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Extraanatomic vascular bypasses are useful in treating renal and visceral occlusive disease. The splenic artery can be a good conduit in such cases and splenorenal bypass is a well-appreciated technique for treating renovascular obstructions. If there is severe ostial celiac stenosis or occlusion, then this particular anastomosis (splenic to renal) actually revascularizes the foregut via retrograde flow in the splenic artery. Although this method of celiac axis reperfusion has not been previously described, it was successfully employed recently in a situation where severe hepatic ischemia persisted following superior mesenteric artery embolectomy The reasons for residual ischemia following visceral embolectomy are discussed as well as the alternative methods for extraanatomic intraabdominal vascular reconstruction. [ABSTRACT FROM AUTHOR]

Concentrations of uric acid in carotid endarterectomy specimens in men and women were measured using high-performance liquid chromatography in comparison wo nonatherosclerotic control specimens. [ABSTRACT FROM AUTHOR]

Objective: Lower extremity amputation continues to be necessary in a significant number of patients with peripheral vascular disease. The 5-year survival following lower limb loss is markedly reduced. Many of these patients are never fitted with a prosthesis, and there is a dearth of knowledge regarding the barriers to prosthetic attainment. The goal of this study was to identify the risk factors for not receiving a prosthesis and the effect of mobility level on survival following major amputation., Methods: This was a retrospective analysis of all patients that underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to December 31, 2019. Abstracted data included: age, sex, race, body mass index, comorbidities, American Society of Anesthesiologists score, statin use, level of amputation, stump revision, fitting for prosthesis, type of prosthesis, and the United States' Medicare Functional Classification Level, also called K level. Survival was determined using a combination of sources, including the Social Security Death Master File, searches of multiple genealogic registries, and general internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis attainment. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality., Results: A total of 464 patients were included in this study. The mean age was 65 years, and mean body mass index was 27 kg/m 2 . The majority of patients were male (68%), White (56%), diabetic (62%), and hypertensive (76%), and underwent below-the-knee amputation (69%). Prosthetic attainment occurred in 185 (40%). On multivariable analysis, age >81 years and current tobacco use were associated with no prosthetic fitting. Overall 5-year survival was 41.9% (95% confidence interval [CI], 37.6%-46.6%) (below-the-knee amputation, 47.7% [95% CI, 42.5%-53.5%]; above-the-knee amputation, 28.7% [95% CI, 22.1%-37.2%]). On multivariable analysis, age >60 years, congestive heart failure, above-the-knee amputation, and no prosthetic attainment were associated with decreased survival. Increasing K level was incrementally associated with improved survival., Conclusions: This study has identified several patient factors associated with prosthetic attainment, as well as multiple factors predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. The Medicare Functional Classification Level K level predicts survival. More research is needed to determine the barriers to prosthetic attainment and if improving a patients K level will improve survival., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic endovascular aortic repair (TEVAR) involving landing zone 2 can require extra-anatomic debranching (SR-TEVAR) to ensure left subclavian artery perfusion, resulting in increased costs. A single-branch device (Thoracic Branch Endoprosthesis [TBE], WL Gore, Flagstaff, AZ) provides a total endovascular solution. Comparative cost analysis of patients undergoing zone 2 TEVAR requiring left subclavian artery preservation with TBE versus SR-TEVAR is presented., Methods: A single-center retrospective cost analysis was performed for aortic diseases requiring a zone 2 landing zone (TBE vs. SR-TEVAR) from 2014 to 2019. Facility charges were collected from the universal billing form UB-04 (form CMS 1450)., Results: Twenty-four patients were included in each arm. There were no significant differences in the overall mean procedural charges between the two groups: TBE, $209,736 ($57,761) vs. SR-TEVAR $209,025 ($93,943), P  = 0.94. TBE resulted in reduced operating room charges ($36,849 [$8750] vs. $48,073 [$10,825], P  = 0.02) and reduced intensive care unit and telemetry room charges, which did not reach statistical significance ( P  = 0.23 and 0.12, respectively). Device/implant charges were the primary cost driver in both groups. Charges associated with TBE were significantly higher: $105,525 ($36,137) vs. $51,605 ($31,326), P  > 0.01., Conclusions: TBE had similar overall procedural charges despite higher device/implant-related expenses and reduced facility resource utilization (lower operating room, intensive care unit, telemetry, and pharmacy charges)., Competing Interests: Dr. Gable is a consultant, on the speakers bureau, and receives research support from WL Gore; is a consultant and on the speakers bureau of Silk Road; and is a consultant, on the speakers bureau, and receives research support from Medtronic. Dr. Shutze is on the speakers bureau and receives research support from both Medtronic and Terumo. Dr. Brinkman is a consultant, on the speakers bureau, and