Background Frailty has been established as an important predictor of health-care outcomes. We hypothesized that the use of a modified frailty index would be a predictor of mortality and adverse occurrences in vascular surgery patients. Methods Under the data use agreement of the American College of Surgeons, and with institutional review board (IRB) approval, the National Surgical Quality Improvement Program (NSQIP) Participant Utilization File was accessed for the years 2005–2008 for inpatient vascular surgery patients. Using the Canadian Study of Health and Aging Frailty Index (FI), 11 variables were matched to the NSQIP database. An increase in FI implies increased frailty. The outcomes assessed were mortality, wound infection, and any occurrence. We then compared the effect of FI, age, functional status, relative value units (RVU), American Society of Anesthesiology (ASA) score, and wound status on mortality. Statistical analysis was done using chi-square analysis and stepwise logistic regression. Results A total of 67,308 patients were identified in the database, 3913 wound occurrences, 6691 infections, 12,847 occurrences of all kinds, and 2800 deaths. As the FI increased, postoperative wound infection, all occurrences, and mortality increased ( P < 0.001). Stepwise logistic regression using the FI with the NSQIP variables of age, work RVU, ASA class, wound classification, emergency status, and functional status showed FI to have the highest odds ratio (OR) for mortality (OR = 2.058, P < 0.001). Conclusions A simplified FI can be obtained by easily identifiable patient characteristics, allowing for accurate prediction of postoperative morbidity and mortality in the vascular surgery population.
Abstract Diabetic foot ulcer is considered a major health problem that predisposes to limb amputation. Among the different methods to achieve ulcer healing, platelet rich plasma (PRP) gel is gaining popularity. It is thought to stimulate wound closure by providing essential growth factors for healing. This study aims to evaluate the value of autologous PRP gel in the treatment of diabetic ulcers. Patients and Methods The study included 56 patients of both sex from 18 to 80 years, with clean chronic diabetic foot ulcers divided into 2 equal groups. The first group was treated by antiseptic ointment dressing and the second group by autologous platelet gel. PRP together with thrombin were prepared by centrifugation at each dressing session. Thrombin and calcium chloride were used to activate the PRP. The formed platelet gel was applied to the wound twice weekly. Results Statically significant increase in healing rate was found in the PRP treated group and complete healing was achieved in 86% of them in comparison to 68% of the control group. In the study group, rate of healing per week was greater during the first 8 weeks and starts to decline afterward. The use of platelet gel showed a lower rate of wound infection. Conclusion Autologous platelet gel is more effective than the local antiseptic dressing in terms of healing rate and prevention of infection in clean diabetic ulcers.
Ischemic wounds of the lower extremity can fail to heal despite successful revascularization. The foot can be divided into six anatomic regions (angiosomes) fed by distinct source arteries arising from the posterior tibial (three), anterior tibial (one), and peroneal (two) arteries. This study investigated whether bypass to the artery directly feeding the ischemic angiosome had an impact on wound healing and limb salvage. Retrospective analysis was performed for 52 nonhealing lower extremity wounds (48 patients) requiring tibial bypass over a 2-year period. Preoperative arteriograms were reviewed to determine arterial anatomy relative to each wound's specific angiosome and bypass anatomy. Patients were divided into two groups; direct revascularization (DR, bypass to the artery directly feeding the ischemic angiosome) or indirect revascularization (IR, bypass unrelated to the ischemic angiosome). Wound outcome was analyzed with regard to the endpoints of complete healing, amputation, or death unrelated to the wound. Time to healing was also noted for healed wounds. Based on preoperative arteriography, 51% ( n = 27) of the wounds received DR to the ischemic angiosome, while 49% ( n = 25) underwent IR. There were no statistically significant differences in the comorbidities of the two groups. Revascularization was via tibial bypass using the saphenous vein ( n = 34, 65%) or polytetrafluoroethylene with a distal vein patch ( n = 18, 35%). Bypasses were performed to the anterior tibial ( n = 22, 42%), posterior tibial ( n = 17, 33%), or peroneal ( n = 13, 25%) arteries based on the surgeon's judgment. One bypass failed in the perioperative period and was excluded from the analysis. The remaining bypasses were patent at the time of wound analysis. Due to a 17% mortality rate during follow-up, 43 wounds were available for endpoint analysis. This analysis demonstrated that 77% of wounds ( n = 33) progressed to complete healing and 23% of wounds ( n = 10) failed to heal with resultant amputation. In the DR group, there was 91% healing with a 9% amputation rate. In the IR group, there was 62% healing with a 38% amputation rate ( p = 0.03). In those wounds that did heal, total time to healing was not significantly different—DR 162.4 days versus IR 159.8 days ( p = 0.95). Revascularization plays a crucial role in the treatment of ischemic lower extremity wounds. We believe that direct revascularization of the angiosome specific to the anatomy of the wound leads to a higher rate of healing and limb salvage. Although many factors must be considered in choosing the target artery for revascularization, consideration should be given to revascularization of the artery directly feeding the ischemic angiosome.
