR for NTOS at a single tertiary care institution between 2016 and 2020. A multivariate stepwise logistic regression analysis was performed to assess the association of the percentage of improvement after FRR with the patient baseline characteristics, pertinent clinical characteristics, and diagnostic criteria set by the Society for Vascular Surgery. The primary outcome was subjective patient improvement after FRR. A prediction risk calculator was developed using backward stepwise multivariate logistic regression coefficients. Bootstrapping was used for internal validation., Results: A total of 208 patients (22.2% male; mean age, 35.8 ± 12.8 years; median follow-up, 44.9 months) had undergone 243 FRRs. Of the 208 patients, 94.7% had had symptoms localized to the supraclavicular area, and 97.6% had had symptoms in the hand. All the patients had had positive symptoms reproduced by the elevated arm stress test and upper limb tension test. Another reasonably likely diagnosis was absent for all the patients. Of the 196 patients who had received a lidocaine injection, 180 (93.3%) had experienced improvement of NTOS symptoms. Of the 95 patients who had received a Botox injection, 82 (74.6%) had experienced improvement of NTOS symptoms. Receiver operating characteristic curve analysis was used to assess the model. The area under the curve for the backward stepwise multivariate logistic regression model was 0.8. The multivariate logistic regression analyses revealed that the significant predictors of worsened clinical outcomes included hand weakness (adjusted odds ratio [aOR], 4.28; 95% confidence interval [CI], 1.04-17.74), increasing age (aOR, 0.93; 95% CI, 0.88-0.99), workers' compensation or litigation case (aOR, 0.09; 95% CI, 0.01-0.82), and symptoms in the dominant hand (aOR, 0.20; 95% CI, 0.05-0.88)., Conclusions: Using retrospective data from a single-institution database, we have developed a prediction calculator with moderate to high predictive ability, as demonstrated by an area under the curve of 0.8. The tool (available at: https://jhhntosriskcalculator.shinyapps.io/NTOS&#95;calc/) is an important adjunct to clinical decision-making that can offer patients and providers realistic and personalized expectations of the postoperative outcome after FRR for NTOS. The findings from the present study have reinforced the diagnostic criteria set by the Society for Vascular Surgery. The calculator could aid physicians in surgical planning, referrals, and counseling patients on whether to proceed with surgery., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We previously demonstrated that everolimus drug-eluting stents (eDES) have reasonable short-term patency for the treatment of infrainguinal bypass stenoses. The aim of this study is to compare mid-term outcomes of eDES, plain balloon angioplasty (PTA), percutaneous cutting balloon (PCB), and drug-coated balloon (DCB) interventions for failing infrainguinal bypasses., Methods: We conducted a retrospective review of patients with infrainguinal bypass stenoses treated by endovascular intervention (August 2010-August 2021). The primary outcome was primary patency (PP). Secondary outcomes were primary-assisted patency (PAP), secondary patency (SP), limb salvage (LS), and mortality. Outcomes were compared by treatment using Kaplan-Meier curves with log-rank tests and Cox proportional hazards models adjusting for baseline differences between groups., Results: Seventy-two consecutive patients with 152 discrete infrainguinal bypass graft stenoses were identified. Mean age was 65.1 ± 10.6 years, 55.6% were male, and 48.6% were Black. In total, 81.9% of patients were originally treated for chronic limb-threatening ischemia, and 57.2% of distal anastomoses were to tibial or pedal targets. Of 152 lesions, 44.1% (n = 67) were treated with PTA, 17.8% (n = 27) with PCB, 20.4% (n = 31) with DCB, and 17.8% (n = 27) with eDES. Median follow-up was 28.5 months (interquartile range 11.5-51.9). There was no difference in bypass configuration, conduit choice, or stenosis location (proximal anastomosis, mid-bypass, distal anastomosis) between groups. At 24 months postintervention, PP was significantly better for eDES (72.9%, 95% confidence interval [CI] 49.8-85.6), followed by PCB (55.9%, 95% CI 34.2-72.9), PTA (34.4%, 95% CI 21.7-47.4), and DCB (33.6%, 95% CI 14.5-53.9) (P = 0.03). PAP, LS, and mortality did not significantly differ between modalities (P > 0.05). After risk adjustment, eDES was associated with the lowest risk of PP loss (hazard ratio versus PTA 0.15, 95% CI 0.05-0.47)., Conclusions: eDES is associated with superior 24-month patency rates compared to other endovascular technologies, and should be considered a primary therapy modality for the treatment of infrainguinal bypass graft stenoses., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Physician-oriented outcomes, such as patency and amputation-free survival (AFS), have traditionally been markers of success after lower extremity revascularization. Previous studies have defined clinical success based on a composite of patient-centered outcomes and have shown this outcome to be achieved in less than 50% of patients, far lower than standard physician-oriented outcomes. The purpose of this study is to evaluate clinical success after lower extremity bypass (LEB) or peripheral vascular intervention (PVI) for tissue loss in diabetic patients treated in a multidisciplinary setting to better understand what factors are associated with success from a patient's perspective., Methods: All patients presenting to our multidisciplinary diabetic limb preservation service from July 2012 to January 2020 were enrolled in a prospective database. Patients who underwent either LEB or PVI for ulcer or gangrene were included in the analysis. Clinical success was defined as the composite outcome of secondary patency to the point of wound healing, limb salvage for 1 year, maintenance of ambulatory status for 1 year, and survival for 6 months. Secondary outcomes included 1-year wound healing, patency, and AFS., Results: A total of 134 revascularizations were performed in 131 patients, including 91 (68%) PVI and 43 (32%) LEB. Patients were more frequently male (64%) and black (61%), and 16% were dialysis-dependent. All patients had tissue loss (53% ulcer, 47% gangrene). There were 5 (3.7%) wound, ischemia, and foot infection stage 1, 6 (6.0%) stage 2, 29 (22%) stage 3, and 92 (69%) stage 4 limbs at the time of revascularization. Overall, 76.9% of patients preserved secondary patency to the point of wound healing, 92.5% had limb salvage for 1 year, 90.3% had maintenance of ambulatory status for 1 year, and 96.3% survived for 6 months. The clinical success composite outcome was achieved in 71.6% of patients and was not statistically different between those undergoing PVI vs LEB (69.2% vs 76.7%, P = .37). Secondary patency, limb salvage, and AFS at 1 year were 80.8% ± 3.6%, 91.8% ± 2.3%, and 83.3% ± 3.1%, respectively. Wound healing at 1 year was 84.3% ± 3.4%. The only covariate associated with clinical failure on multivariable analysis was increased age (odds ratio, 0.95; 95% confidence interval, 0.91-0.99; P = .008)., Conclusions: Among diabetic patients presenting with tissue loss, the composite outcome of patient-centered clinical success is lower than traditional physician-centered outcomes after lower extremity revascularization, mostly due to low rates of secondary patency to the point of wound healing. In the current study, clinical failure was only associated with older age and was no different after PVI compared with LEB., (Copyright © 2022. Published by Elsevier Inc.)

