Objective Specific perioperative risk assessment models have been developed for bariatric, pancreatic, and colorectal surgery. A similar instrument, specific for patients with critical limb ischemia (CLI), could improve patient-centered clinical decision making. We describe a novel tool to predict 30-day major morbidity and mortality (M&M) after bypass surgery for CLI. Methods Data for 4985 individuals from the 2007 to 2009 National Surgical Quality Improvement Program were used to develop and internally validate the model. Outcome measures included mortality, major morbidity, and a composite end point (M&M). M&M included mortality and the most severe postoperative morbidities that were highly associated with death (eg, sepsis and major cardiopulmonary complications). More than 30 preoperative factors were tested for association with 30-day mortality, major morbidity, and M&M. Significant predictors in multivariate models were assigned integer values (points), which were added to calculate a patient's Comprehensive Risk Assessment For Bypass (CRAB) score. Performance was assessed (C-index) across all outcome measures and compared with other general tools (American Society of Anesthesiologists class, Surgical Risk Scale) and existing CLI-specific survival prediction models (Finnvasc score, Edifoligide for the Prevention of Infrainguinal Vein Graft Failure [PREVENT III] score) on a distinct validation sample (n = 1620). Results In the derivation data set (n = 3275), the 30-day mortality rate was 2.9%. The rate of any major morbidity was 19.1%. The composite end point M&M occurred in 10.1%. Significant predictors of M&M by multivariate analysis included age >75 years, prior amputation or revascularization, tissue loss, dialysis dependence, severe cardiac disease, emergency operation, and functional dependence. Applied to a distinct validation sample of 1620 patients, higher CRAB scores were significantly associated with higher rates of mortality, all major morbidities, and M&M (P < .0001). Comparison with other models by assessment of area under the receiver-operating characteristic curve revealed the CRAB was a more accurate predictor of mortality, all major morbidity, and M&M. Conclusions The CRAB is a CLI-specific, risk assessment instrument derived from multi-institutional American College of Surgeons-National Surgical Quality Improvement Program surgical outcomes data that out-performs existing prognostic risk indices in the prediction of clinically significant adverse events after bypass surgery. Use of the CRAB as a risk assessment tool provides an evidence basis for patient-centered clinical decision making and may have a role in identifying patients at higher risk for surgical revascularization in whom an endovascular approach is preferable.

Patients with severe CKD were excluded from the SVS objective performance goals (OPG) derivation cohort due to established poor surgical outcomes in this group. We examine the impact of diminished creatinine clearance (CrCl) on the long-term outcomes of peripheral endovascular interventions. Retrospective review of prospectively collected institutional outcomes data (2006-2012) included calculation of CrCl and stratification by chronic kidney disease (CKD) class. Outcomes among those with mild (class 1, 2) moderate (class 3), and severe (class 4, 5) CKD were compared using SVS OPG outcome metrics. Multivariate models were developed to identify risk factors for poor outcome and specifically assess the impact of CKD. 454 patients underwent treatment of 523 limbs for claudication (56%), rest pain (12%), or tissue loss (32%). Over 77% of patients had abnormally low CrCl, with moderate CKD noted in 37% and severe CKD in 13%. Increasing CKD class was associated with worse outcomes across all outcome metrics by crude survival analysis. Following adjustment for all other risk factors, the impact of severe CKD was independently associated with reduced overall survival (HR, 2.69; 95% CI, 1.70-4.26; P < .001), amputation-free survival (HR, 3.15; 95% CI, 2.04-3.86; P < .001), limb salvage (HR, 4.35; 95% CI, 1.50-12.33; P = .006), major adverse limb events (HR, 2.07; 95% CI, 1.02-4.20; P = .04), freedom from reintervention and amputation (HR, 1.82; 95% CI, 1.12-2.94; P = .015) and freedom from reintervention, amputation, and stenosis (HR, 1.58; 95% CI, 1.02-2.46; P = .041). Moderate and severe CKD are highly prevalent among patients with PAD. While severe CKD adversely affects long-term outcomes after ET as well as surgical bypass, quantification of the impact of reduced CrCl on survival- and limb-based metrics may enhance risk adjustment for comparative effectiveness research and improve patient-centered clinical decision-making.

