BACKGROUND:Single-segment great saphenous vein (ssGSV) is the gold standard conduit for femoral-tibial bypasses in patients with critical limb-threatening ischemia (CLTI). In the absence of a good single-segment saphenous vein, alternative options are prosthetic grafts or spliced-vein (SpV) conduits. Although SpV conduits may provide better long-term patency/limb salvage, prosthetic grafts are more often the chosen conduit due to shorter operative and presumably better immediate postoperative outcomes; nevertheless, there are little data supporting this practice. In this study, we compared 30-day outcomes between SpV and prosthetic conduits in CLTI bypass using a national registry. METHODS:CLTI patients who underwent lower extremity bypass using SpV or prosthetic conduits only were selected from the National Surgical Quality Improvement Program targeted database. A 1:5 propensity score matching was conducted between SpV and prosthetic groups to address preoperative differences. Thirty-day outcomes, including primary patency, reintervention, major amputation, mortality, major morbidity, transfusion, and wound complications, were compared between the 2 groups. RESULTS:There were 886 patients who underwent femoral-tibial bypass without ssGSV (104 SpV and 782 prosthetic grafts). All SpV patients were propensity score matched to 445 prosthetic patients. SpV exhibited significantly better 30-day primary patency than prosthetic (87.5% vs 74.38%, P = 0.004). SpV was associated with significantly longer operative time (346 min vs 222 min, P < 0.001) and higher transfusion (43.3% vs 27.87%, P = 0.003), but those did not translate into higher 30-day mortality or major systemic complications. There was no difference in wound complications or 30-day limb loss. CONCLUSIONS:SpV conduit affords significantly better 30-day primary patency than prosthetic grafts without increased mortality and morbidities. Therefore, despite greater procedural complexity and longer operative time, SpV conduit should be considered when available. Future prospective studies are needed to investigate the long-term outcomes of these 2 conduits.

Background: Numerous angiography-based peripheral arterial disease classification schemes have been developed to stratify severity of preoperative patient disease, but few studies have correlated angiography-based anatomic classification schemes to postoperative outcomes. This study examined whether a proposed pre-operative angiography scoring system was predictive of outcomes after isolated common femoral endarterectomy with profundaplasty (CFEP). Methods: A retrospective review was conducted of patients treated with isolated CFEP for claudication and/or rest pain at a single institution from 2016-19. Pre-operative angiograms were assessed quantitatively by 4 blinded surgeons across 3 domains: profunda stenosis, profunda disease length, and outflow disease severity. Table I describes the proposed angiography scoring system. Internal consistency reliability of rater scores was calculated using Cronbach alpha. Outcomes included clinical improvement, further interventions, major amputations, mortality, and mean increase in ankle-brachial index (ABI) at 30 days, and 6 months. McNemar tests, betweengroup t-tests, Pearson correlations, and linear regression were used. Results: Clinical Outcomes 88% of patients (n = 22) had clinical improvement at 30 days; the remaining 12% of patients (n = 3) required further interventions. One patient (4%) required major amputation between 30 days and 6 months for recurrence of rest pain that had initially resolved after isolated CFEP. There was 0% mortality during the study period. Mean ABI increased by 0.15 +/- 0.21 at 30 days, and by 0.06 +/- 0.21 at 6 months. Angiography Scoring System Profunda stenosis score was associated with clinical improvement at 6 months (P = 0.04). A profunda stenosis score of >= 2.6 was strongly associated with 6 month clinical improvement (64% of those >= 2.6 improved, versus 15% of those < 2.6, P = 0.15). Profunda stenosis score was associated with ABI improvement at 30 days (r = 0.73, P = 0.01) and 6 months (r = 0.82, P = 0.007). Profunda disease length score was associated with clinical improvement at 30 days (P = 0.002). 100% of patients with a profunda disease length score of >= 1.5 clinically improved at 30 days, versus 67% of those with <1.5 (P = 0.04). Angiography scores were not found to be associated with further intervention, major amputation, or mortality. Cronbach alpha for profunda stenosis, profunda disease length, and outflow severity scores were 0.90, 0.90, and 0.79, respectively, indicating strong internal consistency. Conclusions: This institutional angiography scoring system successfully predicts clinical improvement following CFEP. Higher profunda stenosis and profunda disease length scores were most predictive of operative success within 6 months. Future validation studies will investigate these outcomes in a larger population, and over a longer period.

