Since 2006, The Southern Association for Vascular Surgery (SAVS) has administered an annual mock oral examination (MOE) to prepare trainees and recent graduates of vascular residency programs for the Vascular Certifying Examination. A study published in 2015 evaluated the SAVS MOE using surveys of examiners and examinees. Examiners from that study reported pervasive knowledge deficits in open surgical techniques and the management of surgical complications. Although the study authors recommended broad educational efforts by programs and specialty societies to address those deficits, specific areas of deficit were not defined.

The "inside-out" technique eliminates the need for subclavian or femoral catheter placement by placing a supraclavicular catheter via a percutaneous femoral vein access. Few reports of its use in vascular surgery exist. The purpose of this article is to describe our version of the technique and report results. Between 2016 and 2017, the inside-out technique was performed on eight patients. All patients had more than four prior access sites and bilateral internal jugular vein occlusion. The technical success rates were 100% with no periprocedural complications and success in achieving dialysis access. One patient required catheter replacement within 48 hours, one catheter was used as a bridge to Hemodialysis Reliable Outflow (Hemosphere, a Cryolife Inc Company, Eden Prairie, Minn) graft placement, and one patient died of sepsis unrelated to their catheter. Our data show the inside-out technique to be safe and effective, removes the need for subclavian or femoral catheter placement, and should be a component of treatment algorithms for complex dialysis patients, which is consistent with National Kidney Foundation's Kidney Disease Outcomes Quality Initiative recommendations.

Patients with multiple failed dialysis accesses and limited access sites can present a significant challenge to vascular surgeons. The presence of central venous occlusion and the need for temporary or permanent dialysis catheter placement are especially problematic. Previous reports have described an “inside-out” technique that avoids the need for subclavian or femoral catheter placement by placing a supraclavicular catheter through a percutaneous femoral vein. However, very few reports of its use in vascular surgery exist. The purpose of this paper was to describe our version of the technique and to report the results. All procedures were performed using general anesthesia or conscious sedation supplemented with local anesthesia. Ultrasound guidance was used for common femoral venous access, and a superior venacavogram, anteroposterior and oblique views, was obtained to document the level of caval occlusion. An 8F, 81-cm-long, braided trans-septal sheath (Swartz Braided SL1; St. Jude Medical, St. Paul, Minn) was advanced until the tip of the dilator was at the level of the caval occlusion. The tip was then oriented anterolaterally toward the clavicular head. After this, the back end of a 0.014-inch Confianza wire (Asahi Intecc, Aichi, Japan) was passed through the dilator, forced through the vein wall (achieving a subcutaneous location), and advanced until it tented the skin at the base of the neck posterior to the clavicle. Next, a small incision was made over the wire before it was grasped with a hemostat and retrieved from the subcutaneous tissue. A micropuncture sheath was then placed over the back end of the Confianza wire and advanced into the SL1 catheter. After injection of contrast material to confirm placement, a 0.035-inch Amplatz Super Stiff guidewire (Boston Scientific, Marlborough, Mass) was advanced through the microsheath into the SL1 catheter. The guidewire was then advanced into the inferior vena cava while the SL1 catheter was withdrawn. The tunneled catheter was placed in standard fashion. Between August 2016 and July 2017, eight patients underwent dialysis catheter placement by this technique (Table). All patients had more than four prior access sites and had bilateral internal jugular vein occlusion. Technical success rate was 100%, with no periprocedural complications. All procedures were successful in achieving a functioning dialysis access. One patient required catheter replacement within 48 hours secondary to inadequate tip placement proximal to the right atrium. One catheter was used as a bridge to HeRO graft (Merit Medical, South Jordan, Utah) placement. One patient died of sepsis unrelated to the catheter. Our data show the inside-out catheter placement technique to be safe and effective. This procedure allows avoidance of subclavian or femoral catheter placement and should be a component of every vascular surgeon's treatment algorithm for complex dialysis patients.TableDescription of patient characteristics and outcomesNo. of patients8No. of patients8Characteristics Age, years, mean ± standard deviation59.8 ± 14.8 Male sex3 (37.5)Results Technical success8 (100.0) Patency, days, mean (range)81 (7-370) Procedural complications0 (0.0) Contrast agent volume, mL, mean43.1 Fluoroscopy time, minutes, mean15.1Values are reported as number (%) unless otherwise indicated. Open table in a new tab

OBJECTIVE:The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. METHODS:The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. RESULTS:Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. CONCLUSIONS:The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.