BACKGROUND:In this study we examine outcomes of endovascular therapy for critical limb ischemia with tissue loss and identify risk factors for failure of endovascular therapy across a panel of outcome metrics.METHODS:A retrospective review (2006-2010) of patients undergoing endovascular therapy for critical limb ischemia with tissue loss provided data for multivariate models of overall survival, amputation-free survival, limb salvage (LS), and wound healing.RESULTS:One hundred six patients underwent endovascular therapy for Rutherford class 5 (88%) or class 6 (12%) ischemia with ulceration and/or gangrene of the heel (15%), forefoot (16%), toe(s) (43%), calf/ankle (11%), or multiple locations (15%). Sustained limb salvage at 1 year was 87%. One-year overall survival and amputation-free survival were 65% and 49%, respectively. Multivariate regression models identified independent risk factors for reduced primary patency: Rutherford 6 ischemia (P = 0.008; HR 4.7 [95% confidence interval 1.5-14.8]) and infrapopliteal intervention (P = 0.03; HR 2.58 [95% CI 1.08-6.14]). Rutherford class 6 ischemia was independently associated with reduced assisted patency (P = 0.004; HR 5.39 [95% CI 1.74-16.73]). Wound healing was adversely affected by diabetes (P = 0.02; HR 7.0 [95% CI 1.4-36.2]), continued smoking (P = 0.04; HR 5.3 [95% CI 1.1-26.3]), and patency loss (P = 0.04; HR 4.8 [95% CI 1.1-22.30]). Rutherford class 6 ischemia was independently associated with reduced limb salvage (P < 0.0001; HR 35.1 [95% CI 5.4-231.2]) and amputation-free survival (P = 0.007; HR 3.61 [95% CI 1.4-9.18]), in addition to COPD (P = 0.01; 3.58 [95% 1.28-9.55]). Independent predictors of poor overall survival included end-stage renal disease (P = 0.03; HR 2.99 [95% CI 1.1-8.05]), history of angina (P = 0.02; HR 5.08 [95% CI 1.28-20.29]), and COPD (P = 0.001; HR 3.77 [95% CI 1.76-8.34]).CONCLUSIONS:Both increasing severity of tissue loss as well as the presence of severe medical comorbidities are associated with poorer outcomes of endovascular therapy in these patients. Although sustained limb salvage in patients with tissue loss may be achieved with endovascular therapy, this is due to poor overall survival and a competing mortality hazard.

BACKGROUND:Endovascular abdominal aortic aneurysm repair (EVAR) for degenerative abdominal aortic aneurysm (AAA) requires complete aortic exclusion to prevent ongoing aneurysmal degeneration in a diseased aorta. Focal infrarenal aortic pathology, such as penetrating atherosclerotic ulcer (PAU), saccular aneurysm, and/or intramural hematoma (IMH) may not necessitate complete aortic coverage. Here, we review our experience with endovascular management of focal aortic pathology with limited aortic coverage.METHODS:A prospectively maintained institutional database of patients undergoing EVAR was retrospectively reviewed to identify all patients treated with a nonbifurcated device (Current Procedural Terminology code: 34,800). Patients without a diagnosis of PAU, saccular aneurysm, IMH, or iatrogenic pseudoaneurysm were excluded. Medical records and imaging studies were reviewed for confirmation of focal aortic pathology. Preoperative imaging and intraoperative details were reviewed. Outcome measures included technical success, symptom-free survival, and freedom from reintervention.RESULTS:Eight patients were identified who underwent repair of a focal aortic defect with an endovascular tube graft from 2004-2011. Six patients underwent surgery for 7 saccular pseudoaneurysms and 2 patients had iatrogenic infrarenal pseudoaneurysms. Six saccular aneurysms were associated with PAU. Seven patients (88%) were men; the median age was 76 years (range: 50-85 years). Four patients (50%) had symptoms attributable to their aneurysm (2 abdominal pain, 1 gastrointestinal symptoms, 1 lower extremity emboli). Aneurysm repair was classified as urgent in 2 patients (25%). Six patients (75%) required placement of a single aortic component, the other 2 patients (25%) required 2 components. All devices used were Zenith (Cook, Inc., Bloomington, IN) ancillary components. The median device diameter was 22 mm (range: 18-28 mm), while the median device length was 56.5 mm (range: 39-80 mm). The technical success rate was 100%. There were no early graft-related complications. All symptomatic patients experienced improvement or resolution of symptoms. In all cases, radiologic follow-up at 1 month showed stable or decreasing aneurysm size. No endoleaks were detected and no patients have required reintervention to date.CONCLUSIONS:The optimal management of many focal infrarenal aortic defects, particularly those that are incidentally discovered, remains unclear. Our experience with endovascular repair of focal aortic pathology with limited aortic coverage suggests this approach is technically feasible and associated with excellent early results.