Introduction Intermittent claudication (IC) is a common and debilitating symptom of peripheral arterial disease and is associated with a significant reduction in a sufferer’s quality of life. Guidelines recommend a supervised exercise programme (SEP) as the primary treatment option; however, anecdotally there is a low participation rate for exercise in this group of patients. We undertook a systematic review of the uptake and adherence rates to supervised exercise programmes for individuals with IC. Methods The Medline, Embase and PubMed databases were searched up to January 2015 for terms related to supervised exercise in peripheral arterial disease. The review had three aims: firstly to establish the rates of uptake to SEPs, secondly the rates of adherence to programmes and finally to determine the reasons reported for poor uptake and adherence. Separate inclusion/exclusion criteria were applied in selecting reports for each aim of the review. Results Only 23 of the 53 potentially eligible papers for uptake analysis identified on literature searches reported any details of screened patients (n = 7517) with only 24.2% of patients subsequently recruited to SEPs. Forty-five percent of screen failures had no reason for exclusion reported. 67 papers with 4012 patients were included for analysis of SEP adherence. Overall 75.1% of patients reportedly completed a SEP, however only one paper defined a minimal attendance required for SEP completion. 54.1% of incomplete adherence was due to patient withdrawal and no reason for incomplete adherence was reported for 16% of cases. Discussion Reporting of SEP trials was poor with regard the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in the majority of the current literature. Current clinical guidelines based upon this evidence base may not be applicable to the majority of IC patients and changes to SEPs may be needed to encourage/retain participants.
Abstract Background Costs related to diabetic foot ulcer (DFU) care are greater than $1 billion annually and rising. We sought to describe the impact of diabetes (DM) on foot ulcer admissions in the US, and to investigate potential explanations for rising hospital costs. Methods The Nationwide Inpatient Sample (2005-2010) was queried using ICD-9 codes for a primary diagnosis of foot ulceration. Multivariable analyses were used to compare outcomes and per-admission costs among patients with foot ulceration and DM vs. non-DM. Results 962,496 foot ulcer patients were admitted over the study period. The overall rate of admissions was relatively stable over time, but the ratio of DM vs. non-DM admissions increased significantly (2005: 10.2 vs. 2010: 12.7; p<0.001). Neuropathy and infection accounted for 90% of DFU admissions, while PVD accounted for most non-DM admissions. Admissions related to infection rose significantly among DM patients (2005: 39,682 vs. 2010: 51,660; p<0.001), but remained stable among non-DM patients. Overall, DM accounted for 83% and 96% of all major and minor amputations related to foot ulcers, respectively, and significantly increased cost of care (DM: $1.38 vs. non-DM: $0.13 billion/year; p<0.001). Hospital costs per DFU admission were significantly higher for patients with infection compared to all other causes ($11,290 vs. $8,145; p<0.001). Conclusions Diabetes increases the incidence of foot ulcer admissions by 11-fold, accounting for more than 80% of all amputations and increasing hospital costs more than 10-fold over the 5 years. The majority of these costs are related to the treatment of infected foot ulcers. Education initiatives and early prevention strategies through outpatient multidisciplinary care targeted at high-risk populations are essential to preventing further increases in what is already a substantial economic burden.