An international panel of vascular access experts used the RAND Appropriateness Method (RAM) to develop criteria for upper extremity access procedure selection based on patient-specific factors (age, vascular anatomy, dialysis timing, body mass index [BMI], comorbidities). Their recently published work builds on the National Kidney Foundation Dialysis Outcome Quality Initiative (KDOQI) and, like KDOQI, is based on best available medical evidence and expert opinion. Given the large number of potential patient scenarios considered by the group, the publication did not result in a tool useful to the practitioner. Using the RAM project database, we developed a Vascular Access Procedure Selection (VAPS) mobile app that guides procedure selection, and we report the results of a study validating its use. The records of 201 consecutive patients who underwent upper extremity arteriovenous fistula (AVF)/arteriovenous graft (AVG) placement (mean age, 57 years; male, 61%; mean BMI, 31 kg/m2; catheter, 72%; diabetes mellitus, 61%) were retrospectively reviewed. Factors (vein/artery size, BMI, age, dialysis status, functional status) for each patient were entered into the VAPS mobile app, and the recommended and actual procedures were compared for each patient. The nonmaturation rates for AVF recommended by the VAPS mobile app were compared with AVF creations not recommended. The VAPS recommended an AVF as an appropriate procedure option in 170 of 201 patients (85%). The actual and recommended procedure matched in 117 patients (radiocephalic fistula, 55; forearm vein transposition, 2; brachiocephalic fistula, 46; basilic vein transposition, 14). In 53 cases where an AVF was recommended, an AVG was placed or a nonrecommended AVF was created (AVG, 36; AVF, 17). Excluded were 25 patients who were lost to follow-up, died early, or never started dialysis. The functional maturation rate for AVF recommended by the VAPS was 78% (matured, 75; failed, 21). At least one intervention was required in 29% (22 of 75) of matured fistulas required to achieve maturation. The maturation rate for AVF not recommended by the VAPS was 62% (matured, 8; failed, 5). The VAPS mobile app is an easy to use tool that selects the most appropriate vascular access procedure for patient-specific clinical situations based on evidence-based literature and expert opinion. AVF nonmaturation rates using the VAPS may compare favorably to the 30% to 60% nonmaturation rates reported by contemporary series. The VAPS mobile app will improve outcomes by standardizing vascular access procedure selection and by guiding the surgeon toward AVF in situations where AVF are likely to be successful and toward AVG in situations where AVF failure is likely.

This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions.

The Kidney Disease Outcome Quality Initiative (K-DOQI) and Fistula First Breakthrough Initiative indiscriminately call for the creation of arteriovenous fistulas (AVF) over grafts (AVG) without providing patient-specific criteria for procedure selection. This singular focus on increasing AVF has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. Unlike the K- DOQI consensus process, the RAND/UCLA Appropriateness Method (RAM) is a validated tool, used when randomized trials are not feasible, that combines best evidence with expert opinion to determine the appropriateness of performing a procedure at a patient-specific level. This study used the RAM to establish the appropriateness or inappropriateness of vascular access procedures in clinical scenarios constructed with combinations of factors potentially influencing outcomes. According to the RAM, a comprehensive literature search was performed and a synthesis of results was compiled. The RAM was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts graded the appropriateness of each scenario in two rounds. Based on the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. A total of 482 (23%) AVF and 467 (27%) AVG scenarios were scored as appropriate, 703 (34%) AVF and 405 (23%) AVG scenarios were scored as inappropriate, 903 (43%) AVF and 856 (49%) AVG scenarios were indeterminate. Younger age, predialysis status, larger outflow vein diameter, normal or obese body mass index (BMI; vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with fistula or graft appropriateness. BMI and functional status were not associated with graft appropriateness. To simulate surgeon decision making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. A total of 292 of 864 (34%) of the clinical situations were rated as appropriate for AVG but inappropriate/indeterminate for AVF. The results of this RAND/UCLA appropriateness study indicate that patient-specific situations exist where AVG is as appropriate or more appropriate than AVF. These results provide patient-specific guidelines for clinicians to optimize vascular access selection criteria, standardize care, and inform payors/policy. Indeterminate scenarios will guide future research.

Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence (n=25) or absence (n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3-11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.

Background: The decision about the type and location of a hemodialysis vascular access is challenging and can be affected by multiple factors. We explored the effect of several a priori chosen patient characteristics on access outcomes.Methods: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through November 13, 2014. We included studies that evaluated patency, mortality, access infection, and maturation of vascular access in adults requiring long-term dialysis. Pairs of reviewers working independently selected the studies and extracted the data. Outcomes were pooled across studies using the random-effects model.Results: Two hundred studies met the eligibility criteria reporting on 875,269 vascular accesses. Overall, studies appeared to have provided incidence rates at low to moderate risk of bias. The overall primary patency at 2 years was higher for fistulas than for grafts and catheters (55%, 40%, and 50%, respectively). Patency was lower in individuals with diabetes, coronary artery disease, older individuals, and in women. Mortality at 2 years was highest with catheters, followed by grafts then fistulas (26%, 17%, and 15%, respectively).Conclusions: The current evidence remains in support of autogenous access as the best approach when feasible. We provide incidence rates in various subgroups to inform shared decision making and facilitate the conversation with patients about access planning.

Background: The purpose of this analysis is to examine desired patient outcomes after vascular surgery and to measure the achievement of these outcomes when applied to a large cohort of patients undergoing intervention for critical limb ischemia (CLI). Methods: To understand patient expectations after vascular intervention, 102 consecutive patients undergoing elective operations were prospectively administered a standardized preoperative questionnaire regarding the characteristics of a successful outcome. The following were identified: 1) maintenance of living independence, 2) maintenance of ambulatory status, 3) control/relief of pain, 4) no additional/nonroutine physician visits, and 5) survival for 1 year. These outcomes were then applied retrospectively to a cohort of 954 consecutive patients with CLI (37% rest pain, 37% ischemic ulceration, 26% gangrene) undergoing planned intervention (57% open, 41% endo, 2% both) to analyze patient-centered success. Results: While 12-month overall success for maintenance of independence was 89% (n = 849), maintenance of ambulation 84% (n = 802), control/relief of pain 48% (n = 461), no additional physician visits 36% (n = 340), and 1-year survival 79% (n = 755), overall patient-entered success (achievement of all 5 patient-centered success outcomes) was accomplished in only 23% (n = 218) of patients. Of 20 variables examined, end-stage renal disease (OR [95%CI] 2.21[1.26-3.88]; P = .006) and impaired ambulatory status preoperatively (OR [95%CI] 1.76 [1.12-2.79]; P = .015) were independent predictors of failure. The probability of experiencing patient-centered failure was 93% in patients with both end-stage renal disease and impaired ambulatory status preoperatively. Conclusions: If patients alone are allowed to define their outcomes after vascular intervention, success is infrequent. These data suggest that successful overall outcome may best be achieved when physicians and patients mutually target specific attainable goals and strive to achieve them. W hen planning intervention for their patients, surgeons are trained to achieve the best outcome possible. Typically, that outcome is defined by evidence accumulated through medical research from surgical investigators who often focus on postoperative goals they deem as important. In the case of vascular disease, surgeons define treatment success referencing parameters such as survival, intervention patency rate, 30-day complication rate, and freedom from comorbid vascular event. Though important, these definitions of success GHS Proc. May 2016; 1 (1): 13-21 Figure 1 The questionnaire utilized when determining patient-centered outcomes for 102 patients undergoing elective vascular surgery. RESEARCH STAFF: Check the line below if patient refused to participate and save this questionnaire as if patient completed it Patient Refused:_________ RESEARCH STAFF: ASK THE QUESTIONS BELOW AND WRITE THE RESPONSES IN THE SPACES BY OR UNDER THE QUESTIONS: (1) What