The Society for Vascular Surgery's Objective Performance Goals (SVS OPGs) for critical limb ischemia (CLI) are derived from bypass surgery outcomes in a pooled cohort from 3 randomized trials. We examine the effectiveness of endovascular therapy (ET) for CLI in using OPG efficacy benchmarks. CLI patients undergoing ET (2006-2012), were identified in a prospectively maintained database. Unadjusted outcomes were used for comparisons to the overall OPG cohort, as well as between anatomic and clinical high-risk subgroups. ET-specific regression models for each OPG end point identified risk factors for poor outcome. 283 CLI patients underwent ET for tissue loss (77%) or rest pain. Compared to the OPG cohort (n = 838), patients undergoing ET were more likely to be >80 years old (32% vs 19%; P < .0001), female (51% vs 34%; P < .0001), have end stage renal disease (ESRD) (15% vs 0%; P < .0001), or anatomic high-risk features (73% vs 60%; P = .002). The mean reintervention rate after ET was 0.67 per limb-year. The overall effectiveness of ET, with subgroup analysis, is summarized in the Table. Although survival-based benchmarks may be difficult to achieve in "real world" practice that includes poor surgical candidates and those with ESRD, most SVS OPGs are attainable with contemporary endovascular therapy. These findings not only support the role of ET in the management of CLI, but underscore the utility of SVS OPGs for comparative effectiveness and outcomes research.TableOne year results with endovascular therapy compared to suggested OPGsOutcome metricOverallClinical high riskAnatomic high riskOPG (n = 838)Endo (n = 283)OPG (n = 136)Endo (n = 56)OPG (n = 505)Endo (n = 206)Major adverse limb event or post-op death (MALE + POD)71%73 ± 3%61%69 ± 8%67%73 ± 5%Amputation-free survival (AFS)71%66 ± 3%53%60 ± 7%68%66 ± 4%Reintervention, amputation, or stenosis (RAS)39%43 ± 4%29%47 ± 8%36%56 ± 5%Reintervention or amputation (RAO)55%60 ± 4%54%53 ± 8%51%59 ± 5%Limb salvage84%85 ± 3%80%82 ± 7%81%83 ± 4%Survival80%74 ± 3%63%69 ± 7%80%77 ± 4%Rates reported as freedom from adverse events. Open table in a new tab

Inpatient hospital length of stay (LOS) is a metric that is increasingly associated with healthcare efficiency and quality. Infrainguinal bypass has traditionally been associated with a long postoperative LOS. We sought to identify preoperative risk factors for protracted postoperative LOS after lower extremity bypass for critical limb ischemia (CLI) to better anticipate those at risk while in the preoperative phase. Patient data from the 2007-2009 American College of Surgeons National Surgical Quality Improvement Program were used to develop a specific database consisting of patients undergoing bypass surgery for CLI (n = 4894). Protracted postoperative LOS was defined as the top quartile of duration of hospitalization days from surgery until discharge. Over 50 preoperative, procedural, and postoperative variables were tested for association. Risk factors with significant association (Pearson χ2, P < .05) were used to develop a logistic regression model for protracted postoperative LOS. Average postoperative LOS was 7.5 days (median, 6 days). The top quartile of postoperative LOS >8 days, was used to define protracted LOS. Independent risk factors for protracted postoperative LOS included distal bypass target (OR, 1.6; 95% CI, 1.4-1.8), non-Caucasian race (OR, 1.67; 95% CI, 1.4-1.9), obesity (OR, 1.3; 95% CI, 1.1-1.5), partial functional dependence (OR, 2.0; 95% CI, 1.7-2.3), complete functional dependence (OR, 2.8; 95% CI, 1.8-4.3), history of cardiac disease (OR, 1.5; 95% CI, 1.1-2.0), history of peripheral vascular interventions (OR, 1.3; 95% CI, 1.1-1.5), bleeding disorders (OR, 1.2; 95% CI, 1.03-1.4), emergency operation (OR, 1.9; 95% CI, 1.4-2.7), age greater than 80 (OR, 1.45; 95% CI, 1.3-1.7), tissue loss (OR, 1.9; 95% CI, 1.6-2.3), extended preoperative hospitalization (OR, 2.2; 95% CI, 1.8-2.6), and dialysis dependence (OR, 1.6; 95% CI, 1.3-2.0). LOS has received significant attention in the context of the current healthcare climate and the Affordable Care Act. Here, we identify risk factors for protracted postoperative LOS after surgical bypass for CLI, a metric of specific importance to vascular surgeons. These findings provide important evidence for the ongoing dialogue regarding efforts to reduce LOS. Here, we can identify patients early in the preoperative period that may be at risk for increased LOS allowing early multidisciplinary intervention with other medical and social services.