Background Extracorporeal membrane oxygenation (ECMO) provides continuous cardiopulmonary support on a long-term basis. It has been speculated that patients undergoing ECMO via femoral arterial cannulation are more likely to develop peripheral vascular complications. The purpose of this study was to evaluate the incidence of peripheral vascular complications in this group of patients and outline the modalities used for treatment. Methods Data were collected for all patients who had femoral artery cannulation for ECMO therapy from June 2008 to October 2011. Primary outcome was any vascular complication. Secondary outcomes were 30-day mortality and amputation. Operative reports were reviewed to analyze the surgical procedures implied for treating vascular complications. Results One hundred one patients underwent ECMO therapy during the period of study; 63.4% were male with an average age of 47.7 years. Mean length of hospital stay was 19.8 days and average length of time on the ECMO device was 7.33 days. Indications for ECMO included cardiogenic shock in 61 patients (60.4%), pulmonary failure in 37 (36.6%), and combined cardiac and pulmonary failure in 3 (3%). Overall mortality comprised 42 patients (42%). Risk factors for peripheral arterial disease included hypertension (32%), diabetes mellitus (21.8%), hyperlipidemia (21.7%), and smoking (19.8%). Eighteen patients (17.8%) developed peripheral vascular complications (confidence interval 10‒25%). Among the patients who developed vascular complications, 78% were male and average length of time on the device was 7.16 days. Indications for ECMO were cardiac failure in 13 (72%) and pulmonary failure in 5 (28%). Two (11%) were managed nonoperatively and 16 (89%) needed surgical intervention, 8 (44.44%) of whom required femoral endarterectomy with patch angioplasty. One patient required below-knee amputation. None required distal bypass. Mortality among patients with vascular complications was 28% ( P = 0.30). Indications for use of ECMO in these patients included cardiogenic shock in 13 (72%) and pulmonary failure in 5 (28%). The mortality rate was 58% among diabetic patients and 34% in nondiabetic patients ( P = 0.007). Conclusions Vascular complications occur in less then 20% of ECMO patients with the majority requiring femoral reconstruction. Development of vascular complications does not appear to increase risk of amputation or mortality. Among those patients who develop vascular complications, the most common indication for ECMO is cardiogenic shock.
Background Takayasu arteritis (TA) is a rare, systemic, inflammatory vasculitis of granulomatous nature, and still of unknown etiology. It mainly involves the aorta and its major branches and is more commonly seen in women of childbearing age and Asians. TA leads to stenosis, occlusion, or aneurysmal degeneration of large arteries, and its pathogenesis seems to be mainly due to an abnormal cell-mediated immunity, although other molecular and genetic abnormalities may contribute. The diagnosis and treatments lie on clinical and arteriographic findings. Because of its fluctuating course, both clinical scores and biomarkers are currently evaluated. The aim of this review is to report a comprehensive and methodologically robust state of the art about Takayasu arteritis, including the latest data and evidences in the definition, epidemiology, pathogenesis and etiology, clinical manifestations and classification, diagnosis, assessment of disease activity and progression, biomarkers, and treatment. Methods We searched all publications addressing definition, epidemiology, pathogenesis, etiology, classification, diagnosis, biomarkers, and treatment of TA. Randomized trials, cohort studies, and reviews were contemplated to give a breadth of clinical data. PubMed and Scopus were searched from August 2010 to November 2015. Results Of the 3,056 records found, 267 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 169 articles because of the following reasons: (1) no innovative or important content; (2) no multivariable analysis; (3) insufficient data; (4) no clear potential biases or strategies to solve them; (5) no clear end-points; and (6) inconsistent or arbitrary conclusions. The final set included 98 articles. Conclusions This review presents the last updates in all fields of Takayasu arteritis. Still today, large areas of TA pathogenesis and disease-activity assessment need to be further investigated to better treat patients with TA.
Vascular blowout syndrome (VBOS) is a life-threatening condition secondary to direct tumor encasement or invasion in advanced stage malignancies. Endovascular management can be used as an alternative to surgical treatment in this fragile patient population, providing a minimally invasive measure both acutely and prophylactically. Three patients with peripheral VBOS secondary to advanced stage malignancies underwent successful endovascular treatment. Technical success was obtained in all patients with nonsignificant perioperative complications. Endovascular management controlled immediate life-threatening hemorrhage and enabled these high-risk patients to undergo other adjunctive therapeutic modalities. Endovascular treatment can offer a safe and effective palliative measure of peripheral VBOS secondary to neoplastic erosion in patients with advanced stage malignancies.