receives research support from Medtronic; and on the speakers bureau and receives research support from Terumo and WL Gore. The other authors have no potential conflicts to disclose., (Copyright © 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Objective: Hemodialysis accesses suffer from limited primary patency requiring frequent interventions, revisions, or even abandonment. Prolongation of access life and usability with minimization of these adverse events is paramount. Endovascular methods are established first-line interventions for failing arteriovenous access and treatment of venous outflow stenoses. The Primary goal of this feasibility study was to evaluate intravascular ultrasound (IVUS) during interventional treatments on outcomes in those undergoing angiography for failing hemodialysis access. Secondary goals were to determine differences between IVUS and angiography on vessel and lesion characteristics and impact on treatment., Methods: In this prospective, randomized controlled trial, patients scheduled for angiography to evaluate and treat a failing hemodialysis access were randomized to use of angiography (DSA) alone or angiography plus IVUS (DSA + IVUS). Patients were treated by a standardized protocol and seen in follow-up at 2 weeks, and every 3 months for 2 years or until a study endpoint was reached. Measurement of vessel diameters, % stenosis, lesion length, and study endpoints (AV access thrombosis, re-intervention, or surgical revision) were recorded., Results: A total of 55 subjects were enrolled, 27 in the DSA cohort and 28 in the DSA + IVUS cohort. There were 41 treated lesions in each group. Freedom from the composite endpoint of AV access thrombosis or re-intervention was 46.3% in the DSA cohort and 61.0% in the DSA + IVUS cohort ( p = 0.27). Diameter measurements matched between the two imaging modalities only 9 times out of 41 total comparison measures. In pre-treatment lesions with >80% stenosis, IVUS had a greater tendency than DSA to underestimate the severity of stenosis, whereas in pre-treatment lesions with 50-80% stenosis, DSA was more likely than IVUS to underestimate the severity of stenosis. Post-treatment % stenosis had mean difference of -7.5% between DSA versus DSA + IVUS cohorts. In five lesions with <30% stenosis measured by angiogram, IVUS led to treatment escalation., Conclusion: In the interventional treatment of failing angioaccess, IVUS and angiography differ in the vast majority of cases in measurement of vessel diameter. A significant number of patients were found to have suboptimal therapeutic response by IVUS only, which led to an escalation in treatment, and in over one-third of cases, the IVUS results led to a change in treatment plan. The improved patency rates in the IVUS group was not statistically significant in this small population but should be further investigated in a larger trial.

Objective: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI., Methods: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed., Results: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02)., Conclusions: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Transcarotid artery revascularization (TCAR) is a new hybrid approach to carotid artery revascularization. Proctored training on live cases is an effort-, time-, and resource-intensive approach to learning new procedures. We analyzed the worldwide experience with TCAR to develop objective performance metrics for the procedure and compared the effectiveness of training physicians using cadavers or synthetic models to that of traditional in-person training on live cases., Methods: Physicians underwent one of three mandatory training programs: (1) in-person proctoring on live TCAR procedures, (2) supervised training on human cadavers, and (3) supervised training on synthetic models. The training details and information from all subsequent independently performed TCAR procedures were recorded. The composite clinical adverse events (ie, transient ischemic attack, stroke, myocardial infarction, death) and composite technical adverse events (ie, aborted procedure, conversion to surgery, bleeding, dissection, cranial nerve injury, or device failure, occurring within 24 hours were recorded). Four procedural proficiency measures were recorded: procedure time, flow-reversal time, fluoroscopy time, and contrast volume. We compared the adverse event rates between the procedures performed by physicians after undergoing the three training modes and tested whether the proficiency measures achieved during TCAR after training on cadavers and synthetic models were noninferior to proctored training., Results: From March 3, 2009 to May 7, 2020, 1160 physicians had undergone proctored (19.1%), cadaver-based (27.4%), and synthetic model-based (53.5%) TCAR training and had subsequently performed 17,283 TCAR procedures. The proctored physicians had treated younger patients and more patients with asymptomatic carotid stenosis and had had more prior experience with transfemoral carotid stenting. The overall 24-hour composite clinical and technical adverse event rates, adjusted for age, sex, and symptomatic status, were 1.0% (95% confidence interval, 0.8%-1.3%) and 6.0% (95% confidence interval, 5.4%-6.6%), respectively, and did not differ significantly by training mode. The proficiency measures of cadaver-trained and synthetic model-trained physicians were not inferior to those for the proctored physicians., Conclusions: We have presented key objective proficiency metrics for performing TCAR and an analytic framework to assess adequate training for the procedure. Training on