Patients with acute aortoiliac occlusion typically present in extremis and require emergent revascularization using either aorta–bifemoral bypass (ABFB) or axillary–bifemoral bypass (AxBFB). Studies in the elective setting have shown AxBFB to result in lower morbidity and mortality compared with ABFB in high-risk patients. However, data in the emergent setting are lacking. We compared the outcomes for patients undergoing ABFB and AxBFB in the emergent setting. The 2005 to 2019 American College of Surgeons National Surgical Quality Improvement Program database was used to identify the patients who had undergone ABFB or AxBFB using the Common Procedural Terminology codes 35646 and 35654, respectively. Emergent cases with the International Classification of Diseases, 9th or 10th, revision, codes for acute aortoiliac occlusion were included. The outcomes of interest were 30-day mortality, major adverse cardiac events (including stroke, myocardial infarction, cardiac arrest), pulmonary and renal complications, operative time, bleeding requiring transfusion, a return to the operating room, wound infection, length of stay, and discharge destination. Statistical analysis was performed using two different methods: 1) multivariable analysis to correct for differences in preoperative patient characteristics; and 2) propensity score matching (PSM) to ensure clinically comparable patient characteristics between the ABFB and AxBFB groups. A total of 95 ABFB and 129 AxBFB emergent procedures were identified in the 2005 to 2019 database. The patients undergoing AxBFB were more likely to be women and older, have lower hematocrit and platelets, require preoperative transfusion, have chronic renal insufficiency, and have American Society of Anesthesiologists class 4 or 5. Although the initial univariable analysis showed AxBFB resulted in significantly greater 30-day mortality than did ABFB (36% vs 16%; P < .01), both multivariable and PSM analysis revealed comparable outcomes between AxBFB and ABFB, except for pulmonary events. After correcting for patient risk factors via multivariable analysis and, subsequently, 1:1 PSM, only pulmonary events remained significantly different between the two groups (33.3% ABFB vs 11.9% AxBFB; odds ratio, 3.7; 95% confidence interval, 1.23-11.17; P = .02; Table). The associated higher mortality with emergent AxBFB likely results from the selection of higher comorbid patients for the procedure. With the selection bias removed, AxBFB does not reduce mortality but does reduce the incidence of significant pulmonary complications. ABFB might be an acceptable option in the emergent setting for patients with good pulmonary function.TableThirty-day outcomes stratified by treatment group after 1:1 PSM30-Day outcomeABFB (n = 42)AxBFB (n = 42)Univariable P valueOR (ABFB)95% CIP valueMortality10 (23.81)11 (26.19)1.00000.880.31-2.46.81MACE6 (14.29)7 (16.67)1.00000.830.29-2.43.74Wound infection0 (0)6 (14.29).0258NANANARenal complications5 (11.9)4 (9.52)1.00001.280.30-5.59.74Sepsis6 (14.29)6 (14.29)1.00001.000.27-3.741.00DVT2 (4.76)1 (2.38)1.00002.050.17-24.47.57Pulmonary complications14 (33.33)5 (11.9).03523.701.23-11.17.02Return to operating room11 (26.19)10 (23.81)1.00001.140.46-2.79.78Operative time >4 hours18 (42.86)14 (33.33).501.500.68-3.31.31Length of stay >10 days16 (38.1)10 (23.81).23771.970.82-4.74.13Non–home discharge11 (32.35)11 (35.48).79980.820.33-2.00.66ABFB, Aorta–bifemoral bypass; AxBFB, axillary–bifemoral bypass; CI, confidence interval; DVT, deep vein thrombosis; MACE, major adverse cardiac events; NA, not applicable; OR, odds ratio; PSM, propensity score matching.Data presented as number (%).Boldface P values represent statistical significance. Open table in a new tab

BACKGROUND:Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned. METHODS:A single-center, retrospective review of medical records was conducted from March 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access. RESULTS:We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient.  Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO. CONCLUSIONS:Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

Mega-fistulae of autogenous arteriovenous (AV) access could result in arterial steal, high-output cardiac failure, or rupture with resulting hemorrhage. Current treatment options, which include ligation with or without jump prosthetic graft or imbrication, are suboptimal, leaving possible need for new accesses to be placed, cosmetically unappealing results, or future recurrent dilations. We describe a technique that allows for a complete resection of the mega-fistula while allowing continuous use of the AV access. This study is a retrospective, single-center, observational series of patients undergoing revision for mega-fistula from 2018 to 2020. The mega-fistulae were completely resected from the proximal to distal portion of the aneurysmal segment, including all pseudoaneurysms, followed by tunneling of a prosthetic graft lateral to the incision and dissection plane with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access. Outcomes reviewed were immediate technical success, need for long-term catheter placement, time to access use, and short and long-term patency and complications. There were 12 patients who underwent mega-fistula revision. Immediate technical success