Background: Following new dialysis access creation there is no consensus on the optimal use of anti-thrombotic therapy. Recent studies have suggested that single antiplatelet therapy may improve hospital mortality as well as patency. The aim of this study was to assess the role of different antiplatelet and anticoagulation therapies on outcomes following dialysis access creation. Material and Methods: A retrospective study was conducted utilizing patients from the Vascular Quality Initiative who underwent AV fistula (AVF) and AV graft (AVG) creation from 2011-2023. Patients who were antiplatelet and anticoagulation naive were separated into 4 cohorts: no antiplatelet (No APT), single antiplatelet (SAPT), dual antiplatelet (DAPT), and aspirin with anticoagulation (ASA + AC). Univariate Kaplan-Meier (KM) and multivariable regression analyses were conducted to assess overall survival, primary patency, and secondary patency. Results: 49,980 patients with AVF creation and 12,688 patients with AVG creation were identified. AVG patients had improved 1-year primary patency with SAPT compared to No APT (48% vs. 44%, P - 0.03) on KM analysis. No difference on KM analysis was observed for AVF. Regression analysis showed decreased risk of loss of primary patency for AVF (HR 0.90, CI 0.83-0.97, P - 0.009). AVG with SAPT showed decreased risk of mortality (HR 0.80, CI 0.64-1.00, P - 0.05) and decreased risk of loss of primary patency (HR 0.80, CI 0.67-0.94, P - 0.009). DAPT also showed decreased risk of loss of primary patency for AVG (HR 0.64, CI 0.43-0.95, P - 0.028). Survival was worse for both AVF and AVG patients on ASA + AC on KM analysis. for both AVF and AVG, as well as overall survival for those with AVG. DAPT may further improve primary patency in those with AVG. The use of anticoagulation shows no clear benefit and may be harmful, however is more likely to reflect higher risk patients with other co-morbidities. These results suggest that following an AVF one should consider discharging patients on SAPT, and following an AVG one should consider SAPT or DAPT.

Objective: There is no consensus on the optimal anticoagulant regimen following lower extremity bypass. Historically, warfarin has been utilized for prosthetic or compromised vein bypasses. Direct-acting oral anticoagulants (DOACs) are increasingly replacing warfarin in this context, but their efficacy in bypass preservation has not been well-studied. Recent studies have shown that DOACs may improve outcomes following bypasses; however, it is unclear if this is dependent upon type of bypass conduit. The goal of this study was to evaluate whether a difference exists between vein and prosthetic infra-geniculate bypasses outcomes based on the anticoagulant utilized on discharge, warfarin or DOAC. Methods: The Vascular Quality Initiative infra-inguinal bypass database was queried for all patients who underwent an infra-geniculate bypass and were anticoagulation-naive at baseline but were discharged on either warfarin or DOACs. A survival analysis was performed for patients up to 1 year to determine whether the choice of discharge anticoagulation was associated with differences between those with vein vs prosthetic conduits in overall survival, primary patency, risk of amputation, or risk of major adverse limb events (MALE). A multivariable Cox proportional hazards analysis was performed to control for differences in baseline demographic factors between the groups. Results: During the study period (2003-2020), 57,887 patients underwent infra-geniculate bypass. Of these, 3230 (5.5%) were anticoagulated on discharge. There was a similar distribution of anticoagulation between vein (n = 1659; 51.4%) and prosthetic conduits (n = 1571; 48.6%). Thirty-two percent were discharged on DOACs, and 68.0% were discharged on warfarin. For prosthetic conduits, being discharged on a DOAC was associated with improved outcomes on univariate and multivariable analyses revealing lower risk of overall mortality (hazard ratio [HR], 0.61; 95% confidence interval [CI], 0.41-0.93; P = .021), loss of primary patency (HR, 0.70; 95% CI, 0.55-0.89; P = .003), risk of amputation (HR, 0.71; 95% CI, 0.540.93; P = .013), and risk of MALE (HR, 0.80; 95% CI, 0.64-1.00; P = .048). Patients with a vein bypass had improved univariate outcomes for survival and primary patency; however, with multivariable analysis, there were no significant differences in outcomes between DOAC and warfarin. Conclusions: Anticoagulation-naive patients who underwent an infra-geniculate prosthetic bypass had higher rates of overall survival, bypass patency, amputation-free survival, and freedom from MALE when discharged on a DOAC compared with warfarin. Those with vein bypasses had similar outcomes regardless of the choice of anticoagulation.