cadavers or synthetic models achieved clinical outcomes, technical outcomes, and proficiency measures for subsequently performed TCAR procedures similar to those achieved with training using traditional proctoring on live cases., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Despite advances in peripheral vascular disease treatment, lower extremity amputation continues to be necessary in a significant number of patients. Up to 80% of amputees are not referred for prosthetic fitting. The factors contributing to referral decisions have not been adequately investigated, nor has the impact of prosthetic referral on survival. We characterized differences between patients who were successfully referred to our in-house prosthetists and those who were not, and identified factors associated with prosthetic referral and predictive of survival., Methods: This was a retrospective analysis of all patients who underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to June 30, 2017. Data regarding age, sex, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, end-stage renal disease, prior coronary artery bypass graft surgery, congestive heart failure, tobacco use, American Society of Anesthesiologists (ASA) score, previous arterial procedure, chronic obstructive pulmonary disease, statin use, postoperative ambulatory status, level of amputation, stump revision, and referral for prosthesis were collected. Survival was determined from a combination of sources, including the Social Security Death Master Index, multiple genealogic registries, and internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis referral. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality., Results: There were 293 patients included in this study. Mean age was 66 years, and mean BMI 27 kg/m 2 . The majority of patients were male (69%), white (53%), with diabetes (65.4%) and hypertension (77.5%), and underwent below-the-knee amputation (BKA) (73%). Prosthetic referral occurred in 123 (42.0%). Overall 5-year survival was 61.7% (95% confidence interval [CI], 55.9%-68.1%) (BKA 64.7% [95% CI, 57.9%-72.3%]; above-the-knee amputation 53.8% [95% CI, 43.4%-66.6%]). On multivariate analysis, age >70 years, female sex, diabetes, ASA score 4 or 5, and current tobacco use were associated with no referral for prosthetic fitting. Patients with BMI 25 to 30, a previous arterial procedure, BKA, and history of stump revision were more likely to be referred. Factors associated with decreased survival were increasing age, higher ASA class, black race, and BMI; prosthetic referral was seen to be protective., Conclusions: We identified multiple patient factors associated with prosthetic referral, as well as several characteristics predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. Further research is needed to determine whether the factors identified as associated with nonreferral are markers for patient characteristics that make them clinically unsuitable for prosthetic fitting or if they are symptoms of unconscious bias or of the patient's access to care., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection., Methods: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed., Results: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material., (Copyright © 2021. Published by Elsevier Inc.)

Vascular surgeons provide an important service to the health care system. They are capable of treating a wide range of disease processes that affect both the venous and arterial systems. Their presence broadens the complexity and diversity of services that a health care system can offer both in the outpatient setting and in the inpatient setting. Because of their ability to control hemorrhage, they are critical to a safe operating room environment. The vascular surgery service line has a positive impact on hospital margin through both the direct vascular profit and loss and the indirect result of assisting other surgical and medical services in providing care. The financial benefits of a vascular service line will hold true for a wide range of alternative payment models, such as bundled payments or capitation. To fully leverage a modern vascular surgeon's skill set, significant investment is required from the health care system that is, however, associated with substantial return on the investment., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF., Methods: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed., Results: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality., Conclusions: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome (TOS) and may occur from injury, occupational stress, or athletic endeavors. Although most patients with NTOS will improve after first-rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than nonathletes. We hypothesized that athletes would do better after FRRS than nonathletes despite the added physical stress that sporting activity imposes., Methods: We reviewed our office records for all patients treated for TOS from July 2009 to May 2014 and extracted demographic, historical, procedural, and follow-up data. We contacted these patients to complete a survey to assess patient-centered outcomes of FRRS and compared athlete versus nonathlete survey responses., Results: Five hundred sixty-four patients had FRRS for NTOS, and 184 (33%) responded to the survey. Of the 184 who responded, 97 were athletes (53%) and 87 were nonathletes (47%). Survey results suggested that 87% were improved in pain medication use (athletes 93% vs. nonathletes 80%, P = 0.013), 77% would undergo FRRS on the contralateral side if needed (athletes 75% vs. nonathletes 79%, P = 