is the reason you are having surgery? (2) Is there anything that helped you decide surgery was the best choice for you? (3) What will surgery allow you to do that you cannot do now? (4) What do you consider a successful surgery outcome? (5) Is there anything you will need to do to help you get better after surgery? (6) How long do you think it will take you to recover after your surgery? (7a) Do you think the surgery may keep you from doing things you want? [if “yes” to above question] (7b) What are the things you think surgery will keep you from doing? (8) How many times do you think you will have to come back to the doctor for “follow up”? (9) We listed some things that some people hope surgery improves. I’ll put a check by any items you hope your surgery improves. I can check as many or as few as you like. Pain Relief_________ Daily functioning (washing, shopping)_________ Work attendance_________ Avoiding repeat doctor visits for the same problem_________ Hobbies_________ Mobility_________ Anything not listed, but important to you? [IF YES, RESEARCH STAFF WRITE IN “OTHER”]_________ (10) Thinking about what you checked above. Help me order them by how important they are to you; I’ll number the item you think most important with a “1”, the item you think is second most important with a “2”, the item you think is third most important with a “3”. I’ll continue numbering until rank all items you checked. Pain Relief_________ Improve daily functioning(washing, shopping)_________ Work attendance_________ Avoiding repeat doctor visits for the same problem_________ Hobbies_________ Mobility_________ “Other” item patient identified above_________ (11) What is your gender Male _________ Female_________ (12) How old were you on your last birthday Age_________ (13) Are you Hispanic, Latino, or Spanish Origin? No, not Hispanic, Latino or Spanish Origin_________ Yes, Mexican, Mexican American, Chicano_________ Yes, Puerto Rican_________ Yes, Cuban_________ Yes, another Hispanic Latino or Spanish origin_________ (14) What is your Race? Check All that Apply White_________ Black (African American)_________ American Indian or Alaskan Native_________ Asian_________ RESEARCH STAFF: READ THE STATEMENT BELOW TO THE PATIENT: THERE ARE NO MORE QUESTIONS FOR YOU TO ANSWER! THANK YOU FOR SHARING WITH US!

The management of lower extremity occlusive disease involves some of the most complex decision making in the field of vascular surgery. Patients with lower extremity occlusive disease often present with a wide spectrum of clinical manifestations ranging from mild intermittent claudication to severe ischemia with gangrene. Moreover, the prognosis and clinical management are dependent on the location and extent of the atherosclerotic disease burden, the presence of comorbid conditions that affect life expectancy and procedural patency, the revascularization options available, and the functional status of the patient. In an effort to bring order to this challenging disease, a number of lower extremity classification systems have been developed. This review discusses challenges of establishing a classification system, anatomic classification systems, classification systems based on presenting symptoms/clinical presentation, morbidity/mortality risk stratification systems, and disability classification systems. Tables outline the Society for Vascular Surgery runoff score, clinical categories of acute limb ischemia, Rutherford clinical categories of chronic limb ischemia, Fontaine clinical stages of chronic limb ischemia, LEGS (Lower Extremity Grading System) score used to recommend invasive treatment for patients with chronic lower extremity ischemia, WIfI (Wound Ischemia foot Infection) classification system grades, consensus estimate of 1 year amputation risk and likelihood of benefit of/requirement for revascularization based on WIfI spectrum score, predicted and observed 1-year outcomes (limb amputation, wound nonhealing) based on WIfI clinical stage classification, morbidity and mortality risk stratification methods, US social security administration disability criteria for patients with lower extremity occlusive disease and amputation, and criteria for rating impairment due to lower extremity peripheral vascular disease. Figures illustrate the TransAtlantic Inter-Society Consensus classification of aortoiliac and femoropopliteal lesions and Graziani System classes of progressive vascular disease severity and distribution in patients with diabetes mellitus presenting with foot wounds. This review contains 3 figures, 11 tables, and 35 references.