was achieved in all cases. Eight patients received Propaten (W.L. Gore and Associates, Inc, Flagstaff, Ariz), and four patients received Acuseal (W. L. Gore and Associates, Inc) grafts. Long-term catheters were placed in all eight patients receiving Propaten grafts and one receiving an Acuseal graft. The average time to access use was 6 weeks for the Propaten graft and 3.75 days for the Acuseal graft. At 30 days, three patients that received the Propaten graft developed complications, including one with skin necrosis requiring skin grafting; one with a seroma; and one with a hematoma, both requiring evacuation; one patient with Acuseal graft developed central venous occlusion. Of the five patients with follow-up after 6 weeks, three report no complications and continuous use of the access, including one who underwent renal transplant. One patient required thrombectomy and venous angioplasty, and one required a new AV access 17 months postoperatively due to graft thrombosis. Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and eliminates the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

Objective: Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. Methods: All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. Results: There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3 +/- 7.2 vs. 74.2 +/- 7.7, P = 0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups. Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR = 1.22; 95% CI = 0.35 4.22; P = 0.753) or unplanned re-operation (4.5% vs 5.1%; OR = 0.78; 95% CI = 0.22 2.70; P = 0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR = 0.12; 95% CI = 0.03 0.42; P < 0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI = 0.07 0.86; P = 0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P < 0.0001; hospital stay: 3 days vs 8 days, P < 0.0001). Conclusion: For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.

BACKGROUND:Recently, open abdominal aortic aneurysm (AAA) repair (OSR) has become less common and will often be reserved for patients with more complex aortic anatomy. Despite improvements in patient management, the reduced surgical volume has raised concerns for potentially worsened outcomes in the contemporary era (2014-2019) compared with an earlier era in which OSR was more widely practiced (2005-2010). In the present study, we compared the 30-day outcomes of open AAA repair between these two eras. METHODS:The American College of Surgeons National Quality Improvement Program general database was queried for open AAA repair using the Current Procedural Terminology and International Classification of Diseases, 9th and 10th, codes. The cases were stratified into two groups by operation year: 2005 to 2010 (early) and 2014 to 2019 (contemporary). In each era, the cases were further divided into elective and ruptured groups. The 30-day outcomes, including mortality, major morbidity, postoperative sepsis, and unplanned reoperation, were compared between the contemporary and early eras in the elective and ruptured groups. Preoperative variables with a P value <.25 were adjusted for in the multivariate analysis. RESULTS:In the contemporary and early eras, 3749 and 3798 patients had undergone elective OSR and 1148 and 907 had undergone ruptured OSR, respectively. These samples were of similar sizes owing to the National Quality Improvement Program sampling process and our relatively strict inclusion criteria. In the contemporary era, fewer patients were elderly and fewer were smokers or had hypertension or dyspnea in the elective and rupture cohorts. More patients had had American Society of Anesthesiologists class >3 in the elective contemporary era (39% vs 24%; P < .0001). The contemporary elective repair group demonstrated increased 30-day mortality (3.7% vs 3.2%; adjusted odds ratio [aOR], 1.36; P = .006), major adverse cardiac events (5.7% vs 3.4%; aOR, 1.87; P < .0001), and bleeding requiring transfusion (58.5% vs 13.7%; aOR, 8.96; P < .0001). The incidence of pulmonary complications (12.1% vs 15.2%; aOR, 0.80; P = .02) and sepsis (3.7% vs 8.4%; aOR, 0.47; P < .0001) had decreased in the contemporary era, with a similar rate of unplanned reoperations (8.4% vs 7.7%; aOR, 1.16; P = .09). The incidence of renal complications in the contemporary era had increased, with a statistically significant difference. However, the absolute increase of <0.5% was likely not clinically relevant (5.5% vs 5.1%; aOR, 1.23; P = .049). In the ruptured cohort, contemporary repair was associated with increased 30-day mortality (41.4% vs 40%; aOR, 1.53; P < .0001), major adverse cardiac events (25.8% vs 12.8%; aOR, 2.49; P < .0001), and bleeding requiring transfusion (88.2% vs 27%; aOR, 23.03; P < .0001). The incidence of pulmonary complications (36.9% vs 48.1%; aOR, 0.67; P < .0001), sepsis (14.6% vs 23%; aOR, 0.75; P = .03), and unplanned reoperations (18.1% vs 22.7%; aOR, 0.74; P = .008) had decreased in the contemporary OSR group. No differences were detected in the incidence of renal complications. CONCLUSIONS:The 30-day mortality has worsened after open AAA repair in the elective and rupture settings despite the improvements in perioperative management over the years. These complications likely stem from increased bleeding events and major cardiac events, which were increased in the contemporary era.