Background: Thoracic outlet syndrome (TOS) takes on heterogenous upper extremity manifestations depending on whether the artery, vein or brachial plexus is primarily compressed. As a result of these variable vascular and neurogenic symptoms, these patients present to surgeons of various training backgrounds for surgical decompression. Surgeon specialty is known to correlate with outcomes for numerous vascular procedures, but its role in TOS is unclear. In this work we examine the association of surgeon specialty with short-term outcomes following first rib resection (FRRS) for TOS., Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database, 3,070 patients were identified who underwent FRRS for TOS between 2006-2017. The primary outcomes of the study were 30-d complications, including postoperative hemorrhage requiring transfusion, wound complications, pneumothorax and deep venous thrombosis. Arterial, venous, and neurogenic TOS were distinguished with ICD-9 and 10 codes while patient characteristics, provider specialty, and postoperative outcomes were classified through a combination of standard National Surgical Quality Improvement Program variables and ICD data., Results: Most FRRS were performed by vascular surgeons (87.9%), general (6.9%) and thoracic surgeons (4.4%). The relative distribution of vascular TOS between the specialties was not significantly different, with non-vascular surgeons performing an equivalent amount of FRRS for arterial (1.1% versus 2.4%) and venous TOS (8.6% versus 9.1%, both P> 0.05). Patients who underwent FRRS with non-vascular surgeons experienced more frequent perioperative transfusions (3.2% versus 1.2%, P = 0.001) and wound infections (1.9% versus 0.8%, P= 0.04). On multivariable regression, patients undergoing FRRS for venous TOS were more likely to require blood transfusion (odds ratios:3.63, 95% CI 1.43-9.25). Patients operated on by surgeons whose specialty was not among the top three most common specialties performing FRRS had a 40% longer operative time (incidence rate ratios:1.42, 95% CI 1.15-1.74) as well as a significantly increased odds of requiring a transfusion (odds ratios:9.87, 95% CI 2.28-42.68)., Conclusions: The significantly increased operative times and transfusion requirements associated with specialties who uncommonly perform FRRS suggest the role of surgeon experience and volume in this procedure may play more of a role than specialty training. These data also suggest that vascular TOS carries unique risks that should be kept in mind when performing FRRS., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: Selecting optimal hemodialysis access in elderly patients remains challenging, particularly in those requiring new options after failed initial access. We sought to describe the outcomes of redo hemodialysis access in elderly patients., Methods: All patients aged ≥65 undergoing hemodialysis access placement from 2014-2019 were retrospectively identified in the electronic medical record. Characteristics and outcomes of those with initial versus redo access were compared. Patency was depicted utilizing Kaplan-Meier methods, with censoring at loss to follow-up or death, and unadjusted Cox regression., Results: Overall, 211 elderly patients undergoing 257 procedures were included in the study. Of these, 116 (45.1%) were redo access procedures. There were no demographic or comorbidity differences between the two groups with the exception of central venous stenosis which was more common in the redo cohort (27.2% vs. 6.4%, P < 0.001). 91.5% of initial, vs. 60.3% of redo, procedures were arteriovenous fistulas (P < 0.001). Distribution of fistula type differed between the two groups with first time and redo procedures of 25.5% vs. 6.9% radiocephalic, 28.4% vs. 7.8% brachiocephalic, and 35.5% vs. 37.1% brachiobasilic respectively (P < 0.001). At 12 and 24 months, 63.6% and 44.0% of first-time accesses remained patent vs. 51% and 29.0% of redo accesses (HR 1.37, 95% CI 1.05-1.80, P = 0.02). However, there was no difference in primary patency between redo grafts and fistulas (48.7% fistulas vs. 55.0% grafts at 12 months, P = 0.47)., Conclusions: These results demonstrate acceptable outcomes of redo access in elderly patients. There is no evidence from this study that prosthetic grafts are preferential, suggesting elderly patients with meaningful life expectancy who require redo access should be offered autogenous options when possible., (Copyright © 2021. Published by Elsevier Inc.)

Objective: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system was developed to stratify the risk of 1-year major amputation. Recently, the WIfI scores were used to define the estimated revascularization benefit quartiles ranging from high benefit (Q1) to questionable benefit (Q4). The aim of our study was to evaluate the revascularization benefit quartiles in a cohort of diabetic patients presenting with chronic limb-threatening ischemia (CLTI)., Methods: All diabetic patients presenting to our multidisciplinary diabetic foot and wound clinic (June 2012 to May 2020) who underwent lower extremity revascularization for CLTI were included. The affected limbs were graded using the WIfI system and assigned to an estimated benefit of revascularization quartile as previously published. One-year major amputation, complete foot healing, secondary patency, and amputation-free survival were calculated among the quartiles using Kaplan-Meier curve analyses and compared using Cox proportional hazards models., Results: Overall, 136 diabetic patients underwent revascularization of 187 limbs (mean age, 64.9 ± 11.2 years; 63.2% male; 58.8% black). The limbs were revascularized using an endovascular approach for 66.8% and open surgery for 33.2%. Of the 187 limbs, 27.3% had a high estimated benefit of revascularization (Q1), 31.6% had a moderate estimate benefit of revascularization (Q2), 20.3% had a low estimated benefit of revascularization (Q3), and 20.9% had a questionable benefit of revascularization (Q4). The estimated 1-year major amputation rates were 7.2% ± 4.1% for Q1, 3.8% ± 2.6% for Q2, 7.0% ± 4.8% for Q3, and 25.7% ± 7.5% for Q4 (P = .006). The estimated 1-year foot healing rates were 87.3% ± 5.7% for Q1, 84.8% ± 5.6% for Q2, 83.8% ± 7.4% for Q3, and 68.2% ± 9.1% for Q4 (P = .06). The overall secondary patency (P = .23) and amputation-free survival (P = .33) did not significantly differ among the groups. Using Cox proportional hazard modeling, the Q4 group had a significantly greater risk of major amputation compared with Q1 (hazard ratio, 4.26; 95% confidence interval, 1.15-15.70). Of the 14 limbs requiring major amputation, 9 (56.3%) had a patent revascularization at the time of amputation, including one of three limbs in Q1, two of two limbs in Q2, no limb in Q3, and six of nine limbs in Q4., Conclusions: The questionable estimated revascularization benefit quartile using the WIfI classification system is significantly associated with 1-year major amputation in diabetic patients presenting with CLTI. Limbs with a questionable benefit of revascularization (Q4) will frequently require major amputation despite a patent revascularization, suggesting that the wound size and infection burden are the driving factors behind the elevated risk of major amputation in this group. Our findings support the previously described use of the WIfI classification system to predict revascularization benefit among diabetic patients with CLTI., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Objective: Anatomic grading systems have historically been poor predictors of patency after endovascular tibial interventions. The Global Vascular Guidelines proposed a new Global Anatomic Staging System (GLASS) to estimate one-year limb-based patency (LBP). The purpose of this study was to determine the association of GLASS with LBP following endovascular tibial interventions., Methods: We included all patients presenting to our multidisciplinary diabetic limb preservation service between 01/2012 and 8/2020 who underwent first-time endovascular tibial revascularization for chronic limb-threatening ischemia. Diagnostic angiograms were reviewed to define the preferred target artery pathway and assign a GLASS stage to each treated limb. One-year LBP was calculated and compared across GLASS stages using Kaplan-Meier curves with log-rank tests and Cox proportional hazards models., Results: We performed tibial revascularization in 96 limbs (5.2% rest pain, 56.3% ulcer, 37.5% gangrene), including isolated tibial interventions in 61.5% and tibial + femoropopliteal interventions in 38.5%. 15.6% of limbs were GLASS stage 1, 28.1% were GLASS stage 2, and 56.3% were GLASS stage 3. Overall, one-year LBP was 43.2 ± 6.3%, and did not differ significantly across GLASS stages (P = 0.42). The hazard ratio for failed LBP was 1.94 (95% CI 0.70-5.41) for GLASS stage 2 and 1.49 (95% CI 0.56-3.94) for GLASS stage 3 limbs (versus GLASS stage 1). When analyzed excluding the calcium modifier, LBP remained similar across GLASS stages (P = 0.72). Major amputation was uncommon, occurring in 9.3 ± 3.4% of limbs at one year, and did not significantly differ by GLASS stage (P = 0.98)., Conclusion: The Global Anatomic Staging System did not predict limb-based patency following tibial endovascular interventions. Given the low major amputation rates in this cohort, anatomic complexity should not preclude endovascular limb salvage efforts below the knee., (Copyright © 2021. Published by Elsevier Inc.)