0.49), 73% had resolution of TOS symptoms (athletes 80% vs. nonathletes 65%, P = 0.02), and 86% could perform activities of daily living without limitation (athletes 95% vs. nonathletes 77%, P = 0.0004). Although 24% of respondents required another non-TOS procedure (athletes 27% vs. nonathletes 22%, P = 0.6), 89% felt that they had made the right decision (athletes 93% vs. nonathletes 80%, P = 0.09). Multivariable analysis of age, race, gender, previous surgery, preoperative physical therapy, preoperative narcotic use, and athletic status confirmed that athletic status was a significant predictor for improvement in pain medication use, complete TOS resolution, and the ability to perform activities of daily living., Conclusions: Most patients undergoing FRRS for NTOS are improved and satisfied with the result and indicate they made the correct choice to have FRRS. Although being an athlete was an independent variable for better outcomes in activity and pain medication use, their satisfaction after FRRS was similar to that in nonathletes. Further investigation is needed to determine if these findings are due to physical and/or psychosocial factors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The Gore Global Registry for Endovascular Aortic Treatment (GREAT) was designed to evaluate real-world outcomes after treatment with Gore aortic endografts used in a real-world, global setting. We retrospectively analyzed the GREAT data to evaluate the incidence and effects of noncylindrical neck anatomy in patients undergoing endovascular aortic aneurysm repair., Methods: The present analysis included patients with data in the GREAT who had been treated with the EXCLUDER endograft from August 2010 to October 2016. A noncylindrical neck was defined when the proximal aortic landing zone diameter had changed ≥2 mm over the first 15 mm of the proximal landing zone, indicating a tapered, conical, or hourglass morphology. Cox multivariate regression analyses were performed for any reintervention (including reinterventions on aortic branch vessels), device-related reinterventions, and reintervention specifically for endoleak. Independent binary (cylindrical vs noncylindrical necks) and continuous (percentage of neck diameter change) variables were assessed. The abdominal aortic aneurysm (AAA) diameter, proximal neck length, maximal infrarenal neck angle, gender, and use of aortic extender cuffs were also assessed., Results: Of 3077 GREAT patients with available proximal aortic landing zone diameter measurements available, 1765 were found to have cylindrical necks and 1312 had noncylindrical necks. The noncylindrical neck cohort had a significantly greater proportion of women (17.4% vs 12.6%; P < .001) and more severe infrarenal angulation (33.8° vs 28.4°; P < .001). A total 14.7% of noncylindrical neck patients and 11.2% cylindrical neck patients underwent implantation outside of the EXCLUDER instructions for use regarding the anatomic inclusion criteria (P = .004). The procedural characteristics were similar between the two cohorts; however, noncylindrical neck patients required significantly more aortic extender cuffs (P = .004). The average follow-up was 21.2 ± 17.5 months and 17.8 ± 15.8 months for the cylindrical and noncylindrical cohorts, respectively (P < .001). The Cox multivariate regression models demonstrated female gender and maximum AAA diameter were significant risk factors for subsequent reintervention (overall, device-related, and endoleak-specific). Women were 2.2 times as likely to require device-related intervention during the follow-up period compared with men (P < .001). Neck shape morphology was not a significant predictor, except for device-related intervention, for which cylindrical necks (binary definition) resulted in a slightly elevated risk (1.5 times; P = .03)., Conclusions: Noncylindrical neck morphology was more common in women and was associated with an increased use of aortic extender cuffs but did not increase the risk of intervention. Female gender and AAA diameter were associated with an increased need for reintervention., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective Postoperative pain following lower extremity revascularization procedures is traditionally controlled with narcotic administration. However, this may not adequately control the pain and puts the patient at risk for complications from opiate use. Here we report an alternative strategy for pain management using a continuous catheter-infused local anesthetic into the operative limb. Design Retrospective case-control study. Methods Patients undergoing lower extremity revascularization procedures using continuous catheter-infused local anesthetic were compared to similar patients undergoing similar procedures during the same time period who did not receive continuous catheter-infused local anesthetic. Records were reviewed for pain scores, narcotics consumption, length of stay, need for postoperative chest X-ray, supplemental oxygen use, wound complications, and 30-day readmission. Results There were 153 patients (mean age 69.5 years) from September 2011 to December 2014 who underwent common femoral artery procedures, femoral-popliteal bypass, femoral-tibial bypass, popliteal aneurysm repair, popliteal to pedal bypass, popliteal artery thrombo-embolectomy, sapheno-popliteal venous bypass, or ilio-femoral bypass. There were no significant differences between the continuous catheter-infused local anesthetic ( n=57) and control ( n=96) groups regarding age, body mass index, cardiac history, diabetes, hypertension, and procedures performed. The continuous catheter-infused