May–Thurner syndrome (MTS) is an anatomically variable condition of venous outflow obstruction caused by extrinsic compression. Although this syndrome is rare, its prevalence is likely underestimated. The pathology of this condition is secondary to a partial obstruction of the common iliac vein by an overlying common iliac artery with subsequent entrapment of the left common iliac vein. Regardless of the mechanism, this causes partial or complete impedance to the iliac vein outflow with subsequent possible obstruction and extensive ipsilateral deep vein thrombosis (DVT) of the ipsilateral extremity. Clinical presentations include, but are not limited to pain, swelling, venous stasis ulcers, and skin discoloration. With extensive DVT, postphlebetic syndrome, with all of its sequelae, may also develop. Treatment is based on the clinical presentation and includes staged thrombolysis with/without prophylactic retrievable inferior vena cava filter placement, followed by angioplasty/stenting of the left iliac vein in MTS patients with extensive DVT. This review highlights the variable presentations of MTS and outlines possible management within the current Society for Vascular Surgery consensus.
Isolated spontaneous dissection of the superior mesenteric artery (SMA) without aortic dissection is being increasingly recognized. This study aimed to evaluate the latest clinical characteristics and optimal treatment. We searched the Cochrane Library, MEDLINE, and Clinical Trial.gov databases through December 31, 2016, using the following words: “superior mesenteric artery” and “dissection.” We retrieved articles presenting the treatment and outcomes of isolated SMA dissection published in English. We investigated the patient characteristics, treatments, follow-up, and prognoses. Additionally, we compared mortality rates and assessed the need for additional interventions between treatment strategies in symptomatic patients without accompanying proof of bowel ischemia or aneurysm, which require immediate endovascular treatment or surgery. We identified 51 articles with 721 patients. The initial treatments in symptomatic patients without accompanying proof of bowel ischemia or aneurysm were conservative treatment (82.1%), endovascular treatment (14.3%), catheter-directed infusion of medication (2.1%), and surgery (1.5%). Additional treatment was needed in 18.1% of patients receiving conservative treatment and 2.4% of patients receiving endovascular treatment ( = 0.0003). Mortality was not significantly different between each treatment strategy ( = 0.92). There was no significant difference in mortality of symptomatic SMA dissection patients without accompanying proof of bowel ischemia or aneurysm between interventional treatment and conservative treatment. An additional treatment is needed in a minority of patients receiving conservative treatment, however, more frequently than in those receiving endovascular treatment.
Chronic venous disease is a potentially prevalent and debilitating condition affecting millions of individuals, mostly in Western world. Predisposing genetic and environmental factors contribute to its development. However, the main etiology remains to be elucidated. An extensive literature search was conducted in Medline using the following key words algorithm: (“Chronic venous disease” OR “Chronic venous insufficiency” OR “varicose veins”) AND (“endothelial dysfunction” OR “inflammation”). Besides being a multifactorial disease, it is now recognized that the hallmark of chronic venous disease pathophysiology likely remains in inflammation, possibly triggered by sustained venous hypertension and valvular incompetence. Shear stress changes are directly sensed by endothelial cells, leading to its activation and subsequent recruitment of leukocytes and release of proinflammatory agents. Dysfunctional endothelium has a pivotal role perpetuating the inflammatory cascade, with consequent pathological venous changes and chronic venous disease worsening. Endothelial dysfunction may be the central player in the link between varicose veins and deep vein thrombosis. In this article, we aim to analyze the crucial role of endothelial activation in the persistent inflammatory cycle that characterizes chronic venous disease.
Compressive stockings are considered the centerpiece of treatment in chronic venous disease (CVD). It is known that stockings fail in some patients for varied reasons: they are ineffective despite wear in some, but more commonly patients are unable or unwilling to use them as prescribed. Detailed statistics regarding stocking compliance have not been available except in a few selected series focused on leg ulcers. This study focuses on use, compliance, and efficacy of compression stockings among a large cohort of patients referred to a tertiary venous practice. A total of 3,144 new CVD patients were seen from 1998 to 2006. As a referral practice, patients had been under the care of primary-care physicians or specialists for variable times before. A detailed history of past and present compressive regimens was part of our initial evaluation of CVD patients. These data were entered into a time-stamped electronic medical record and later analyzed. Only 21% of patients reported using the stockings on a daily basis, 12% used them most days, and 4% used them less often. The remaining 63% did not use the stockings at all or abandoned them after a trial period in the past. The primary reasons given for nonusage were as follows: unable to specify a reason, 30%; not prescribed by the primary physician, 25%; did not help, 14%; binding/“cutting off” of circulation, 13%; “too hot” to wear, 8%; limb soreness, 2%; poor cosmetic appearance, 2%; unable to apply without help, 2%; contact dermatitis or itching, 2%; and other (cost, work situation, etc), 2%. Multiple factors were cited by 8%. Surprisingly, there was no difference in compliance between men and women (39% vs. 38%) or among different decile age groups. Compliance was relatively better at 50% in patients who gave a prior history of deep vein thrombosis ( n = 675) compared to 35% in those without such a prior history ( n = 2,437) ( p 10 years, 44% ( p < 0.003). Symptoms were still persistent in about a third (37%) of the patients despite apparent compliance with prescribed stockings. Compressive stockings are inapplicable in about a quarter of patients due to the condition of the limb or the general health of the patient. They are ineffective despite wear in about a third of patients seen. In the remainder, noncompliance with prescribed compressive stockings is an apparent major cause of treatment failure. Noncompliance is very high in patients with CVD regardless of age, sex, etiology of CVD, duration of symptoms, or disease severity. The reasons for noncompliance can be grouped into two interdependent major categories: (1) wear-comfort factors and (2) intangible sense of restriction imposed by the stockings.