In the absence of adequate continuous segment of saphenous vein for infrapopliteal bypasses, early patency of prosthetic bypasses has been disappointing. Whether the performance of infrapopliteal bypasses can be improved if performed using spliced vein (SpV) grafts remains unclear. Our study investigates 30-day limb-related outcomes of SpV and prosthetic grafts for infrapopliteal (to tibial or peroneal arteries) bypasses. Procedures from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Database module for “Lower Extremity Open (LEO)” from 2012 to 2019 were first identified by two procedure types: “femoral-distal bypass with vein” or “femoral-distal bypass with PTFE/spliced/composite.” From these cases, SpV was defined as a combination of two Current Procedural Terminology (CPT) codes (35566 for fem-tib with vein and 35802 or 35803 for spliced vein segments). The PTFE group was defined as fem-tib with other than vein with or without vein cuff (CPT code 35666 with or without 35801). The two studied groups (PTFE vs SpV) were propensity matched (4:1 PTFE:SpV) for all preoperative characteristics, and 30-day outcomes were measured between the matched groups. The primary outcomes were 30-day major amputation, patency, and major reintervention. Other outcomes included 30-day mortality, major morbidity, bleeding events, and wound complications. SpV conduit exhibited significantly better 30-day patency than PTFE (92.5% vs 81.3%; P = .0014). There was a trend toward lower 30-day limb loss (adjusted odds ratio [aOR], 0.35; P = .09), and fewer major reinterventions (aOR, 0.37; P = .06) compared with PTFE, but the differences did not reach statistical significance. SpV bypasses also exhibited significantly longer operative time (364 vs 242 minutes; P < .0001), higher bleeding risk (1.81; P = .0015) and increased wound complications (1.95; P = .01). There was no significant difference in 30-day mortality or major complications between the two groups (Table). Due to a low number of events in the SpV group, overall power was low for amputation and reintervention and likely contributes to our inability to find a statistical difference (Type II error). In conclusion, SpV conduit affords significantly better 30-day bypass patency and is preferable compared with PTFE for acceptable risk patients without severe medical comorbidities or at high risk of wound complications. In patients unable to tolerate longer procedures, or at high risk of wound complications, PTFE bypass can be offered with acceptable short-term outcomes. Additional studies will be needed to evaluate the long-term outcomes of these procedures.TablePropensity matched outcomes between SpV vs PTFEOutcomeUnivariable comparisonAccounting for correlated outcomes in matched groupsPTFE (n = 715) No. (%)SpV (n = 156) No. (%)P valueaOR for SpV vs PTFE (95% CI)P valuePrimary patency492 (81.3)136 (92.5).00072.83 (1.50-5.36).0014Major reintervention47 (6.6)4 (2.6).060.37 (0.13-1.05).06Major amputation38 (6.0)3 (2.2).090.35 (0.10-1.18).0930-day mortality17 (2.4)3 (1.9).990.81 (0.23-2.82).74Major morbidity MACE37 (5.2)10 (6.4).561.26 (0.62-2.54).53 Pulmonary26 (3.6)5 (3.2).990.87 (0.36-2.14).77 Renal7 (1.0)2 (1.3).671.32 (0.27-6.47).73 Return to OR127 (17.8)26 (16.7).820.92 (0.58-1.47).74 Sepsis21 (2.9)3 (1.9).600.65 (0.20-2.12).47 Wound events45 (6.3)18 (11.5).031.95 (1.11-3.42).02 Bleeding with transfusion210 (29.4)67 (43.0).0011.81 (1.26-2.61).0015PTFESpVKruskal-Wallis POperative time, minutes242 ± 101364 ± 115<.0001aOR, Adjusted odds ratio; CI, confidence interval; MACE, major adverse cardiac event; OR, operating room; SpV, spliced vein.Boldface P represents statistical significance. Open table in a new tab