local anesthetic group showed better cumulative average pain scores, better high pain scores on postoperative days 1-3, and better average pain scores on postoperative days 2-3 ( P<0.03). The continuous catheter-infused local anesthetic group had lower median narcotics consumption on postoperative days 1-2 ( P=0.02). No differences were found in postoperative length of stay, urinary catheter use, number of postoperative chest X-rays, oxygen use, mobilization, or fever. Wound complications occurred in 8.8% of the continuous catheter-infused local anesthetic group and in 11.5% of controls (P=0.79). Readmission rates were 23% (continuous catheter-infused local anesthetic) and 21% (controls; P=0.84). Conclusion Postoperative continuous catheter-infused local anesthetic reduces pain scores and pain medication use compared to standard opiate therapy in these patients, without increasing wound complication or readmission rates. Continuous catheter-infused local anesthetic appeared to have no effect on the incidence of pulmonary complications, mobilization, or fever.

Background: Neurogenic thoracic outlet syndrome (NTOS) results from compression of the brachial plexus by the clavicle, first rib, and scalene muscles and may develop secondary to repetitive motion of the upper extremity. Athletes routinely perform repetitive motions, and sports requiring significant arm and shoulder use may put the participant at increased risk for NTOS. Competitive athletes who develop NTOS may require first rib resection and scalenectomy (FRRS) for symptomatic relief. However, the effectiveness of FRRS has not previously been studied in this vulnerable population., Methods: This is a cross-sectional study of competitive athletes with NTOS who received FRRS by the senior author between 2009 and 2014. Eligible patients were contacted by phone and invited to complete a nine-item survey assessing the long-term effects of FRRS on pain medication use, postoperative physical therapy duration, patient satisfaction, symptom relief, activities of daily living, athletic performance, time to return of athletic performance, and need for other operations. Multivariate analyses of the following risk factors were performed: age, pectoralis minor release, preoperative narcotic use, athletic shutdown, and involvement in a throwing sport., Results: There were 232 competitive athletes who met the inclusion criteria, and 67 of these (age, 14-48 years; 35 male; 99% white) responded to the survey. The average time between surgery and survey completion was 3.9 years (range, 2.2-7.0 years). The most frequent sports conducted by this group were baseball and softball (n = 44 [66%]), volleyball (n = 7 [10%]), and cheerleading and gymnastics (n = 5 [7%]), ranging from high-school to professional levels. The survey results revealed that 96% were improved in pain medication use, 75% would undergo FRRS on the contralateral side if needed, 82% had resolution of symptoms, and 94% were able to perform activities of daily living without limitation; 70% returned to the same or better level of athletic activity after FRRS, and this occurred within 1 year in 50%. Multivariate regression analysis identified younger age as a predictor of the length of physical therapy and preoperative narcotics use as a predictor of symptom resolution., Conclusions: At our center, >40% of patients requiring FRRS for NTOS are competitive athletes. The results of this study show that the majority of them are able to return to their precompetitive state after FRRS, and few experience limitations in their daily living activities. Half can return to competition at or exceeding their premorbid ability level within 6 months of surgery. The majority are pleased with their decision to undergo FRRS. Further investigation is needed to identify predictive factors for successful return to competitive athletics., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Patients undergoing endovascular repair (EVAR) of aortoiliac or iliac artery aneurysm may require sacrifice of one or both internal iliac arteries (IIAs). Until Food and Drug Administration-approved commercial grafts became available, endovascular IIA preservation was accomplished using the "sandwich" technique, but limited information is available regarding the results of this method. After obtaining institutional review board approval, we identified patients undergoing IIA preservation with the sandwich technique during EVAR at our institution. The patients have been followed prospectively since being identified to record patency rates and vascular symptoms or events. Twenty-four procedures were performed from 2011 through 2015 to treat iliac artery aneurysms. Fourteen of these procedures were done with concomitant EVAR using different endografts (Gore Excluder 11, Endologix AFX 2, Cook Zenith 1). Five were done to extend a previous EVAR that had developed a type Ib endoleak, 2 for an isolated external iliac artery aneurysm, 3 for an anastomotic aneurysm from a previous aortobiiliac graft, and 2 for isolated iliac aneurysm repair. There were 25 sandwich grafts (unilateral in 19, bilateral in 6). Contralateral embolization was performed in 5 cases. Immediate success rates were high, and patency rates were excellent at intermediate follow-up. Intraoperative type 3 endoleaks were not uncommon but usually resolved postoperatively. Endovascular IIA preservation is feasible with currently available devices using this technique. This procedure is recommended for preservation of the IIA during endovascular treatment of aortoiliac and iliac artery aneurysms when anatomy requires IIA preservation.