Background Although patients with critical limb ischemia (CLI) commonly undergo major limb amputation, the quality of life (QOL) of this group remains poorly described. Therefore, we sought to describe which domains vascular amputees consider important in determining their health-related QOL. Methods We performed 4 focus groups in patients who had major lower extremity amputations resulting from CLI. They were conducted at 4 distinct centers across the United States to ensure broad geographic, socioeconomic, and ethnic representation. Results Of 26 patients (mean age, 64 years), 19 (73%) were Caucasian, 6 (23%) were African American, and 1 (4%) was Native American. Nearly, three-quarter of patients were men ( n = 19, 73%) and had a high-school education or more ( n = 19, 73%). Overall, 8 (31%) were double amputees and 17 (65%) had diabetes. Time since amputation varied across patients and ranged from 3 months to more than 27 years (mean, 4.3 years). Patients stated that their current QOL was determined by impaired mobility (65%), pain (60%), progression of disease in the remaining limb (55%), and depression/frustration (54%). Across 26 patients, more than half ( n = 16, 62%) described multiple prior revascularization procedures. Although most felt that their physician did his/her best to salvage the affected leg (85%), a sizable minority would have preferred an amputation earlier in their CLI treatment course (27%). Furthermore, when asked how their care might have been improved, patients reported that facilitating peer support (88%), more extensive rehabilitation and prosthetist involvement (71%), earlier mention of amputation as a possible outcome (54%), and the early discontinuation of narcotics (54%) were potential areas of improvement. Conclusions Although QOL in vascular amputees seems primarily determined by mobility impairment, pain, and emotional perturbation, our focus groups identified that physician-controlled factors such as the timing of amputation, informed decision making, and postamputation support may also play an important role. The assessment of patient preferences regarding maintenance of mobility at the cost of increased pain versus relief of pain with amputation at a cost of diminished mobility is central to shared decision making in CLI treatment.
In situ fenestration of aortic stent grafts for treatment of aortic arch aneurysms is a new option for endovascular aortic arch repair. So far, only few reports have shown perioperative and short-term results of in situ fenestrations for aortic arch diseases. We present the multicenter experience with the aortic arch in situ fenestration technique documented in the AARCHIF registry for treatment of aortic arch aneurysms or localized type A aortic dissections and analyzed perioperative outcome and midterm follow-up. Patients with aortic arch pathologies treated by aortic arch in situ fenestration with proximal stent graft landing in aortic arch Ishimura zones 0 and 1 were included in the registry. Stent-graft in situ fenestrations were created using needles or radiofrequency or laser catheters and completed by implantation of covered connecting stent grafts. Single in situ fenestrations for the left subclavian artery (LSA) were excluded. Between 06/2009 and 03/2017, twenty-five patients were treated by in situ stent-graft fenestrations for aortic arch pathologies at 9 institutions in 7 different countries, 3 of them as bailout procedures for stent-graft malplacement. In situ fenestrations were performed for the brachiocephalic trunk ( = 20), the left common carotid artery ( = 21) and the LSA ( = 9). Technical success for intended in situ fenestrations was 94.0% (47/50), with additional supraaortic bypass procedures performed in 14 patients. Perioperative mortality occurred in 1 (4.0%) patient, treated as a bailout procedure and 3 (12.0%) perioperative strokes were observed. One proximal aortic stent-graft nonalignment and 4 type III endoleaks, 2 early and 2 late, required reeintervention. During follow-up (1–118 months), the diameter of aortic arch aneurysms decreased from 61.5 ± 4.1 mm to 48.4 ± 3.2 mm ( = 0.02) and, so far, 6 patients died from diseases unrelated to their aortic arch pathologies with a mean survival time of 79.5 months and 3 endovascular reinterventions for distal aortic expansion were performed. Cerebrovascular event ( = 4) was the most relevant prognostic factor for mortality during midterm follow-up ( = 0.003). The aortic arch in situ fenestration technique for endovascular aortic arch repair seems to be valuable treatment option for selected patients, although initial consideration of other treatment options is mandatory. Data about long-term durability are required.