Background: The Agency for Healthcare Research and Quality Patient Safety Indicators (PSI) are quality improvement indicators used to determine hospital performance and, increasingly, to rank surgical programs. The American College of Surgeons National Surgical Quality Improvement Program and the Society for Vascular Surgery Vascular Quality Improvement databases are also frequently used to compare outcomes, but definitions of complications vary between the systems and the optimal system for tracking complications in complex endovascular repair remains unclear. Herein we assess the three outcome tracking systems and their ability to capture complications after fenestrated endovascular abdominal aortic aneurysm repair (FEVAR) and open aortic aneurysm repair in a large complex aortic program., Methods: Demographic and operative data for patients undergoing repair of juxtarenal or pararenal aortic aneurysms between 2004 and 2018 via both open and FEVAR approaches at the Johns Hopkins Medical Institutions were compiled in a prospectively maintained retrospective database. Postoperative complications were defined according to a surgeon-defined system, the Society for Vascular Surgery Vascular Quality Initiative, the American College of Surgeons National Surgical Quality Improvement Program, and the Agency for Healthcare Research and Quality PSI data dictionaries and were compared between surgical approaches as well as eras before and after the introduction of FEVAR. Complication rates between the classification systems were compared using proportion testing and the strength of the correlation between the systems was evaluated with Spearman's rank test., Results: Of 145 patients, 60 (41.4%) underwent FEVAR and 85 (58.6%) underwent open aortic aneurysm repair. The introduction of fenestrated technology was associated with a decrease in the overall number of complications from 37.2% to 20.6% by surgeon-defined classification system (P = .036). The VQI identified the most complications (39.9% of the entire cohort and 25% of FEVAR cases), followed by the NSQIP (29.0% and 33.3%, respectively) and PSI (4.1% and 5%). The two clinically focused databases were found to correlate well with a surgeon-designed classification system, as well as each other (Spearman ρ ≥ 0.735) but not with PSI (ρ < 0.23). Proportion testing demonstrated the rate of complications identified by PSI to be significantly less than either VQI or NSQIP (P < .001). Specifically, PSI did not effectively identify renal complications (1.4% vs 9.0% by NSQIP and 27.3% by VQI definitions; P < .001)., Conclusions: The introduction of FEVAR is associated with an overall decrease in complications in this study. The clinically relevant VQI and NSQIP databases show good concordance in capturing complications; however, PSI did not correlate with either and captured significantly fewer complications. These data highlight the value of high scrutiny classification systems to track postoperative complications and suggest that PSI are insufficient to rank complex aortic programs with high levels of FEVAR use., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The Society for Vascular Surgery Alternative Payment Model (APM) Taskforce document explores the drivers and implications for developing objective value-based reimbursement plans for the care of patients with peripheral arterial disease (PAD). The APM is a payment approach that highlights high-quality and cost-efficient care and is a financially incentivized pathway for participation in the Quality Payment Program, which aims to replace the traditional fee-for-service payment method. At present, the participation of vascular specialists in APMs is hampered owing to the absence of dedicated models. The increasing prevalence of PAD diagnosis, technological advances in therapeutic devices, and the increasing cost of care of the affected patients have financial consequences on care delivery models and population health. The document summarizes the existing measurement methods of cost, care processes, and outcomes using payor data, patient-reported outcomes, and registry participation. The document also evaluates the existing challenges in the evaluation of PAD care, including intervention overuse, treatment disparities, varied clinical presentations, and the effects of multiple comorbid conditions on the cost potentially attributable to the vascular interventionalist. Medicare reimbursement data analysis also confirmed the prolonged need for additional healthcare services after vascular interventions. The Society for Vascular Surgery proposes that a PAD APM should provide patients with comprehensive care using a longitudinal approach with integration of multiple key medical and surgical services. It should maintain appropriate access to diagnostic and therapeutic advancements and eliminate unnecessary interventions. It should also decrease the variability in care but must also consider the varying complexity of the presenting PAD conditions. Enhanced quality of care and physician innovation should be rewarded. In addition, provisions should be present within an APM for high-risk patients who carry the risk of exclusion from care because of the naturally associated high costs. Although the document demonstrates clear opportunities for quality improvement and cost savings in PAD care, continued PAD APM development requires the assessment of more granular data for accurate risk adjustment, in addition to largescale testing before public release. Collaboration between payors and physician specialty societies remains key., (Copyright © 2020 Society for Vascular Surgery. All rights reserved.)