OBJECTIVE:More than 85% of patients with end-stage renal disease start dialysis through a tunneled dialysis catheter (TDC) for long periods while their arteriovenous fistula or vascular access graft (arteriovenous graft [AVG]) matures. Because TDCs are associated with a high risk of complications, including death and infection, use of an AVG that can be cannulated safely immediately after implantation may reduce morbidity in these patients by allowing earlier TDC removal. We report a prospective multicenter study of a new early-cannulation AVG (Gore ACUSEAL Vascular Graft; W. L. Gore & Associates, Flagstaff, Ariz).METHODS:Patients requiring creation of a prosthetic vascular access for hemodialysis were enrolled between July 2010 and February 2012 and observed for 12 months. Data were collected on the patients' baseline characteristics; location, position, loss of patency, and revisions of prior AVGs; dialysis sessions using the AVG; and major adverse events related to graft implantation or cannulation. Cumulative and primary unassisted graft patency rates were calculated. A subgroup analysis compared outcomes in patients in whom the AVG was first cannulated within 72 hours after implantation with outcomes in patients in whom the initial cannulation was performed >21 days postoperatively.RESULTS:The population of this study was formed by 138 patients who received an ACUSEAL graft. During follow-up, 17 patients died and the AVG was abandoned in 27. The median value for follow-up was 360 days for all patients (variance 15,387). The overall mean time to initial cannulation was 15 days, with 54 grafts (40%) first cannulated within 72 hours after graft implantation and 33 grafts first cannulated >21 days afterward. The reason for late cannulation in some patients was dependent on the implanting surgeon's decision and the surgeon's personal experience with early cannulating grafts. The 1-year overall cumulative patency rate was 79% (95% confidence interval, 71%-85%); the primary unassisted patency rate was 35% (95% confidence interval, 27%-44%). Adverse events included 6 hematomas (two of which were related to cannulation and occurred 107 and 169 days, respectively, after AVG implantation), 15 graft infections, and 15 cases of steal syndrome requiring intervention. Patients in the early- and later-cannulation groups had similar characteristics and no significant differences in rates of cumulative or primary unassisted patency or adverse events.CONCLUSIONS:This study demonstrated that the new, early-cannulation AVG graft can be cannulated soon after implantation without a significant difference in patency and complication rates compared with rates associated with standard cannulation of expanded polytetrafluoroethylene grafts in the literature. This new AVG may allow early removal or avoidance of TDC use in patients undergoing hemodialysis, potentially reducing or eliminating the number of days of catheter-dependent dialysis, but further studies will be needed to demonstrate this potential.

Background: The incidence of end-stage renal disease is increasing most rapidly in patients aged older than 75 years. Meanwhile, their 5-year survival rate remains the lowest of any dialysis cohort. The purpose of this study was to evaluate the benefit of arteriovenous fistula (AVF) construction in octogenarians, as the data regarding the effects of age on fistula success are conflicting.Methods: Using our hemodialysis database, we performed a retrospective review of all AVFs placed between 1 November, 2007, and 17 July, 2013, in patients aged 80 years or older. Patient demographics, presence of catheters, time to first fistula use, fistula interventions, fistula patency, and time to patient death were all evaluated.Results: We placed 32 fistulas in 31 patients. Our average patient was 82-year-old, men (75%) and Caucasian (71%). Three patients were excluded, as they never required dialysis. One patient required 2 fistulas; the second fistula was excluded from analysis. Of the remaining 28 patients, 22 (78%) were used for hemodialysis and 19 (68%) required catheter-based dialysis before fistula use. The mean length of catheter use was 166 days, and the median time to first fistula use was 109 days. Primary functional patency was 51% at year 1 and 38% at year 2, respectively. Secondary patency was 75% at year 1 and year 2. Of the 22 patients, 17 (77%) required intervention to achieve or maintain patency. The median time to death was 26 months.Conclusions: With substantial effort, successful fistula utilization can be achieved in an extremely elderly patient population. Our patients experienced significant catheter utilization and over 3 quarters required secondary interventions to achieve or maintain fistula utilization. Given this group's limited survival and the fact that 21% of their survival time was spent dialyzing with a catheter, the benefit of a functioning fistula to a patient older than 80 years can be questioned.