Extracorporeal membrane oxygenation (ECMO) is an important life-saving modality for patients with cardiopulmonary failure. Vascular complications, including clinically significant limb ischemia, may occur as a result of femoral artery cannulation for venoarterial (VA) ECMO. This study examines our institutional experience with femoral VA ECMO and the development of ipsilateral limb ischemia. We performed a retrospective review of all consecutive patients undergoing femoral VA ECMO between 2011 and 2016. The primary endpoint was clinical evidence of limb-threatening ischemia. Multivariate logistic regression analysis was used to identify predictors for limb ischemia after cannulation. Between March 2011 and September 2016, 154 patients underwent femoral cannulation for VA ECMO. Overall in-hospital mortality was 59.7%. Clinically significant ipsilateral limb ischemia occurred in 34 (22%) patients; 7 required four-compartment fasciotomy, and 3 of these patients required amputation. On univariate analysis, a history of pulmonary disease, peripheral arterial disease, and stroke or transient ischemic attack was significantly associated with clinical limb ischemia. On multivariate analysis, younger age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93–0.99), diabetes (OR, 2.77; 95% CI, 1.08–7.12), pulmonary disease (OR, 3.86; 95% CI, 1.38–10.78), and peripheral arterial disease (OR, 13.68; CI, 2.75–68.01) were associated with limb ischemia. Lack of prophylactic distal perfusion catheter and arterial cannula size were not independently associated with limb ischemia. Femoral ECMO cannulation can be associated with significant limb ischemia necessitating surgical intervention. Younger patients, as well as those with a history of diabetes, pulmonary disease, and peripheral arterial disease, may be at increased risk for this complication.
An endovascular-first approach to limb salvage and relief from lifestyle-limiting claudication is widely accepted. Stenosis or short occlusion of common, superficial femoral, and popliteal arteries can be corrected with percutaneous transluminal angioplasty (PTA) with stent positioning. Patency rates of these procedures are limited. We report our experience with external iliac artery to the infrapopliteal vessels vein grafts when the endovascular treatment fails. Between January 2013 and January 2019, 16 patients (16 limbs) were operated on for limb-threatening ischemia after the occlusion of PTA with stent positioning of the common, superficial femoral, and popliteal arteries. Three patients were treated at our hospital by interventional radiologists; the remaining were operated on elsewhere. An external iliac artery to the infrapopliteal vessels vein bypass graft was anatomically interposed to restore blood flow. End points of the study were death-related events, vein graft failure, and major (above- or below-knee amputation) or minor (foot or toe amputation) limb loss. There were 12 men and 4 women. Mean age of patients was 68 years. Indication for the initial PTA with stent positioning of the common and superficial femoral artery was according to the Rutherford classification Grade I: Category 1, 11 patients (69%) and Category 2, 5 (31%) patients (Stage IIa and IIb according to Fontaine classification, respectively). Great saphenous vein was used in 14 (87%) cases and in 2 (13%) cases a composite graft with a segment of cephalic vein was required. The distal anastomoses were performed on the posterior tibial artery in 6 (37%) cases, anterior tibial artery in 4 (26%), and peroneal artery in 6 (37%). Four-year survival and primary patency rates were 71% (standard error [SE] = 0.15) and 73% (SE = 0.14), respectively. One graft occlusion required an above-knee amputation. Four-year limb salvage rate was 86% (SE = 0.13). We recommend the external iliac artery as source of inflow in patients in whom the vein bypass cannot originate from the common femoral or from a more distal inflow source because of previous PTA with stent positioning or it is deemed hazardous.