Background: Hostile anatomic characteristics in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) and the placement of endografts not in concordance with the specific device anatomic guidelines (or instructions for use [IFU]) have shown decreased technical success of the procedure. But these factors have never been evaluated in regard to patient postoperative survival. We sought to assess the association between survival and (1) aneurysm anatomy and characteristics and (2) implantation in compliance with manufacturer's anatomic IFU guidelines in patients undergoing endovascular aortic aneurysm repair., Methods: The cohort included 273 consecutive patients who underwent EVAR at Baylor Heart and Vascular Hospital between January 1, 2002 and December 31, 2009 and had their preoperative computed tomography (CT) scan digitally retrievable. The CT scans and operative notes were then reviewed, and the anatomic severity grading (ASG) score, maximum aneurysm diameter, thrombus width, patency of aortic side branch vessels, and implantation in compliance with IFU guidelines were assessed. The unadjusted association between survival (assessed until November 1, 2011) and these variables was assessed with the Kaplan-Meier method. Moreover, propensity-adjusted (for a comprehensive array of clinical and nonclinical risk factors) proportional hazard models were developed to assess the adjusted associations., Results: Seven (2.56%) patients died within 30 days from EVAR, and 88 (30.04%) patients died during the study follow-up. Patient mean survival was 6.3 years. The unadjusted analysis showed a statistically significant association between survival and thrombus width (P = 0.007), ASG score (P = 0.004), and implantation in compliance with IFU guidelines (P = 0.007). However, the adjusted analysis revealed that none of the anatomic and compliance factors were significantly associated with long-term survival (ASG, P = 0.149; diameter, P = 0.836; thrombus, P = 0.639; patency, P = 0.219; and implantation compliance, P = 0.219)., Conclusions: Unfavorable aneurysm morphologic characteristics and endograft implantation not in compliance with IFU guidelines did not adversely affect patient survival after EVAR in this group of patients. This implies that unfavorable anatomy, even that which would necessitate implantation of the EVAR device outside of the IFU guidelines, should not necessarily contraindicate EVAR., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Maintaining long-term hemodialysis access in end-stage renal disease patients presents a serious challenge to surgeons. Over time, patients' remaining access sites diminish while complications and comorbidities simultaneously multiply; often resulting in the use of permanent tunneled catheters, which have a well-known high rate of complications and short-term usefulness. In this study, we report the results of a dialysis graft based on the axillary artery and ipsilateral axillary vein and tunneled in the subcutaneous tissues of the chest., Methods: We identified patients who had a chest wall arteriovenous graft (CWAVG) placed at our institution between May 2007 and December 2012. After institutional review board approval, the patients were retrospectively and then prospectively identified and followed for 2 years to document the performance, required maintenance, and complications of the graft., Results: Sixty-seven grafts in 67 patients were reviewed, representing 0.56% of our 1,192 total dialysis access creations during the study period. The average patient was 55-year-old with an average history of 3.97 explicitly documented prior accesses. Sixty interventions were performed postoperatively including 32 for thrombosis and 28 for venous stenosis. Six documented graft infections occurred (9%). Three minor wound complications occurred, but the graft was preserved. Notably, no patient developed symptoms of steal syndrome. The primary and secondary patency rates at 1 and 2 years were 69.5% and 36.9% and 81.6% and 57.6%, respectively. Twenty-three of the 67 patients died in the 2-year follow-up period (34%)., Conclusions: CWAVGs are useful and appropriate for patients with difficult upper extremity access. The patency rates for this "exotic" procedure are at least equivalent to other upper extremity grafts. The infection rate is lower than that for femoral grafts or tunneled catheters, and there is no risk of steal syndrome. CWAVGs can even be considered for primary use in patients who have disadvantaged upper extremity vasculature or who are at increased risk of steal syndrome., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Endovenous laser ablation (EVLA) of the saphenous vein has become one of the preferred treatments for treating saphenous vein reflux that has resulted in symptomatic lower extremity venous insufficiency or varicose veins. This procedure was noted during initial reports to have a low incidence of postoperative thrombosis of the femoral or popliteal vein adjacent to the treated