Hospitals are responsible for 4% to 5% of global greenhouse gas production and are significant contributors to climate change. We sought to understand the contributions of vascular surgery to the carbon footprint of hospitals by examining emissions from fluoroscopy and physical waste across common vascular surgeries. Fourteen vascular operations at a tertiary hospital were prospectively audited for the waste produced (kg) and length of operations (min). An additional 122 cases were audited retrospectively for energy expenditure during fluoroscopy digital subtraction angiography (DSA). The fluoroscopy time (min), number of DSA runs, amplitude, and voltage were recorded, and subsequently, power (kW) and energy (kWh) were calculated. The operations were separated into five cohorts: endovascular aneurysm repair (EVAR), thoracic endovascular aortic repair (TEVAR), transcarotid artery revascularization (TCAR), femoral endarterectomy with iliac intervention (Fem/Iliac), and lower extremity bypass. Using a certified Greenhouse Gas Equivalencies Calculator from the US Environmental Protection Agency, total carbon dioxide emissions (CO2e) were estimated. Results were compared using χ2 analysis and logistical regression. The average combined CO2e produced by waste and fluoroscopy were as follows: EVAR 114.34 kg CO2, TEVAR 106.79 kg CO2, TCAR 61.87 kg CO2, Fem/Iliac 78.27 kg CO2, and bypass 78.15 kg CO2. Bypasses produced the largest amount of CO2e from waste (76.14 kg, 95% CI 69.4-82.3), while the least was produced by TCAR (54.56 kg, 95% CI 45.1-64.0). EVAR produced the largest CO2e from DSA runs (41.11 kg, 95% CI 28.82- 53.40), while the least was produced by bypasses (2.0 kg, 95% CI 0.36-3.67). When DSA CO2e were analyzed against fluoroscopy time, TEVAR produced CO2e at the highest rate of 3.63 kg/min DSA, while bypasses produced CO2e at the lowest rate of 1.35 kg/min DSA. Although no linear correlation was found between operation length and CO2e from waste (r2 = 0.025), a significant linear correlation was found between fluoroscopy time and CO2e from fluoroscopy (r2 = 0.673). Vascular operations, on average, generate 108.47 kg of CO2 emissions from waste and fluoroscopy, the equivalent of driving an average gasoline-powered vehicle for 278 miles. This study found a correlation between increased fluoroscopy time and CO2 emissions. It also found that the rate of emissions differs between different operations, suggesting a role in optimizing fluoroscopy and intraoperative techniques to lower emissions. Efforts to track current energy output from imaging devices, investing in efficient devices, and adjusting intraoperative settings may all play a role in decreasing vascular surgery's environmental footprint.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Introduction: Handoffs between the operating room (OR) and post-anesthesia care unit (PACU) require a high volume and quality of information to be transferred. This study aimed to improve perioperative communication with a handoff tool. Methods: Perioperative staff at a quaternary care center was surveyed regarding perception of handoff quality, and OR to PACU handoffs were observed for structured criteria. A 25-item tool was implemented, and handoffs were similarly observed. Staff was then again surveyed. A multidisciplinary team led this initiative as a collaboration. Results: After implementation, nursing reported improved perception of time spent (2.63-3.68, p = .02) and amount of information discussed (2.85-3.73, p = .05). Anesthesia also reported improved personal communication (3.69-4.43, p = .004), effectiveness of handoffs (3.43-3.82, p = .02), and amount of information discussed (4.26-4.76, p = .05). After implementation, observed patient information discussed during handoffs increased for both surgical and anesthesia team members. The frequency of complete and near-complete handoffs increased (40%-74%, p < .001). Conclusions: A structured handoff tool increased the amount of essential information reported during handoffs between the OR and PACU and increased team members' perception of handoffs.