Abstract Objectives The study evaluates the readmission diagnoses after vascular surgical interventions and the associated hospital costs. Methods Patients readmitted after undergoing carotid artery stenting (CAS), carotid endarterectomy (CEA), Infrarenal endovascular abdominal aortic aneurysm repair (EVAR), open abdominal aortic aneurysm repair (OAAA), suprainguinal revascularization (SUPRA) or infrainguinal revascularization (INFRA) between 1/1/2008 and 10/20/2013 at a single academic institution were retrospectively identified. Demographic, preoperative, and postoperative event variables were obtained by chart review. The diagnoses and the costs of the readmission event were obtained by chart review and from hospital financial data. Readmission indications were grouped as unrelated or planned readmissions, procedure specific complications, wound complications, cardiac causes, and other. Univariate analyses of categorical variables were performed with χ2 or Fisher exact test where appropriate. Continuous variables were analyzed using the Wilcoxon rank sum test. Results A total of 1170 patient records were identified. Thirty-day readmission occurred in 112 patients (9.6%). The readmission rate was significantly different between groups: 4.5% in CAS (n=8/177), 8.5% in CEA (21/246), 5.8% in EVAR (18/312), 11.4% in OAAA (4/35), 15.6% in INFRA (33/212), 13.5% in SUPRA (24/178), and 40% in combined SUPRA and INFRA (4/10), (p value<0.0001). Readmissions were unrelated or planned in 19.6% of patients. Wound complications were the most common readmission diagnoses 36.6% (41/112). There was a difference in the distribution of readmission indications among procedure groups, with wound complications being predominant in INFRA and SUPRA groups (60.6 % and 58.3%, respectively), and cardiac events predominantly in EVAR patients (42%) (p <0.001). In univariable analysis of predictors of readmission, significant preoperative factors were chronic obstructive pulmonary disease, renal insufficiency, and lower hematocrit. Significant postoperative predictors included any postoperative complication, number of complications, increased length of stay, wound complications, postoperative infections, blood transfusion, and reoperation. The median hospital cost for readmission for wound complications was 29,723 USD (IQR 23,841 to 36,878), and for cardiac complications was 39,784 USD (26,305 to 46,918). The median cost of readmission for bypass graft occlusion was 33,366 USD (20,530 to 43,170.) The median length of stay also differed depending on the readmission diagnosis and was highest for bypass graft occlusion (8.5 days). Conclusions Readmissions after vascular procedures are associated with high cost and hospital bed utilization. Wound complications continue to be the dominant readmission etiology. The characterization of these costs and risk factors in this study can allow for resource allocation to minimize preventable related readmissions. A significant proportion of readmissions after vascular interventions are planned or unrelated, which should be taken into consideration in metric benchmarking and performance comparisons.
Revascularization to relieve ischemic pain and prevent limb loss is the cornerstone of critical limb ischemia (CLI) treatment; however, not all elderly patients are deemed fit for revascularization. Patient-related outcome measurements are important in these patients. Quality of life (QoL) results regarding the effect of endovascular, surgical, and conservative treatment on the QoL in the elderly are scarce in the current literature. The goal of this study was to explore the outcomes of the different treatment modalities in elderly patients suffering from CLI, with a specific focus on QoL. A total of 195 CLI patients ≥70 years were prospectively included between January 2012 and February 2016 and divided into 6 groups (endovascular revascularization, surgical revascularization, and conservative treatment). Two age groups (70–79 and >80 years) were analyzed. Follow-up was performed at 5–7 days, 6 weeks, and 6 months. World Health Organization Quality of Life-BREF questionnaire was used to determine QoL. The Vascular–Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity score was noted. QoL was used as the primary end point, with mortality and limb salvage as the secondary end points. Six-month mortality was significantly lower in surgically treated patients aged 70–79 years (4%) as compared with endovascular (24%, = 0.001) or conservative treatment (25%, = 0.02). There was no significant difference in 6-month mortality in patients >80 years among endovascularly (38%), surgically (15%), and conservatively treated patients (27%). QoL significantly increased at all follow-up moments in surgically treated patients between 70 and 79 years and at 6 months in endovascularly treated patients. Conservatively treated patients did not improve their QoL in this age group. All patients aged >80 years, including conservatively treated patients, showed significantly improved QoL results at 6 months. Elderly patients judged fit for surgery may benefit the most from surgical revascularization, reporting low mortality rates, low adverse events and significantly gained QoL in multiple domains. However, all 3 treatment modalities have significantly increased physical health at 6 months. Conservative therapy seems to be an acceptable treatment option in patients unfit for revascularization with gained physical health at 6 months.