Objective: Endovascular repair of juxtarenal abdominal aortic aneurysms (JAAAs) with fenestrated grafts (fenestrated endovascular aneurysm repair [FEVAR]) has been reported to decrease operative mortality and morbidity compared with open surgical repair (OSR). However, previous comparisons of OSR and FEVAR have not necessarily included patients with comparable clinical profiles and aneurysm extent. Although FEVAR has often been chosen as the first-line therapy for high-risk patients such as the elderly, many patients will not have anatomy favorable for FEVAR. At present, a paucity of data has examined the operative outcomes of OSR in elderly patients for JAAAs relative to FEVAR. Therefore, we chose to perform a propensity-matched comparison of OSR and FEVAR for JAAA repair in patients aged >= 70 years. Methods: Patients aged >= 70 years who had undergone elective nonruptured JAAA repairs from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted endovascular aneurysm repair (EVAR) and AAA databases. Patients who had undergone FEVAR were identified in the targeted EVAR database as those who had received the Cook Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind). Because our study specifically examined JAAAs, those patients who had undergone OSR with supraceliac proximal clamping or concomitant renal/visceral revascularization were excluded. A 1:1 propensity-match algorithm matched the OSR and FEVAR patients by preoperative clinical and demographic characteristics, operative indications, and aneurysm extent. The 30-day outcomes, including mortality, major adverse cardiovascular events, and pulmonary and renal complications, were compared between the propensity-matched OSR and FEVAR groups. Results: A 1:1 propensity match was achieved, and the final analysis included 136 OSR patients and 136 FEVAR patients. No significant differences were found in 30-day mortality (4.4% vs 3.7%; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.36-4.06; P = .759) between the OSR and FEVAR groups. OSR was associated with a higher incidence of major adverse cardiovascular events compared with FEVAR; however, the trend was not statistically significant (8.1% vs 3.7%; OR, 2.31; 95% CI, 0.78-6.82; P = .131). Compared with FEVAR, the OSR group had significantly greater rates of pulmonary complications (19.1% vs 3.7%; OR, 6.19; 95% CI, 2.30-16.67; P < .001) and renal complications (8.1% vs 2.2%; OR, 3.90; 95% CI, 1.06-14.31; P = .040). Conclusions: In the samples assessed in the present study, the results with OSR of JAAAs in the elderly did not differ from those of FEVAR with respect to 30-day mortality despite a greater incidence of pulmonary and renal complications. Although FEVAR should remain the first-line therapy for JAAAs in elderly patients, OSR might be an acceptable alternative for select patients with anatomy unfavorable for FEVAR.