The aim of this study was to generate extended length, small diameter vascular scaffolds that could serve as potential grafts for treatment of acute ischemia. Biological tissues are considered excellent scaffolds, which exhibit adequate biological, mechanical, and handling properties; however, they tend to degenerate, dilate, and calcify after implantation. We hypothesized that chemically stabilized acellular arteries would be ideal scaffolds for development of vascular grafts for peripheral surgery applications. Based on promising historical data from our laboratory and others, we chose to decellularize bovine mammary and femoral arteries and test them as scaffolds for vascular grafting. Decellularization of such long structures required development of a novel "bioprocessing" system and a sequence of detergents and enzymes that generated completely acellular, galactose-(α1,3)-galactose (α-Gal) xenoantigen-free scaffolds with preserved collagen, elastin, and basement membrane components. Acellular arteries exhibited excellent mechanical properties, including burst pressure, suture holding strength, and elastic recoil. To reduce elastin degeneration, we treated the scaffolds with penta-galloyl glucose and then revitalized them in vitro using a tunic-specific cell approach. A novel atraumatic endothelialization protocol using an external stent was also developed for the long grafts and cell-seeded constructs were conditioned in a flow bioreactor. Both decellularization and revitalization are feasible but cell retention in vitro continues to pose challenges. These studies support further efforts toward clinical use of small diameter acellular arteries as vascular grafts.

The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic/Ischemia/foot Infection (WIfI) to stratify the risk of limb amputation at 1 year. Although intuitive in nature, the new system has not been validated. The purpose of this study was to determine whether the WIfI system is predictive of limb loss/wound healing. Between 2008 and 2010, we prospectively scored 139 patients with foot wounds (158 revascularizations) at the time of the revascularization procedure using a novel wound classification grading system similar to WIfI. The ischemic component of the grading system was obtained immediately postprocedure. Adapting our data to the WIfI classification, the influence of grading system factors on time to wound healing was analyzed. Empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion. Seventy-nine percent (125 of 158) of the foot wounds healed. The median time to wound healing was 4 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). A comparison of observed vs theoretical outcomes is shown in the Table. The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.Tabled 1Table. One-year outcomes (predicted and observed) of revascularized foot wounds by estimated Wound characteristic/Ischemia/foot Infection (WifI) classificationEstimated WIfI classificationNo.Predicted outcome, %Observed outcome, %Limb lossLimb lossNonhealing woundClass 0-very low risk40∼33 ± 38 ± 4Class 1-low risk63∼810 ± 4%19 ± 5Class 2-moderate risk46∼2523 ± 630 ± 7Class 3-high risk6∼5040 ± 2263 ± 21 Open table in a new tab

Objective: The Society for Vascular Surgery (SVS) recently established the Lower Extremity Threatened Limb Classification System, a staging system using Wound characteristic, Ischemia, and foot Infection (WIfI) to stratify the risk for limb amputation at 1 year. Although intuitive in nature, this new system has not been validated. The purpose of the following study was to determine whether the WIfI system is predictive of limb amputation and wound healing.Methods: Between 2007 and 2010, we prospectively obtained data related to wound characteristics, extent of infection, and degree of postrevascularization ischemia in 139 patients with foot wounds who presented for lower extremity revascularization (158 revascularization procedures). After adapting those data to the WIfI classifications, we analyzed the influence of wound characteristics, extent of infection, and degree of ischemia on time to wound healing; empirical Kaplan-Meier survival curves were compared with theoretical outcomes predicted by WIfI expert consensus opinion.Results: Of the 158 foot wounds, 125 (79%) healed. The median time to wound healing was 2.7 months (range, 1-18 months). Factors associated with wound healing included presence of diabetes mellitus (P = .013), wound location (P = .049), wound size (P = .007), wound depth (P = .004), and degree of ischemia (P < .001). The WIfI clinical stage was predictive of 1-year limb amputation (stage 1, 3%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and wound nonhealing (stage 1, 8%; stage 2, 10%; stage 3, 23%; stage 4, 40%) and correlated with the theoretical outcome estimated by the SVS expert panel.Conclusions: The theoretical framework for risk stratification among patients with critical limb ischemia provided by the SVS expert panel appears valid. Further validation of the WIfI classification system with multicenter data is justified.