Background: The U.S. healthcare system is undergoing a broad transformation from the traditional fee-for-service model to value-based payments. The changes introduced by the Medicare Quality Payment Program, including the establishment of Alternative Payment Models, ensure that the practice of vascular surgery is likely to face significant reimbursement changes as payments transition to favor these models. The Society for Vascular Surgery Alternative Payment Model taskforce was formed to explore the opportunities to develop a physician-focused payment model that will allow vascular surgeons to continue to deliver the complex care required for peripheral arterial disease (PAD)., Methods: A financial analysis was performed based on Medicare beneficiaries who had undergone qualifying index procedures during fiscal year 2016 through the third quarter of 2017. Index procedures were defined using a list of Healthcare Common Procedural Coding (HCPC) procedure codes that represent open and endovascular PAD interventions. Inpatient procedures were mapped to three diagnosis-related group (DRG) families consistent with PAD conditions: other vascular procedures (codes, 252-254), aortic and heart assist procedures (codes, 268, 269), and other major vascular procedures (codes, 270-272). Patients undergoing outpatient or office-based procedures were included if the claims data were inclusive of the HCPC procedure codes. Emergent procedures, patients with end-stage renal disease, and patients undergoing interventions within the 30 days preceding the index procedure were excluded. The analysis included usage of postacute care services (PACS) and 90-day postdischarge events (PDEs). PACS are defined as rehabilitation, skilled nursing facility, and home health services. PDEs included emergency department visits, observation stays, inpatient readmissions, and reinterventions., Results: A total of 123,180 cases were included. Of these 123,180 cases, 82% had been performed in the outpatient setting. The Medicare expenditures for all periprocedural services provided at the index procedure (ie, professional, technical, and facility fees) were higher in the inpatient setting, with an average reimbursement per index case of $18,755, $34,600, and $25,245 for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility interventions had an average reimbursement of $11,458, and office-based index procedures had costs of $11,533. PACS were more commonly used after inpatient index procedures. In the inpatient setting, PACS usage and reimbursement were 58.6% ($5338), 57.2% ($4192), and 55.9% ($5275) for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility cases required PACS for 13.7% of cases (average cost, $1352), and office-based procedures required PACS in 15% of cases (average cost, $1467). The 90-day PDEs were frequent across all sites of service (range, 38.9%-50.2%) and carried significant costs. Readmission was associated with the highest average PDE expenditure (range, $13,950-$18.934). The average readmission Medicare reimbursement exceeded that of the index procedures performed in the outpatient setting., Conclusions: The cost of PAD interventions extends beyond the index procedure and includes relevant spending during the long postoperative period. Despite the analysis challenges related to the breadth of vascular procedures and the site of service variability, the data identified potential cost-saving opportunities in the management of costly PDEs. Because of the vulnerability of the PAD patient population, alternative payment modeling using a bundled value-based approach will require reallocation of resources to provide longitudinal patient care extending beyond the initial intervention., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Local market competition has been previously associated with more aggressive surgical decision-making. For example, more local competition for organs is associated with acceptance of lower quality kidney offers in transplant surgery. We hypothesized that market competition would be associated with the size of an abdominal aortic aneurysm (AAA) at the time of elective endovascular aneurysm repair (EVAR)., Methods: We included all elective EVARs reported in the Vascular Quality Initiative database (2012-2018). Small AAAs were defined as a maximum diameter <5.5 cm in men or <5.0 cm in women. We calculated the Herfindahl-Hirschman Index (HHI), a measure of physician market concentration (higher HHI = less market competition), for each US census region. Multilevel regression was used to examine the association between the size of AAA at EVAR and HHI, clustering by region., Results: Of 37,914 EVARs performed, 15,379 (40.6%) were for small AAAs. There was significant variation in proportion of EVARs performed for small AAAs across regions (P < 0.001). The South had both the highest proportion of EVARs for small AAAs (44.2%) as well as the highest market competition (HHI 50), whereas the West had the lowest proportion of EVARs for small AAAs (35.0%) and the lowest market competition (HHI 107). Adjusting for patient characteristics, each 10 unit increase in HHI was associated with a 0.1 mm larger maximum AAA diameter at the time of EVAR (95% CI 0.04-0.24 mm, P = 0.005)., Conclusions: Physician market concentration is independently associated with AAA diameter at time of elective EVAR. These data suggest that physician decision-making for EVAR is impacted by market competition., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite guidelines cautioning against the use of endovascular peripheral vascular interventions (PVI) for claudication, more than 1.3 million PVI procedures are performed annually in the United States. We aimed to describe national rates of PVI for claudication, and identify patient and county-level risk factors associated with a high rate of PVI., Methods: We used the Medicare claims database to identify all Medicare beneficiaries with a new diagnosis of claudication between January 2015 and June 2017. A hierarchical logistic regression model accounting for patient age, sex, comorbidities; county region and setting; and a patient race-county median income interaction was used to assess the associations of race and income with a high PVI rate., Results: We identified 1,201,234 patients with a new diagnosis of claudication for analysis. Of these, 15,227 (1.27%) underwent a PVI. Based on hierarchical logistic regression accounting for patient and county-level factors, black patients residing in low-income counties had a significantly higher odds of undergoing PVI than their white counterparts (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.20-1.40), whereas the odds of PVI for black versus white patients was similar in high-income counties (OR, 1.06; 95% CI, 0.99-1.14). PVI rates were higher for low versus high-income counties in both the black (OR, 1.46; 95% CI, 1.31-1.64) and white (OR, 1.19; 95% CI, 1.12-1.27) groups. There were no significant associations of Hispanic, Asian, North American native, or other races with PVI in either low- or high-income counties after risk adjustment (all P ≥ .09)., Conclusions: In the Medicare population, the mean rate of PVI of 12.7 per 1000 claudication patients varies significantly based on race and income. Our data suggest there are racial and socioeconomic differences in the treatment of claudication across the United States., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Increased health care spending concerns have generated interest in reducing operating room (OR) costs, but the cost awareness of the surgical team selecting intraoperative supplies remains unclear. This work characterizes knowledge of supply cost among surgeons and OR staff in a large academic hospital and seeks to examine the role of experience and training with regards to cost insight., Methods: This work is a cross-sectional study of surgeons, trainees, nurses, and surgical technicians (n = 372) across all surgical specialties at a large academic hospital. Participants completed a survey reporting frequency of use and estimated cost for 11 common surgical supplies as well as opinions on access to cost information in the OR. Cost estimation error was expressed as the ratio of estimated-to-actual cost, and groups were compared with one-way analysis of variance and chi-squared testing. Spearman correlation (ρ) was used to describe the relationship between monotonic variables., Results: Overestimation error was universal and ranged widely (3.80-49.79). There was no significant difference in estimation accuracy when stratified by role or years of experience. Less expensive items had higher rates of estimation error than more expensive items (P < 0.001), and a moderately strong relationship was found between decreased item cost and increased estimation error (ρ: 0.49). The overwhelming majority (91%) of respondents expressed a desire to learn more about supply pricing., Conclusions: Price knowledge of common supplies is globally impaired for entire surgical team but coexists with a strong desire to augment cost awareness. Improved access to cost information has a high potential to inform surgical decision-making and decrease OR waste., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Myelopathy selectively involving the lower extremities can occur secondary to spondylotic changes, tumor, vascular malformations, or thoracolumbar cord ischemia. Vascular causes of myelopathy are rarely described. An uncommon etiology within this category is diaphragmatic crus syndrome, in which compression of an intersegmental artery supplying the cord leads to myelopathy. The authors present the operative technique for treating this syndrome, describing their experience with 3 patients treated for acute-onset lower-extremity myelopathy secondary to hypoperfusion of the anterior spinal artery., Methods: All patients had compression of a lumbar intersegmental artery supplying the cord; the compression was caused by the diaphragmatic crus. Compression of the intersegmental artery was probably producing the patients' symptoms by decreasing blood flow through the artery of Adamkiewicz, causing lumbosacral ischemia., Results: All patients underwent surgery to transect the offending diaphragmatic crus. Each patient experienced substantial symptom improvement, and 2 patients made a full neurological recovery before discharge., Conclusions: Diaphragmatic crus syndrome is a rare or under-recognized cause of ischemic myelopathy. Patients present with episodic acute-on-chronic lower-extremity paraparesis, gait instability, and numbness. Angiography confirms compression of an intersegmental artery that gives rise to a dominant radiculomedullary artery. Transecting the offending diaphragmatic crus can produce complete resolution of neurological symptoms.