great saphenous vein (GSV) or small saphenous vein (SSV). Later clinical experience suggested that the actual incidence of this event is higher and it was subsequently termed endothermal heat-induced thrombosis (EHIT)., Methods: We reviewed the office records and the pre- and post-treatment ultrasounds of patients undergoing EVLA in our office from 2005 to 2010 to determine the frequency of EHIT in patients we had treated and then graded them according to a previously published classification., Results: There were 528 veins treated in 192 men and 336 women. The clinical, etiology, anatomy, pathophysiology (CEAP) class for these patients was 1 (0), 2 (291), 3 (65), 4 (104), 5 (26), and 6 (40), respectively. The GSV was treated in 496 patients, the SSV in 22, and both were treated in 10 patients. EHIT occurred in 29 of the legs treated for an incidence of 5.1%. The EHIT in the femoral vein were of level 3 (3), 4 (7), 5 (12), and 6 (3), respectively. Two patients developed EHIT in the popliteal vein after EVLA of the SSV. Treatment for the EHIT consisted of observation (13), anticoagulation (9), antiplatelet therapy (2), and nonsteroidal anti-inflammatory agents (1). Duration of therapy was usually 1 week, but 7 patients were treated for periods ranging from 1 to 7 weeks. No pulmonary emboli occurred in any of these patients. The EHIT resolved completely in all patients., Conclusions: EHIT after EVLA occurs frequently and mainly consists of low-risk level 3, 4, and 5 deep vein thrombosis. The risk of pulmonary embolism is low and the EHIT typically resolves after 1 week. It can be treated with a short course of antiplatelet or anticoagulation therapy, although observation appears to be sufficient as well for lesser grades of EHIT., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Vertebral arterial disease (VAD) is a less commonly recognized and treated source of cerebrovascular ischemia compared with carotid artery disease. Patients are often referred for treatment after they have developed symptoms in the form of transient ischemic attacks or had a posterior hemispheric stroke. Traditional treatment of VAD has been surgical. More recently, endovascular treatment of VAD has been utilized. We performed a retrospective review of our institutional experience in treating VAD from 2001 to 2010. For treatment of proximal VAD, perioperative morbidity is lower for the endovascular group than for the surgical group, but six-week mortality was higher for the endovascular group. Complete resolution of symptoms occurred more frequently with surgery than with endovascular therapy. Therefore surgical reconstruction appears to be preferable to angioplasty and stenting for treatment of proximal vertebral artery occlusive disease.

With the widespread use of endovascular surgery, aneurysms can be managed selectively with the use of stent grafts. Standard treatment of mycotic aneurysms usually requires resection and extraanatomic bypass. Although stent graft repair of a mycotic femoral aneurysm with autologous graft has been reported, we present a case of an infrarenal mycotic aneurysm in a patient with the human immunodeficiency virus (HIV) that was successfully treated with a novel endovascular approach.

Patch angioplasty during carotid endarterectomy (CEA) has been shown to reduce the incidence of both early and late complications. Controversy continues, however, over the ideal patch material. Bovine pericardium (Vascu-Guard Biovascular Inc., Saint Paul, MN) offers an attractive alternative to other patch materials because of its handling and suturing characteristics that are similar to that of autogenous material. This study examines the perioperative and midterm results of bovine pericardial patch angioplasty during CEA. We studied 112 patients who underwent 129 CEAs with bovine pericardial patch angioplasty during an 18-month period. Data were collected regarding demographics, operative indications, perioperative complications, and the occurrence of late adverse outcomes based primarily on follow-up arterial duplex studies. Among this group there were 63 male (56%) and 49 female (44%) patients whose mean age was 71.8 +/- 9.1 years. In these patients there was the typical distribution of atherosclerotic risk factors. Seventy-four patients (66%) had symptomatic disease preoperatively and the remaining 38 patients (34%) were asymptomatic. Temporary cranial nerve palsy occurred in three patients (2%). There were no perioperative strokes, acute occlusions, bleeding episodes requiring reoperation, or deaths. The patients were followed up to 54 months postoperatively with a mean follow-up time of 41.7 +/- 4.4 months. During this period two patients (2%) developed three significant restenoses (70-99%). All required reoperation. There were no asymptomatic occlusions, infections, aneurysms, or rupture. These data demonstrate that bovine pericardial patch angioplasty during CEA is associated with a low incidence of both perioperative and midterm adverse outcomes.