OBJECTIVES:Geographic variability exists in the use of IVC filters (IVCF). We hypothesized that variation in IVCF use is incompletely explained by variation in the prevalence of deep-vein thrombosis (DVT) and pulmonary embolism (PE) and may result from different practice patterns regarding prophylactic IVCF use. We characterize geographic variation in IVCF use at the state level and evaluate its association with clinical factors, patient demographics, and the medicolegal environment. METHODS:Healthcare Cost and Utilization Project State Inpatient Database records were accessed to identify 230,445 IVCFs placed from 2006 to 2008 in 33 states. Similar queries were performed for DVT and PE. Additional state data were obtained from public sources. Analyses included descriptive statistics, Spearman Correlation (SC), Wilcoxon rank-sum test, and characterization of variability. RESULTS:Overall, IVCF use correlated with the prevalence of DVT (SC = 0.89, P < .01). States on the East coast have significantly greater rates of IVCF use per 100K (mean ± SD = 41.2 ± 16.7 vs 27.8 ± 11.1, P < .05) and greater rates of IVCF per DVT (20.2 ± 4.5% vs 15.2 ± 2.9%; P < .005), despite similar rates of DVT per 100K (198.1 ± 51.2 vs 177.7 ± 46.7, P = NS) compared with all other states. Overall, states with the greatest rate of IVCF per DVT were (in descending order): Rhode Island, New Jersey, Florida, New York, and West Virginia. Rates of detected PE per 100K in these states were not significantly different from all other states (95.6 ± 16.6 vs 90.4 ± 16.1, P = NS). In these states, a greater percentage of IVCF recipients were older than 85 (15.3% vs 11.8%; P < .01); fewer were pediatric (0.3% vs 0.7%; P < .05) or aged 45 to 64 (26.1% vs 32.4%; P < .001). There were no differences in patient sex, race, insurance type, hospital size, or teaching status. States with high rates of IVCF per DVT were noted to have significantly greater rates of paid malpractice claims per 100K (4.9 ± 2.51 vs 1.1 ± 0.8; P = .001), and annual general surgeon liability insurance premiums ($78,630 ± 34,822 vs $43,989 ± 17,794; P < .05). CONCLUSION:Variation in IVCF use is incompletely explained by clinical factors. High rates of IVCF per DVT in some states may represent increased use of prophylactic IVCF in states with litigious medicolegal environments.