In patients with critical limb ischemia, an association is assumed between depression and worse outcome for morbidity, such as major limb amputation. After major amputation, anxiety and depression are common. We aimed to determine the association of depressive and anxiety symptoms in the elderly with critical limb ischemia, especially after major limb amputation. Patients with critical limb ischemia aged ≥70 years were included in this prospective observational cohort study between January 2012 and February 2016 in 2 Dutch hospitals. After a multidisciplinary vascular conference, patients were divided into 4 treatment groups: endovascular revascularization, surgical revascularization, conservative therapy, and primary major amputation. In a 1-year follow-up period, depression and anxiety were measured 4 times using the Dutch versions of the Center for Epidemiological Studies Depression Scale and the State-Trait Anxiety Inventory. One Hundred eighty-seven patients were included. Within 1 year, 44 patients underwent a major limb amputation. Lower amputation-free survival did not differ significantly for patients with versus without greater anxiety (X  = 0.689, = 0.407) and also not for patients with versus without more depressive symptoms (X  = 0.614, = 0.433). For both groups, there were no significant changes in anxiety scores over time. After a median follow-up time of 336.5 days and 365 days, depressive symptoms significantly decreased in amputees, respectively, 8.5 vs. 4.5 (95% CI 1.76–7.48, = 0.002) and 8.5 vs. 4.3 (95% CI 0.61–9.82, = 0.027) when compared to the baseline measurement. Similarly, nonamputees had significantly lower overall score for depressive symptoms after a median follow-up time of 365 days (10.1 vs. 4.1, 95% CI 4.49 to 6.90, < 0.001). In the opinion of the medical health care provider, amputation is a severe and unwanted end phase of critical limb ischemia. However, depressive symptoms seem to decrease over time and anxiety symptoms do not seem to be affected in patients after major limb amputation. In addition, patients with greater trait anxiety or more depressive symptoms at baseline did not have significantly higher amputation rates. These findings are similar to the course of depressive and anxiety symptoms for the elderly patients without major limb amputation.
The current results of endovascular repair of abdominal aortic aneurysms (EVAR) and the wide use of percutaneous closure systems suggest that ambulatory treatment is feasible in selected patients. The objective of this study was to evaluate the rate of eligibility to ambulatory EVAR (EVAR-Ambu) and its potential medicoeconomic impact. Between January 2014 and December 2016, 245 patients were operated of an abdominal aortic aneurysm (AAA) in our center. The 128 patients whose anatomy was unfavorable with EVAR, which were operated in urgency or who were classified as American society of anesthesiologists 4, were excluded from the study. The 117 remaining files were reexamined to evaluate the eligibility for EVAR-Ambu retrospectively. The patients were considered as eligible if they presented all the following criteria: (1) normal surgical risk, (2) logistic feasibility of an ambulatory procedure (home <1 hr away from the hospital, available relatives), and (3) anatomical criteria of percutaneous feasibility according to angio–computed tomography. The surgical risk was evaluated according to the French High Health Authority (HAS) and the Society for Vascular Surgery (SVS) score. The balance between costs and revenue was evaluated for each patient according to the length of stay. Among the 117 patients, 43 (37%) and 57 (49%) were eligible for EVAR-Ambu by percutaneous route according to whether the surgical risk was assessed according to the HAS or the SVS criteria. If a conventional surgical approach was considered as compatible with EVAR-Ambu, 12 (10%) and 13 (11%) additional patients were eligible according to whether the surgical risk was assessed according to the HAS or the SVS criteria, respectively. In terms of medicoeconomic evaluation, the cost of the initial intervention depended was mainly on the cost of the stent graft and the operating room services. The cost spent of 1 night conventional hospitalization (CH) after EVAR was 603€ per day versus 490€ in the Day Surgery Unit (DSU). In comparison, the revenue for the institution was identical for DSU and a 1-night CH. According to our estimates, the balance between revenue and expenditures amounted to +122€ per patient for EVAR-Ambu versus +10€ or +119€ per patient hospitalized 1 or 2 nights, respectively. EVAR-Ambu is possible in a substantial proportion of patients treated for infrarenal AAA. Its medicoeconomic interest is real for the health system although it appears low at the individual level. The safety of this approach in clinical practice must be confirmed by a prospective study in selected patients.