The Global Vascular Guidelines' “Global Limb Anatomic Staging System” (GLASS) was designed to provide an angiography-based anatomic classification of peripheral vascular disease and to guide revascularization strategies. Our study uses GLASS to evaluate outcomes after open and endovascular isolated infrapopliteal revascularization for chronic limb-threatening ischemia. This is a single institution study that retrospectively reviewed patients undergoing below-knee popliteal-to-tibial bypass (PTB) or tibial angioplasty/atherectomy/stenting (TA) for chronic limb-threatening ischemia from 2014 to 2020. A panel of blinded surgeons scored preoperative angiograms using established GLASS criteria. After examining preoperative characteristics, we compared rest pain improvement, wound healing, major reintervention, major amputation, and mortality at 6 weeks, 6 months, and 1 year. We evaluated patency rates for PTB. We compared the above outcomes based on procedure only and then on the GLASS stage within each procedure cohort. A total of 25 PTB patients and 47 TA patients met inclusion criteria. There were more patients with preoperative dialysis in the TA cohort; otherwise the cohorts were similar (8% PTB vs 28.9% TA; P = .03). Most patients in both cohorts underwent intervention for tissue loss (80% PTB vs 87% TA; P = .18). Procedure-based Results most patients (68%) were GLASS III; however, this varied by procedure (84% PTB vs 58% TA; P = .05). There was no difference in rest pain improvement, major intervention, major amputation, or morality at 6 weeks, 6 months, or 1 year. The TA cohort had significantly greater foot-wound healing at 1 year compared with the PTB cohort (12.5% PTB vs 71.4% TA; P = .04). Cumulative patency was 89%, 89%, and 69% at 6 weeks, 6 months, and 1 year, respectively. GLASS-based Results within the PTB cohort, GLASS I was associated with rest pain improvement at 6 weeks (100%, P < .0001), whereas GLASS I and III were associated with rest pain improvement at 6 months (100% vs 8.3%; P = .029) (Table I). GLASS I and II exhibited improved wound healing at 6 months (P = .005) (Table I). Alternatively, in the TA cohort, patients with GLASS I required more reinterventions at 6 weeks than those with higher GLASS stage (20%, P = .04) (Table II). Our study revealed improved wound healing after TA at 1 year, compared with PTB. This may be due to a drop in patency rates between 6 months and 1 year seen in the PTB cohort. GLASS stage did not consistently correlate with expected clinical outcomes. Larger studies will be needed to confirm these findings.Table IIProcedural outcomes and complications related to tibial angioplasty/atherectomy/stenting (TA) for critical limb-threatening ischemia staged according to the Global Limb Anatomic Staging System (GLASS)OutcomeGLASS IGLASS IIGLASS IIIPSix weeksn = 10n = 7n = 23Reintervention2 (20)00.043Major amputation01 (14.3)1 (4.3).403Mortality01 (14.3)0.09Data are presented as number (%). Open table in a new tab Table IProcedural outcomes and complications related to below-knee popliteal-to-tibial bypass (PTB) for critical limb-threatening ischemia staged according to the Global Limb Anatomic Staging System (GLASS)OutcomeGLASS IGLASS IIGLASS IIIPSix weeksn = 1n = 3n = 17Rest pain1 (100)00<.0001Preoperative wound healed004 (23.5).56Reintervention001 (5.9).88Major amputation000–Mortality01 (33.3)0.04Six monthsn = 1n = 2n = 2Rest pain1 (100)01 (8.3)0.03Preoperative wound healed1 (100)1 (50)00.005Reintervention000–Major amputation001 (8.3)0.875Mortality000– Open table in a new tab

Carotid endarterectomy (CEA) is a common surgical procedure performed by different surgical specialties. We compared the patient characteristics, operative techniques, and 30-day outcomes of CEA performed by vascular surgeons (VSs), cardiac surgeons (CSs), and neurosurgeons (NSs). We performed a retrospective, propensity-matched, cohort study of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted database for CEA. We selected all patients in the targeted CEA module who had undergone CEA from 2012 to 2019. Patients who had undergone concomitant coronary artery bypass grafting were excluded. The patients were divided by reported surgeon specialty (VSs, CSs, and NSs). The preoperative characteristics