During a 28-year period, 637 patients underwent 770 supraclavicular first rib resections and scalenectomies for thoracic outlet syndrome (TOS). The neurologic type of TOS was found in 705 cases (92%) and the remaining 65 cases (8%) had the vascular form of TOS. Of those extremities with brachial plexus irritation, the symptom complex consisted of paresthesia in 30 (4%), pain in 221 (31%), and pain with paresthesia in 454 (64%). In the cases of vascular TOS, 47 limbs (6%) had venous complications and 18 limbs (2%) had arterial sequelae. Following supraclavicular scalenectomy and rib resection, an excellent response was achieved in 59% (455 cases) and a good result was achieved in another 27% (206 cases). A fair outcome was present in 13% (95 cases) and a poor result was found in only 1% (13 cases). There was a single occurrence of lymphatic leakage and no brachial plexus injuries resulted. Postoperative causalgia requiring subsequent sympathectomy developed in two cases. No vascular or permanent phrenic nerve injuries occured and only 12 patients (2%) required operative intervention for recurrent TOS. First rib resection and scalenectomy can be performed by the supraclavicular route with an acceptable outcome, minimal morbidity, and long-lasting results.

One of the rarer anatomic variants is persistent sciatic artery. Only 93 cases have been reported since the first description of this anomaly. The earlier reports were mainly pathologic descriptions, whereas the more recent have been clinically oriented. There is a slight male predominance, and the average age of presentation is 49 years old (range 6 months to 85 years). The majority of patients have symptoms of a mass, ischemia, or gluteal pain. There is no preference for the right or left side, and one in four patients has both legs affected. In this anomaly the sciatic vessel acts as the principal blood supply to the lower limb. One half of all patients develop aneurysms that are characteristically located caudal to the sciatic notch as opposed to gluteal aneurysms that are cephalad to this landmark. Various methods (some now obsolete) have been tried to treat these aneurysms, but the best results were obtained through aneurysm ablation and vascular reconstruction. Arterial bypasses succeeded when used for ischemic complications of persistent sciatic artery. Optimal management of this condition requires prompt recognition, an understanding of the developmental anatomy, exclusion and bypass of aneurysms, appropriate vascular intervention for ischemic sequelae, and close observation of asymptomatic individuals.

From 1976 to 1988, 35 patients were treated for Stage IE and Stage IIE primary gastric lymphoma (non-Hodgkin's). Pain and weight loss were the predominant symptoms, physical findings were usually absent and 20 per cent of the patients were anemic. The results of gastrointestinal contrast studies suggested a malignant condition in 75 per cent, but findings were not specific for lymphoma. Endoscopic findings suggested a malignant process in 85 per cent, but the yield for biopsy was only 60 per cent. Of 28 patients undergoing operative exploration, 75 per cent were resectable. Nine patients received postresectional adjuvant therapy. Five had chemotherapy; three, radiotherapy, and one patient, a combination of the two. Primary nonsurgical treatment consisted of chemotherapy in 11, radiotherapy in two and combined therapy in one instance. Three of five recurrences were successfully treated. The five year survival rate was 65 per cent without significant differences between surgical and nonsurgical regimens. Those with tumors smaller than 7 centimeters had a five year survival rate of 100 per cent versus 50 per cent for larger neoplasms. Patients more than 60 years of age appeared to have a more favorable course after surgical therapy compared with those who had nonsurgical treatment. We concluded that endoscopy is a most useful, although limited diagnostic study and since no treatment program is obviously superior, the choice of therapy can be individualized accordingly.

Fewer than 100 cases of Paget's disease located in the perianal skin have been reported since the extramammary location was first described in 1893. Two patients seen and treated in the authors' institutions with disease limited to the epidermis and its adnexae are described to illustrate the usual presentation and pathobiology of the disease. A staging classification based on the disease pathology has been developed from the cases reported in the literature and correlated with appropriate surgical treatment. Stage I disease treated with wide local excision promises unlimited survival, whereas the prognosis worsens for Stage II, with synchronous localized malignancies, and for Stages III and IV, with regional and distant metastatic disease, respectively.