A 20-year-old woman with previous COVID-19 diagnosis presented with abdominal pain and colitis on CT scan. She was admitted in septic shock, with etiology of colitis unclear. After resuscitation, antibiotics, and steroids, she clinically deteriorated. Worsening Clostridioides difficile infection was most likely and she was taken to the operating room. Intraoperatively, only a segment of transverse colon appeared abnormal on gross and endoscopic evaluation. Total colectomy was deferred in favor of segmental resection. Given her unusual disease pattern and recent COVID-19 infection, diagnosis of MIS-C was considered. Steroids were continued and treatment broadened to include heparin and IVIG. The patient returned to the operating room for planned reexploration, endoscopy, and end colostomy. On hospital day three, the patient had an acute mental status change. Computed tomography demonstrated acute cerebral edema with brainstem herniation. The family chose comfort-care measures. Final pathology from the transverse colon demonstrated COVID-19-associated vasculitis.

Objective: No consensus has yet been reached regarding the optimal antiplatelet and anticoagulant regimen for patients after lower extremity bypass. Usually, patients who have undergone below-the-knee bypass will begin oral anticoagulation therapy. Historically, the bypass has been with prosthetic conduits and the anticoagulation therapy has been warfarin. However, the use of direct-acting oral anticoagulants (DOACs) has been increasing owing to their relative ease of dosing. The goal of the present study was to evaluate whether a difference exists in the postoperative outcomes for patients who have undergone infrageniculate bypass stratified by the use of on DOACs vs warfarin. Methods: The Vascular Quality Initiative infrainguinal bypass database was queried for all patients who had undergone infrageniculate bypass, been anticoagulation naive at baseline, and been discharged with anticoagulation therapy. A survival analysis was performed for patients for #2 years postoperatively to determine whether discharge with warfarin vs DOACs was associated with differences in overall mortality, loss of primary patency, risk of amputation, and risk of major adverse limb events (MALE). A multivariable Cox proportional hazards analysis was performed to control for differences in the baseline demographic factors between the two groups. Results: During the study period (2007-2020) 57,887 patients had undergone infrageniculate bypass. Of these patients, 2786 had been anticoagulation naive and discharged with either warfarin (n =1889) or DOACs (n = 897). Discharge with a DOAC was associated with a lower risk of overall mortality (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.47-0.83; P = .001), loss of primary patency (HR, 0.74; 95% CI, 0.62-0.87; P < .001), risk of amputation (HR, 0.70; 95% CI, 0.57-0.86; P = .001), and risk of MALE (HR, 0.83; 95% CI, 0.71-0.97; P = .017). Conclusions: Anticoagulation-naive patients who had undergone infrageniculate bypass had had higher rates of overall survival, bypass patency, amputation-free survival, and freedom from MALE when discharged with a DOAC than with

Badrinathan, Avanti MD; Ebertz, David MD; Acosta, Gi-Ann A MD; Kishawi, Sami MD; Nash, Joshua E DO, FACS; Moorman, Matthew L MD, FACS; Rushing, Amy Page Associate Professor - Clinical; Loudon, Andrew MD, FACS Author Information

In recent years, the advent of atherectomy devices using different mechanical principles has expanded the armamentarium of the interventionalist. Many studies have demonstrated their effectiveness when compared with plain balloon angioplasty, but few have compared these newer technologies head-to-head. As more practitioners use these adjunctive techniques, it is unclear as to which lead to the best outcomes for patients.