Background: Randomized studies suggest that open lower extremity revascularization procedures are associated with improved outcomes compared with endovascular peripheral vascular interventions (PVIs). However, advances in endovascular technologies and treatment by multidisciplinary limb preservation teams have shown improved outcomes. The aim of our study was to compare perioperative and long-term outcomes after open versus PVI procedures in diabetic patients with chronic limb-threatening ischemia (CLTI) treated in a multidisciplinary setting., Methods: All patients presenting to our multidisciplinary diabetic limb-preservation service from 6/2012 to 07/2018 were enrolled in a prospective database. Patients who underwent either an open lower extremity bypass (LEB) or a PVI for CLTI were included in the analysis. Perioperative (30-day) complications and 4-year patency and limb salvage rates were compared between PVI and LEB using chi-squared tests, Kaplan-Meier curve analyses, and stepwise multivariable Cox proportional hazards models., Results: A total of 195 lower extremity revascularization procedures were performed in 120 patients (mean age: 65.0 ± 1.0 years, 61.7% male, 63.3% black), including 53 (27.2%) open procedures and 142 (72.8%) PVIs. Nearly two-thirds of procedures (65.6%) treated multilevel diseases, while 27.2% treated isolated tibial disease and 7.2% treated isolated femoropopliteal disease. More than half of the procedures (53.3%) were performed for Wound, Ischemia, and foot Infection (WIfI) classification stage 4 limbs, 25.1% for stage 3, and 21.6% for stage 1/2. In the LEB group, 67.9% of targets were infrapopliteal. In the PVI group, 63.4% of procedures were isolated tibial interventions or were multilevel interventions including the tibial segment. Perioperative complications occurred in 52.8% of LEB versus 12.0% of PVI (P < 0.001). At 4 years postoperatively, there was no significant difference in crude (unadjusted) primary patency for PVI versus LEB (34.5 ± 6.6% vs. 49.6 ± 8.1, P = 0.89). Secondary patency was better for the LEB group (50.3 ± 7.4% vs. 55.4 ± 7.5%; P = 0.04), but amputation-free survival was similar (65.1 ± 6.7% vs. 60.9 ± 9.7%; P = 0.79). After adjusting for baseline differences between groups, primary patency (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.34 to 1.10) and amputation-free survival (HR: 1.51; 95% CI: 0.71 to 2.34) remained similar for PVI versus LEB, but secondary patency was persistently lower for PVI (HR: 0.35; 95% CI: 0.14 to 0.90)., Conclusions: In this cohort of diabetic patients with CLTI undergoing predominantly tibial interventions, open revascularization was associated with a higher risk of perioperative complications than PVIs. While secondary patency rates were better after LEBs, our data suggest that an endovascular-first approach results in equivalent long-term amputation-free survival for diabetic patients treated in a multidisciplinary setting., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: In accordance with the Kidney Disease Outcomes Quality Initiative recommendations, attaining autogenous hemodialysis access, specifically via creation of radiocephalic arteriovenous fistulas (AVF), brachial-basilic (BB)-AVF, or brachial-cephalic AVFs, is preferred for mortality and morbidity benefits over catheter access in patients with end-stage renal disease. The aim of this study is to determine the suitability of forearm basilic vein transposition (FBVT) fistulas as an alternative access option by comparing outcomes with those of BB-AVFs., Methods: All patients who underwent creation of FBVT between 2007 and 2015 were identified retrospectively in the electronic medical record and compared with a sample of patients undergoing BB-AVF placement during this time. Access patency was examined using Kaplan-Meier methods and Cox proportional hazards regression., Results: We included 34 patients with FBVT (median age, 54 years; 67.6% male) and 49 with BB-AVF (median age, 57 years; 42.9% male) in this study. There were no significant differences in comorbid conditions between the two groups, with the exception of hyperlipidemia (29.4% FBVT vs 53.1% BB-AVF; P = .03). Although those with FBVT were more likely to have had previous permanent access attempts (70.6% vs 38.7%; P = .002), and access attempts on the same extremity (44.1% vs 24.4%; P = .04), there were no significant differences in primary patency (46.9% vs 53.3%; P = .6), primary-assisted patency (65.6% vs 73.3%; P = .5), or secondary patency (68.8% vs 82.2%; P = .2) at 1 year when compared with BB-AVF. The risk of loss of patency was not statistically different for FBVT as compared with BB-AVF (hazard ratio, 1.37; 95% confidence interval 0.65-2.88; P = .4). This risk did not vary for those who had previous access on the same arm (interaction P = .8). Four fistulas in each group failed to mature. Only one infectious complication was identified in the FBVT group., Conclusions: No prior studies have directly compared outcomes of FBVTs with BB-AVFs at 1 year or longer. Despite the increased difficulty of harvesting the forearm basilic vein, particularly in patients who have had prior access attempts, there was no significant difference in patency between FBVTs and BB-AVFs. FBVTs are a reasonable option for hemodialysis access, particularly in patients without adequate cephalic veins or who previously failed radiocephalic fistula attempts., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) is a treatment strategy for pediatric patients with cardiopulmonary failure. Femoral cannulation is a commonly used technique for obtaining central access in children and adolescents despite high rates of vascular complications. Ischemic limb complications remain one of the most common problems facing survivors of femoral VA ECMO. Our aim is to review the literature on femoral cannulation in children and to present a review of techniques for femoral cannula placement, decannulation, and arterial repair to help minimize and ameliorate complications related to cannulation. We performed a literature review for pediatric ECMO cannulation, complications, and femoral artery repair in pediatric patients. We focused on the management of arterial and ischemia-related complications during and after ECMO support via femoral cannulation. Vascular complications are not infrequent for patients requiring ECMO support via femoral cannulation. As such, judicious distal perfusion monitoring as well as augmentation of distal flow are important strategies during mechanical support. The use of distal perfusion catheters can be used to minimize the risk of limb ischemia. As femoral cannulation grows more popular in pediatric patients, strategies for arterial repair are essential to ensure extremity perfusion upon decannulation.

Importance: Initial hemodialysis access with arteriovenous fistula (AVF) is associated with superior clinical outcomes compared with arteriovenous graft (AVG) and should be the procedure of choice whenever possible. To address the national underuse of AVF in the United States, the Centers for Medicare & Medicaid has established an AVF goal of 66% or greater in 2009., Objective: To explore contemporary practice patterns and physician characteristics associated with high AVG use compared with AVF use., Design, Setting, and Participants: This review of 100% Medicare Carrier claims between January 1, 2016, and December 31, 2017, includes both inpatient and outpatient Medicare claims data. All patients undergoing initial permanent hemodialysis access placement with an AVF or AVG were included. All surgeons performing more than 10 hemodialysis access procedures during the study period were analyzed., Exposures: Placement of an AVF or AVG for initial permanent hemodialysis access., Main Outcomes and Measures: A surgeon-level AVG (vs AVF) use rate was calculated for all included surgeons. Hierarchical logistic regression modeling was used to identify patient-level and surgeon-level factors associated with AVG use., Results: A total of 85 320 patients (median age, 70 [range, 18-103] years; 47 370 men [55.5%]) underwent first-time hemodialysis access placement, of whom 66 489 (77.9%) had an AVF and 18 831 (22.1%) had an AVG. Among the 2397 surgeons who performed more than 10 procedures per year, the median surgeon level AVG use rate was 18.2% (range, 0.0%-96.4%). However, 498 surgeons (20.8%) had an AVG use rate greater than 34%. After accounting for patient characteristics, surgeon factors that were independently associated with AVG use included more than 30 years of clinical practice (vs 21-30 years; odds ratio, 0.85 [95% CI, 0.75-0.96]), metropolitan setting (odds ratio, 1.25 [95% CI, 1.02-1.54]), and vascular surgery specialty (vs general surgery; odds ratio, 0.77 [95% CI, 0.69-0.86]). Surgeons in the Northeast region had the lowest rate of AVG use (vs the South; odds ratio, 0.83 [95% CI, 0.73-0.96]). First-time hemodialysis access benchmarking reports for individual surgeons were created for potential distribution., Conclusions and Relevance: In this study, one-fifth of surgeons had an AVG use rate above the recommended best practices guideline of 34%. Although some of these differences may be explained by patient referral practices, sharing benchmarked performance data with surgeons could be an actionable step in achieving more high-value care in hemodialysis access surgery.