and operative techniques were compared between all specialties using χ2 analysis. We then compared the following groups after propensity matching (5 VSs to 1 NS/CS) for all preoperative variables: VSs vs CSs and VSs vs NSs. The 30-day outcomes, including mortality, major morbidity, stroke, reoperation, operative time, and hospital stay, were evaluated between the matched groups. A total of 30,336 patients had been treated by VSs, 1052 by NSs, and 353 by CSs. After 5:1 matching, the analysis consisted of 1707 VSs vs 345 CSs and 5115 VSs vs 1027 NSs. CSs had treated the greatest proportion of asymptomatic patients, and NSs had treated the greatest proportion of symptomatic patients (72.8%, 56.6%, and 24.4% for CSs, VSs, and NSs, respectively; P < .0001). CSs had the highest proportion of patients with American Society Anesthesiologists class >III (39.9%, 22%, and 21.2% for CSs, NSs, and VSs, respectively; P < .0001). VSs had used general anesthesia the least often (84.8%, 99.6%, and 100% for VSs, NSs, and CSs, respectively; P < .0001) and intraoperative shunting the most frequently (33.2%, 9.2%, and 11.6% for VSs, NSs, and CSs, respectively; P < .0001). After matching, no significant preoperative differences were found within the groups. No significant differences were found between the VSs and CSs in mortality or stroke. However, compared with the CSs, the VSs reported fewer pulmonary complications (adjusted odds ratio [aOR], 0.36; P = .0005) and unplanned reoperations (aOR, 0.45; P = .005), with longer operative times (122 minutes vs 76 minutes; P < .0001; Tables I and II). Compared with NSs, VSs had significantly reduced rates of stroke (aOR, 0.54; P = .0012), pulmonary complications (aOR, 0.50; P = .0005), and cardiac complications (aOR, 0.50; P = .01), with shorter operative times (123 minutes vs 145 minutes; P < .0001; Tables I and II). Differences in patient selection, anesthesia techniques, and operative times were found between VSs, CSs, and NSs. In our propensity-matched analysis, VSs had fewer postoperative complications than either NSs or CSs.Table IOutcomes in propensity-matched cohort: VSs vs CSsOutcomeVS (n = 1707)CS (n = 345)aOR for outcomes (95% CI)P valueMortality19 (1.1)7 (2.0)0.54 (0.22-1.31).17Cardiac29 (1.7)6 (1.7)0.98 (0.40-2.38).96MI/arrhythmia33 (1.9)10 (2.9)0.66 (0.32-1.35).25Cardiac arrest8 (0.5)3 (0.9)0.54 (0.14-2.18).39Pulmonary35 (2.1)19 (5.5)0.36 (0.20-0.64).0005Renal4 (0.2)2 (0.6)0.40 (0.07-2.22).30Sepsis4 (0.2)4 (1.2)0.20 (0.05-0.81).024Wound11 (0.6)1 (0.3)2.23 (0.28-17.67).45Return to OR41 (2.4)18 (5.2)0.45 (0.25-0.79).005Bleeding37 (2.2)9 (2.6)0.83 (0.40-1.73).63Stroke32 (1.9)10 (2.9)0.64 (0.31-1.33).23TIA8 (0.5)1 (0.3)1.62 (0.20-13.04).65Restenosis5 (0.3)2 (0.6)0.50 (0.10-2.62).42Distal embolization1 (0.1)0 (0)NA.99Operative time, minutes122 ± 4773 ± 25NA<.0001aHospital LOS, days2.7 ± 3.93.2 ± 5.1NA.55aaOR, Adjusted odds ratio; CI, confidence interval; CS, cardiac surgeon; LOS, length of stay; MI, myocardial infarction; NA, not applicable; OR, operating room; TIA, transient ischemic attack; VS, vascular surgeon.Data presented as number (%) or mean ± standard deviation.Boldface P values represent statistical significance.aUsing the nonparametric Kruskal-Wallis test. Open table in a new tab Table IIOutcomes in propensity-matched cohort: VSs vs NSsOutcomeVS (n = 5115)NS (n = 1027)aOR for outcomes (95% CI)P valueMortality40 (0.8)9 (0.9)0.89 (0.43-1.86).76Cardiac48 (0.9)19 (1.9)0.50 (0.30-0.85).01MI/arrhythmia56 (1.1)17 (1.7)0.66 (0.39-1.12).11Cardiac arrest15 (0.3)4 (0.4)0.75 (0.25-2.28).61Pulmonary88 (1.7)35 (3.4)0.50 (0.34-0.73).0005Renal12 (0.2)3 (0.3)0.80 (0.23-2.85).73Sepsis18 (0.4)12 (1.2)0.30 (0.14-0.62).0013Wound29 (0.6)2 (0.2)2.92 (0.69-12.32).14Return to OR157 (3.1)32 (3.1)0.98 (0.67-1.45).94Bleeding67 (1.3)23 (2.2)0.58 (0.36-0.94).03Stroke107 (2.1)39 (3.8)0.54 (0.37-0.78).0012TIA47 (0.9)12 (1.2)0.78 (0.41-1.49).46Restenosis19 (0.4)7 (0.7)0.54 (0.23-1.27).16Distal embolization15 (0.3)6 (0.6)0.50 (0.19-1.30).15Operative time, minutes123 ± 48145 ± 53NA<.0001aHospital LOS, days3.2 ± 4.24.8 ± 5.7NA<.0001aaOR, Adjusted odds ratio; CI, confidence interval; CS, cardiac surgeon; LOS, length of stay; MI, myocardial infarction; NA, not applicable; OR, operating room; TIA, transient ischemic attack; VS, vascular surgeon.Data presented as number (%) or mean ± standard deviation.Boldface P values represent statistical significance.aUsing the nonparametric Kruskal-Wallis test. 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Pomy, Benjamin J. MD; Lala, Salim MD, FACS; Amdur, Richard L. PhD; Sidawy, Anton N. MD, FACS; Macsata, Robyn A. MD, FACS Author Information