A number of surgery practice models have been developed to address general and trauma surgeon workforce shortages and on-call issues and to improve surgeon satisfaction. These include the creation of acute or urgent care surgery services and "surgical hospitalist" programs. To date, no practice models corresponding to those developed for general and trauma surgeons have been proposed to address these same issues among vascular surgeons or other surgical subspecialists. In 2003, our practice established a Vascular Surgery Hospitalist program. Since its inception nearly a decade ago, it has undergone several modifications. We reviewed hospital administrative databases and surveys of faculty, residents, and patients to evaluate the program's impact. Benefits of the Vascular Surgery Hospitalist program include improved surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians and ancillary staff, and resident teaching/supervision. Elements of this program may be applicable to a variety of surgical subspecialty settings.

Objective: Endovascular volume during vascular surgery training has increased profoundly over recent decades, providing heavy exposure to ionizing radiation. The study purpose was to examine the radiation safety training and practices of current vascular surgery trainees.Methods: An anonymous survey was distributed to all current U.S. trainees. Responses were compared according to the presence of formal radiation safety training and also the trainees' perception of their attendings' adherence to As Low As Reasonably Achievable (ALARA) strategies.Results: The response rate was 14%. Forty-five percent had no formal radiation safety training, 74% were unaware of the radiation safety policy for pregnant females, 48% did not know their radiation safety officer's contact information, and 43% were unaware of the yearly acceptable levels of radiation exposure. Trained residents knew more basic radiation safety information, and more likely wore their dosimeter badges (P<.05). Trained residents found their radiation safety officer helpful in developing safety habits; untrained residents relied on other residents (P<.05). Trainees who felt their attendings consistently practiced ALARA strategies more likely practiced ALARA themselves (P<.05).Conclusions: The lack of formal radiation safety training in respondents may reflect an inadequate state of radiation safety education and practices among U.S. vascular surgery residents.

BACKGROUND:Initiatives to increase arteriovenous fistula (AVF) use are based on studies that show that AVFs require fewer interventions and have better patency than arteriovenous grafts (AVGs). Because patients who receive AVFs typically have more favorable vascular anatomy and are referred earlier for access placement than those who receive AVGs, the advantages of AVF might be overestimated. We compared outcomes for AVFs and AVGs in patients with equivalent vascular anatomy who were on dialysis via catheter at the time of vascular access placement. STUDY DESIGN:The study included patients who underwent placement of a first-time AVF or AVG between 2006 and 2009, who were on dialysis via catheter at the time of access placement, and who had favorable arterial and venous (>3 mm) anatomy. Outcomes for AVF and AVG were compared. RESULTS:Eighty-nine AVF and 59 AVG patients met study inclusion criteria. Similar secondary patency was achieved by AVG and AVF at 12 (72% vs 71%) and 24 months (57% vs 62%), respectively (p = 0.96). The number of interventions required to maintain patency for AVF (n = 1; range 0 to 10) and AVG (n = 1; range 0 to 11) were not different (p = 0.36). However, the number of catheter days to first access use was more than doubled in the AVF group (median 81 days) compared with the AVG group (median 38 days; p < 0.001). CONCLUSIONS:For patients who are receiving dialysis via catheter at the time of access placement, the maturation time, risk of nonmaturation, and interventions required to achieve a functional AVF can negate its benefits over AVG. A fistula first approach might not always apply to patients who are already on dialysis when referred for chronic access placement.