Background: Local anesthetic (LA) blocks of the anterior scalene muscle are used to predict which patients with neurogenic thoracic outlet syndrome (TOS) may benefit from surgical decompression. The block is thought to work through both analgesic and muscle relaxation effects, but evidence of the latter is lacking. The aim of our study was to assess the effects of LA blocks on anterior scalene muscle anatomy as captured by magnetic resonance imaging (MRI)., Methods: Over a two-year period, a series of patients with neurogenic TOS underwent MRI-guided anterior scalene blocks with an LA. Patients underwent MRI both before injection and 30 minutes after injection. Anterior scalene muscle heights (measured from the superior border of the first rib to the top of C3 vertebrae) before and after injection were compared for the injected side and the noninjected (control) side, both overall and stratified by subjective patient response to injection., Results: A total of 54 patients with neurogenic TOS were included. The median age was 39 years (interquartile range, 27-45), 61% were women, and 46% had a history of neck trauma. Forty-five patients (83%) had a favorable response to injection. Overall, there was no significant change in scalene muscle height for either the injected side (preinjection: 90.0 ± 1.2 mm vs. postinjection: 90.7 ± 1.2; P = 0.12) or the control side (preinjection: 89.3 ± 1.4 mm vs. postinjection: 88.9 ± 1.3 mm; P = 0.83). However, when stratified by patient response, those with a positive response had a larger increase in muscle height for the injected side than for the control side (change in baseline: 0.65 ± 0.58 mm vs. -0.53 ± 0.48 mm; P = 0.05). In contrast, nonresponders had no significant change in scalene height for either the injected or control side (change in baseline: 0.59 ± 1.30 mm vs. 0.37 ± 1.07; P = 1.00). Notably, responders had significantly longer anterior scalene muscles at baseline than nonresponders (92.2 ± 1.1 mm vs. 79.5 ± 2.5; P < 0.001)., Conclusions: LA blocks of the anterior scalene muscle may provide symptomatic relief in patients with neurogenic TOS by increasing muscle height, although the clinical significance of this small change is unclear. Patients who do not have a response to the block tend to have significantly shorter anterior scalene muscle heights than patients who respond, suggesting an anatomic difference in responders versus nonresponders., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: We investigated the feasibility of renal duplex ultrasound in the identification of renal malperfusion in acute aortic dissection and evaluated whether intervention for renal malperfusion improved outcomes over best medical management alone., Methods: All patients with acute aortic dissections involving the renovisceral aorta who underwent a duplex ultrasound were included (2004-2016). We assessed duplex findings among patients who developed acute kidney injury (AKI; 50% increase in serum creatinine) and compared AKI, 30-day mortality, and overall survival among patients who underwent a procedure to treat malperfusion versus those who did not., Results: Of 37 patients with acute dissection involving the renovisceral aorta (73% were male, 59% had type B dissection, mean follow-up 4.6 ± 0.6 years), 70% developed AKI, 11% required dialysis, and 5% developed permanent dialysis dependence. AKI was correlated with higher peak creatinine levels (4.2 vs. 2.2 mg/dL, P < 0.001), although 30-day mortality and overall survival were similar (both, P ≥ 0.24). Progression to AKI was associated with significantly lower end-diastolic velocity (EDV) measurements on renal duplex (17 vs. 27 cm/sec, P = 0.03); an EDV threshold of 23 cm/sec had a positive predictive value of 85% for AKI. Operative intervention (n = 10) was associated with lower follow-up creatinine (0.9 vs. 2.1 mg/dL, P = 0.002), although there was no difference in progression to dialysis dependence, 30-day mortality, or overall survival (all, P ≥ 0.34)., Conclusions: Patients who developed AKI demonstrated characteristic renal duplex ultrasound findings with lower EDV measurements in the distal renal arteries bilaterally. Performing a renal malperfusion procedure was associated with normalization of postoperative creatinine without affecting 30-day mortality or overall survival., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Existing endovascular therapies for failing infrainguinal bypass grafts are associated with modest patency rates. The use of everolimus drug-eluting stents (eDESs) for endovascular bypass graft revision has not yet been reported. The objective of this study was to describe and to compare clinical outcomes of eDESs vs percutaneous cutting balloons (PCBs) vs percutaneous transluminal angioplasty (PTA) for the treatment of infrainguinal bypass graft stenoses., Methods: A multicenter, single-institution retrospective analysis of patients with infrainguinal bypass graft stenoses treated by endovascular intervention (August 2010-December 2017) was conducted. The primary study outcome was primary patency of the treated lesion. The secondary outcome was limb salvage. Outcomes are described overall and stratified by endovascular treatment modality using Kaplan-Meier curves and log-rank tests., Results: During the 7-year study period, 43 patients with 78 infrainguinal bypass stenoses were treated by endovascular intervention (eDES, 15; PCB, 23; PTA, 40). Mean age was 63.3 ± 1.7 years, 53.5% were male, and 55.8% were black. The majority of patients were diabetic (60.5%) with a history of smoking (74.4%), and nearly all (83.7%) had two or more comorbidities. Half (48.7%) of bypasses treated were femoral-popliteal bypasses, followed by popliteal-distal (25.6%) and femoral-tibial (25.6%) configurations. The location of revision was the proximal anastomosis in 37.2%, midbypass in 25.6%, and distal anastomosis in 37.2%. There were no significant differences in baseline characteristics, bypass configuration, or revision location between treatment groups (P ≥ .19). Technical success for endovascular bypass intervention was 100%. At 2 years after intervention, primary patency was significantly better for patients treated with eDES (81.8%) compared with PCB (54.7%) or PTA (33.2%; log-rank, P = .03). Limb salvage was achieved in 93.6% of patients, including 86.7%, 91.3%, and 97.5% for eDES, PCB, and PTA, respectively (P = .30)., Conclusions: This is the first study reporting the results of eDESs for the treatment of infrainguinal bypass graft stenoses. Use of eDESs for endovascular bypass graft revision not only is feasible but may have better primary patency than other endovascular therapies. These data suggest that eDESs may be considered a safe and efficacious endovascular technique in the armamentarium for treatment of infrainguinal bypass graft stenoses., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The burden of metabolic syndrome (MetS) is increasing in the United States and is pervasive among patients with peripheral arterial disease. Whereas MetS has been implicated in the development of all types of cardiovascular disease and adverse outcomes after vascular interventions, little is known about how MetS influences perioperative outcomes of lower extremity bypass surgery and whether any negative effects can be modified by use of cardiovascular risk-modifying medications., Methods: We used the National Surgical Quality Improvement Program vascular procedure-targeted database to capture patients undergoing infrainguinal bypass surgery between 2011 and 2015. We defined MetS using the modified MetS criteria: concomitant diabetes, hypertension, and body mass index >30 kg/m 2 . We used multivariable logistic regression analyses to examine the association between MetS and 30-day postoperative morbidity and mortality. We also examined whether preoperative aspirin, statin, and beta blockade modify the effects of MetS on 30-day postoperative outcomes., Results: Of 10,053 patients who underwent infrainguinal bypass, 16% (1693) met criteria for MetS. After adjusting for covariates, MetS was significantly (P ≤ .05) associated with higher odds of postoperative myocardial infarction (odds ratio [OR], 1.66), infection (OR, 1.76), renal dysfunction (OR, 2.42), and length of stay (0.34 days). Within the MetS subgroup, there were no significant associations between use of preoperative cardiovascular risk-modifying agents and postoperative outcomes, with the exception of beta blockade and an increase in length of stay (0.33 days)., Conclusions: Patients with MetS undergoing infrainguinal bypass surgery are at an increased risk of postoperative complications, including myocardial infarction. This elevated risk persists despite medical therapy with preoperative aspirin, statin, and beta blockade., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Margin negative resection offers the best chance of long-term survival in retroperitoneal sarcoma (RPS). En-bloc resection of adjacent structures, including the inferior vena cava (IVC), is often required to achieve negative margins. We review our 20-year experience of en-bloc IVC and RPS resection., Methods: Retrospective review of patients with RPS resection involving the IVC were matched 1:3 by age and histology to RPS without IVC resection. Prognostic factors for overall survival (OS) and disease free survival (DFS) were assessed., Results: Thirty-two patients underwent RPS resection en-bloc with IVC. They were matched with 96 cases of RPS without IVC resection. Median OS of 59 months and DFS 18 months in IVC resection group was comparable to RPS resection without vascular involvement: median OS 65 months, DFS 18 months (P = 0.519, P = 0.604). On multivariate analyses, R2 margin (OS: HR = 6.52 [95%CI: 1.18-36.09], P = 0.032) was associated with inferior OS. R2 margin and increased number of organs resected (DFS: HR = 5.07, [1.15-22.27], P = 0.031, HR = 1.28 [1.01-1.62], P = 0.014) were associated with inferior DFS. Reconstructions included graft (n = 19, 59%), patch (n = 4, 13%), primary repair (n = 6, 19%), and ligation (n = 4, 13%)., Conclusions: RPS resection en-bloc with IVC can achieve equivalent rates of DFS and OS to patients without vascular involvement., (© 2018 Wiley Periodicals, Inc.)