Objective: Open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) has often been reserved in contemporary practice for complex aneurysms requiring a suprarenal or supraceliac proximal clamp level. The present study investigated the associated 30-day outcomes of different proximal clamp levels in OSR of complex infrarenal/juxtarenal AAA in patients with normal renal function and those with chronic renal insufficiency (CRI). Methods: All patients undergoing elective OSR of infrarenal and juxtarenal AAA were identified in the American College of Surgeons National Surgical Quality Improvement Program-targeted AAA database from 2012 to 2018. The patients were stratified into two cohorts (normal renal function [estimated glomerular filtration rate, >= 60 mL/min] and CRI [estimated glomerular filtration rate, <60 mL/min and no dialysis]) before further substratification into groups by the proximal clamp level (infrarenal, inter-renal, suprarenal, and supraceliac). The 30-day outcomes, including mortality, renal and pulmonary complications, and major adverse cardiovascular event rates, were compared within each renal function cohort between proximal clamp level groups using the infrarenal clamp group as the reference. Supraceliac clamping was also compared with suprarenal clamping. Results: A total of 1284 patients with normal renal function and 524 with CRI were included in the present study. The proximal clamp levels for the 1808 patients were infrarenal for 1080 (59.7%), inter-renal for 337 (18.6%), suprarenal for 279 (15.4%), and supraceliac for 112 (6.2%). In the normal renal function cohort, no difference was found in 30-day mortality with any clamp level. Increased 30-day acute renal failure was only observed in the supraceliac vs infrarenal clamp level comparison (5.9% vs 1.5%; adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 1.04-5.18; P = .044). In the CRI cohort, supraceliac clamping was associated with an increased rate of renal composite complications (22.7% vs 5.6%; aOR, 8.81; 95% CI, 3.17-24.46; P<.001) and ischemic colitis (13.6% vs 3.0%; aOR, 4.78; 95% CI, 1.38-16.62; P = .014) compared with infrarenal clamping and greater 30-day mortality (13.6% vs 2.4%; aOR, 6.00; 95% CI, 1.14-31.55; P = .034) and renal composite complications (22.7% vs 10.8%; aOR, 2.87; 95% CI, 1.02-8.13; P = .047) compared with suprarenal clamping. Suprarenal clamping was associated with greater renal dysfunction (10.8% vs 5.6%; aOR, 2.77; 95% CI, 1.08-7.13; P = .035) compared with infrarenal clamping, with no differences in mortality. No differences were found in 30-day mortality or morbidity for inter-renal clamping compared with infrarenal clamping in either cohort. No differences were found in major adverse cardiovascular events with higher clamp levels in either cohort. Conclusions: In elective OSR of infrarenal and juxtarenal AAAs for patients with CRI, this study found a heightened mortality risk with supraceliac clamping and increased renal morbidity with suprarenal clamping, though these effects were not present for patients with normal renal function. Every effort should be made to keep the proximal clamp level as low as possible, especially in patients with CRI.

Renal artery aneurysms (RAAs) are rare, with an estimated incidence of 0.01% to 0.97%. These aneurysms are often asymptomatic, although they occasionally manifest with hypertension, back pain, hematuria, or rupture. Despite limited evidence guiding treatment, women of childbearing age are consistently offered treatment because of the high risk of rupture. We present a case of a woman planning pregnancy with bilateral RAAs after failed endovascular management. She underwent bilateral laparoscopic nephrectomy, ex vivo reconstruction, and autotransplantation for treatment of her aneurysms. This appears to be safe and effective for treatment of RAAs and should be considered in similar patients.