Rationale: Thoracic outlet syndrome (TOS) is a rare cause of upper extremity deep vein thrombosis (UEDVT). The treatment usually involves catheter directed thrombolysis followed by systemic anticoagulation. Surgical decompression is frequently recommended after anticoagulation for definitive therapy., Patient Concerns: We report two cases of UEDVT secondary to venous TOS with important clinical presentations., Diagnoses: Venous TOS., Interventions: One patient was initially treated conservatively but had a recurrent UEDVT. The second patient had a residual stump from a prior rib resection that was causing compression on the subclavian vein, resulting in recurrent venous symptoms., Outcomes: Both patients achieved significant improvement in their symptoms at 1 year follow-up., Lessons: UEDVTs can be debilitating, and may limit activities of daily living. Surgical decompression may offer significant improvement in quality of life and symptom relief in such patients.

Purpose of Review: This review provides an overview of the current literature surrounding the medical and surgical treatment of aortic graft infection with particular focus on the role of endovascular aortic grafts in the changing demographics and management of these infections., Recent Findings: Definitive therapy for aortic graft infection continues to include parenteral antibiotics and surgical explantation and revascularization procedures, which are historically vast operations and sources of significant operative stress. Surgical management has evolved to include more options for infection resistant in situ conduits, attempts at partial explantations, and use of endovascular therapy to temporize the urgent sequelae of these infections, such as aortoenteric fistula. Aortic graft infection continues to be a significant and morbid complication of graft placement even with the advent of endovascular therapy, and its treatment will only increase in difficulty as a more frail population has gained access to complex aortic repair. In the future, more flexible revascularization and partial explantation options are keys, along with long-term suppressive antibiotics where appropriate.

We evaluated the occurrence of thoracic outlet syndrome (TOS) and 30-day postoperative outcomes. Patients undergoing cervical/first rib resection surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Thoracic outlet syndrome types were then examined. Propensity score matching was performed to account for potential confounders; 1180 patients were explored during the study period, 1007 (85.3%) were of the neurogenic TOS (NTOS), 32 (2.7%) patients had arterial TOS (ATOS), and 141 (12.0%) patients had venous TOS (VTOS). Patients with ATOS were significantly older (median age [interquartile range, IQR]-NTOS: 34 [25-44], ATOS: 49.5 [42.5-57], VTOS: 34 [23-43]; P < .001). Median operating time was significantly longer for patients with ATOS. Median in-hospital stay was also longer for patients with ATOS (median length of in-hospital stay [LOS; IQR]-NTOS: 2 [1-4]; ATOS: 6 [3-7]; and VTOS: 5 [2-7] days; P < .001). Patients with VTOS showed twice longer LOS when compared to NTOS after matching. Presentation and treatment of TOS have been studied extensively at highly experienced centers.

Objective: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification has been shown to correlate well with risk of major amputation and time to wound healing in heterogeneous diabetic and nondiabetic populations. Major amputation continues to plague the most severe stage 4 WIfI patients, with 1-year amputation rates of 20% to 64%. Our aim was to determine the association between WIfI stage and wound healing and major amputation among patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting., Methods: All patients presenting to our multidisciplinary DFU clinic from July 2012 to December 2015 were enrolled in a prospective database. Wound healing and major amputation were compared for patients stratified by WIfI classification., Results: There were 217 DFU patients with 439 wounds (mean age, 58.3 ± 0.8 years; 58% male, 63% black) enrolled, including 28% WIfI stage 1, 11% stage 2, 33% stage 3, and 28% stage 4. Peripheral arterial disease and dialysis were more common in patients with advanced (stage 3 or 4) wounds (P ≤ .05). Demographics of the patients, socioeconomic status, and comorbidities were otherwise similar between groups. There was a significant increase in the number of active wounds per limb at presentation with increasing WIfI stage (stage 1, 1.1 ± 0.1; stage 4, 1.4 ± 0.1; P = .03). Mean wound area (stage 1, 2.6 ± 0.6 cm 2 ; stage 4, 15.3 ± 2.8 cm 2 ) and depth (stage 1, 0.2 ± 0.0 cm; stage 4, 0.8 ± 0.1 cm) also increased progressively with increasing wound stage (P < .001). Minor amputations (stage 1, 18%; stage 4, 56%) and revascularizations (stage 1, 6%; stage 4, 55%) were more common with increasing WIfI stage (P < .001). On Kaplan-Meier analysis, WIfI classification was predictive of wound healing (P < .001) but not of major amputation (P = .99). For stage 4 wounds, the mean wound healing time was 190 ± 17 days, and risk of major amputation at 1 year was 5.7% ± 3.2%., Conclusions: Among patients with DFU, the WIfI classification system correlated well with wound healing but was not associated with risk of major amputation at 1 year. Although further prospective research is warranted, our results suggest that use of a multidisciplinary approach for DFUs may augment healing time and reduce amputation risk compared with previously published historical controls of standard wound care among patients with advanced stage 4 disease., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Neurogenic thoracic outlet syndrome is a widely recognized, yet controversial, syndrome. The lack of specific objective diagnostic modalities makes diagnosis difficult. This is compounded by a lack of agreed upon definitive criteria to confirm diagnosis. Recent efforts have been made to more clearly define a set of diagnostic criteria that will bring consistency to the diagnosis of neurogenic thoracic syndrome. Additionally, advancements have been made in the quality and techniques of various imaging modalities that may aid in providing more accurate diagnoses. Surgical decompression remains the mainstay of operative treatment; and minimally invasive techniques are currently in development to further minimize the risks of this procedure. Medical management continues to be refined to provide non-operative treatment modalities for certain patients, as well. The aim of the present work is to review these updates in the diagnosis and treatment of neurogenic thoracic outlet syndrome., Competing Interests: The authors declare no conflict of interest.

Problem: Because reported use of simulation in preclinical basic science courses is limited, the authors describe the design, implementation, and preliminary evaluation of a simulation-based clinical correlation curriculum in an anatomy course for first-year medical students at Perdana University Graduate School of Medicine (in collaboration with Johns Hopkins University School of Medicine)., Approach: The simulation curriculum, with five weekly modules, was a component of a noncadaveric human anatomy course for three classes (n = 81 students) from September 2011 to November 2013. The modules were designed around major anatomical regions (thorax; abdomen and pelvis; lower extremities and back; upper extremities; and head and neck) and used various types of simulation (standardized patients, high-fidelity simulators, and task trainers). Several methods were used to evaluate the curriculum's efficacy, including comparing pre- versus posttest scores and comparing posttest scores against the score on 15 clinical correlation final exam questions., Outcomes: A total of 81 students (response rate: 100%) completed all pre- and posttests and consented to participate. Posttest scores suggest significant knowledge acquisition and better consistency of performance after participation in the curriculum. The comparison of performance on the posttests and final exam suggests that using simulation as an adjunctive pedagogy can lead to excellent short-term knowledge retention., Next Steps: Simulation-based medical education may prove useful in preclinical basic science curricula. Next steps should be to validate the use of this approach, demonstrate cost-efficacy or the "return on investment" for educational and institutional leadership, and examine longer-term knowledge retention.

Herpes simplex virus infection following surgery is an unusual postoperative phenomenon. Many mechanisms have been suggested, with the most likely explanation related to latent virus reactivation due to a proinflammatory response in the setting of local trauma. Here, we present a case of herpes simplex virus reactivation in an immunocompetent female following a conventional right lower extremity stab phlebectomy. Salient clinical and physical examination findings are described, and management strategies for herpes simplex virus reactivation are outlined. This is the first known case report of herpes simplex virus reactivation following lower extremity phlebectomy.

Objective: The perioperative risk of an acute venous thromboembolism (VTE) event after inferior vena cava (IVC) reconstruction is unknown. We sought to describe VTE outcomes of our 15-year IVC reconstruction experience., Methods: We performed a retrospective institutional review of all patients who underwent IVC reconstruction (September 1999-October 2014) and describe perioperative VTE outcomes., Results: Sixty-five patients (mean age 58 ± 2 years) underwent IVC reconstruction (primary repair, 25%; patch, 43%; graft, 32%), most commonly for renal cell carcinoma (51%) and retroperitoneal sarcoma (22%). The overall incidence of perioperative VTE was 22% (n = 14), including isolated deep vein thrombosis (DVT) in 9% (n = 6) and pulmonary embolism in 12% (n = 8; 4 with concomitant DVT). Median time to diagnosis was 6 days (range, 1-37 days). Most VTE patients were symptomatic (57%; 8 of 14), including lower extremity edema in 50%, acute desaturation in 43%, and hemodynamic compromise in 36%. No patient died as a result of his or her VTE. There was a trend for more overall VTE events in patients who underwent graft reconstruction (primary, 13%; patch, 18%; graft, 33%; P = .06). VTE was also significantly associated with larger tumor size, renal vein reimplantation, and blood transfusions (P ≤ .05). Late complications of VTE included lower extremity edema in two patients and graft thrombosis in one patient., Conclusions: IVC reconstruction can be performed safely with low VTE-associated morbidity. Routine anticoagulation might not be warranted in these patients, but early postoperative screening for DVT should be considered, especially in cases with large tumor burden or when graft reconstruction is performed., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Infections of vascular grafts are associated with significant mortality and morbidity risk and cost an estimated $640 million annually in the United States. Clinical presentation varies by time elapsed from implantation and by surgical site. A thorough history and physical examination in conjunction with a variety of imaging modalities is often essential to diagnosis. For infected aortic grafts, there are several options for treatment, including graft excision with extra-anatomic bypass, in situ reconstruction, or reconstruction with the neo-aortoiliac system. The management of infected endovascular aortic grafts is similar. For infected peripheral bypasses, graft preservation techniques can be utilized, but in cases where it is not possible, graft removal and revascularization through uninfected tissue planes is necessary. Infected dialysis access can be surgically treated by complete or subtotal graft excision. Diagnosis, general management, and surgical approaches to infected vascular grafts are discussed in this review., (© The Author(s) 2015.)

Background: The safety and effectiveness of using venovenous and cardiopulmonary bypass for resection of the inferior vena cava (IVC) is not well studied. The goal of this study was to compare outcomes following IVC resection with and without bypass support., Methods: We analyzed all patients undergoing IVC resection at our institution (September 1999 to June 2014) and compared the use of bypass support with cross-clamp alone using univariable and Kaplan-Meier analyses. The outcomes included perioperative complications and survival., Results: Sixty-three patients underwent IVC resection (mean age 58 ± 2 years, mean follow-up 21 ± 3 months). Bypass patients (32%) were similar to non-bypass patients (68%) in age, gender, tumor size, type, and grade (P = nonsignificant [NS]). Bypass patients were more likely to undergo complete IVC reconstruction (55% vs. 24%, P = 0.01) at the suprarenal level (62% vs. 35%, P = 0.05), and had higher intraoperative blood loss (9.6 ± 2.1 vs. 3.2 ± 1.4 L, P = 0.01). Complete R0 resection was similar between groups (50% vs. 52%, P = NS). There were more overall perioperative complications in bypass patients (P = 0.0005), with a trend toward more frequent venous thromboembolic events (40% vs. 21%, P = 0.13). The incidence of acute kidney injury (10% vs. 9%) and renal failure requiring dialysis (10% vs. 2%) was similar (P = NS). Length of stay was longer following bypass (12.2 ± 1.2 vs. 8.0 ± 0.1 days, P = 0.004). There were no differences in overall mortality (15% vs. 14%, P = NS) or tumor recurrence (50% vs. 47%, P = NS). Bypass patients had a nonsignificant trend toward longer disease-free survival (20.7 ± 5.2 vs. 10.4 ± 3.8 months, P = 0.12)., Conclusions: The use of bypass support for IVC resection is associated with more complex operations and higher rates of perioperative complications. However, the overall mortality and morbidity of bypass, including renal complications, is similar to cross-clamping alone. Thus, the need for bypass should not preclude attempts at complete tumor resection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To evaluate the diagnostic role of venous and arterial duplex scanning in neurogenic thoracic outlet syndrome (NTOS)., Methods: Retrospective review of patients who underwent duplex ultrasonography prior to first rib resection and scalenectomy (FRRS) for NTOS from 2005 to 2013. Abnormal scans included ipsilateral compression (IC) with abduction of the symptomatic extremity (>50% change in subclavian vessel flow), contralateral (asymptomatic side) compression (CC) or bilateral compression (BC)., Results: A total of 143 patients (76% female, average age 34, range 13-59) underwent bilateral preoperative duplex scanning. Ipsilateral compression was seen in 44 (31%), CC in 12 (8%), and BC in 14 (10%). Seventy-three (51%) patients demonstrated no compression. Patients with IC more often experienced intraoperative pneumothoraces (49% vs. 25%, P < .05) and had positive Adson tests (86% vs. 61%, P < .02)., Conclusion: Compression of the subclavian vein or artery on duplex ultrasonography can assist in NTOS diagnosis. Ipsilateral compression on abduction often correlates with Adson testing., (© The Author(s) 2016.)