Background: We apply an innovative and novel analytic approach, based on reliability engineering (RE) principles frequently used to characterize the behavior of manufactured products, to examine outcomes after peripheral endovascular intervention. We hypothesized that this would allow for improved prediction of outcome after peripheral endovascular intervention, specifically with regard to identification of risk factors for early failure. Methods: Patients undergoing infrainguinal endovascular intervention for chronic lowerextremity ischemia from 2005 to 2010 were identified in a prospectively maintained database. The primary outcome of failure was defined as patency loss detected by duplex ultrasonography, with or without clinical failure. Analysis included univariate and multivariate Cox regression models, as well as RE-based analysis including product life-cycle models and Weibull failure plots. Early failures were distinguished using the RE principle of ‘‘basic rating life,’’ and multivariate models identified independent risk factors for early failure. Results: From 2005 to 2010, 434 primary endovascular peripheral interventions were performed for claudication (51.8%), rest pain (16.8%), or tissue loss (31.3%). Fifty-five percent of patients were aged ! 75 years; 57% were men. Failure was noted after 159 (36.6%) interventions during a mean follow-up of 18 months (range, 0e71 months). Using multivariate (Cox) regression analysis, rest pain and tissue loss were independent predictors of patency loss, with hazard ratios of 2.5 (95% confidence interval, 1.6e4.1; P < 0.001) and 3.2 (95% confidence interval, 2.0e5.2, P < 0.001), respectively. The distribution of failure times for both claudication and critical limb ischemia fit distinct Weibull plots, with different characteristics: interventions for claudication demonstrated an increasing failure rate (b 1.22, q 13.46, mean time to failure 12.603 months, index of fit 0.99037, R 2 0.98084), whereas interventions for critical limb ischemia demonstrated a decreasing failure rate, suggesting the predominance of early failures (b 0.7395, q 6.8, mean time to failure 8.2, index of fit 0.99391, R 2 0.98786). By 3.1 months, 10% of interventions failed. This point (90% reliability) was identified as the basic rating life. Using multivariate analysis of failure data, independent predictors of early failure (before 3.1 months) included tissue loss, long lesion length, chronic total occlusions, heart failure, and end-stage renal disease. Conclusions: Application of a RE framework to the assessment of clinical outcomes after peripheral interventions is feasible, and potentially more informative than traditional techniques. Conceptualization of interventions as ‘‘products’’ permits application of product life-cycle models

We compare the utility of endovascular therapy (ET) with bypass surgery for critical limb ischemia (CLI) with tissue loss and identify risk factors for failure of ET. A retrospective review (2004 to 2010) of patients undergoing ET for tissue loss (Rutherford class 5 and 6) provided data for multivariate models of overall survival, amputation-free survival (AFS), limb salvage, and wound healing. Comparisons were made with a bypass surgery cohort matched for tissue loss. Ninety-four patients underwent ET (58% TransAtlantic InterSociety Concensus [TASC] C/D; 44% tibial) for Rutherford 5 (88%) or Rutherford 6 (12%) CLI with tissue loss of the heel (15%), forefoot (16%), toe(s) (43%), calf/ankle (11%), or multiple locations (15%). Sustained limb salvage was 83% ± 5%. Overall survival was 44% ± 7% and AFS was 40% ± 7% at 2 years. Predictors of failure by multivariate models are reported in the Table. Comparison between the Rutherford 5 WRsubgroup (n = 83) and an Rutherford 5 bypass cohort (n = 66), suggest equivalent limb salvage, with reduced AFS (P = .04) and a trend toward reduced overall survival (P = .09). Early would healing was higher after bypass: 43% vs 11% at 3 months (P = .001) and 57% vs 30% at 6 months (P = .01).TableHazard ratio (HR/AOR)95% CI for HR/AORP valueOverall survival Dialysis dependence3.01.1–81..03 Angina5.11.3–20.3.02 COPD3.81.8–8.3.001Amputation free survival Rutherford 63.61.4–9.2.007 COPD3.61.3–9.6.01Limb salvage Rutherford 635.15.4–231Wound healing at 12 months Diabetes7.01.4–36.02 Current smoking5.31.1–26.04 Patency loss4.81.1–22.04 Open table in a new tab Given the short life expectancy of patients with tissue loss, ET permits sustained limb salvage in patients at high risk for bypass (particularly Rutherford 5). However, wound healing is slow compared with bypass and requires sustained patency.

Background: We apply an innovative and novel analytic approach, based on reliability engineering (RE) principles frequently used to characterize the behavior of manufactured products, to examine outcomes after peripheral endovascular intervention. We hypothesized that this would allow for improved prediction of outcome after peripheral endovascular intervention, specifically with regard to identification of risk factors for early failure.Methods: Patients undergoing infrainguinal endovascular intervention for chronic lower-extremity ischemia from 2005 to 2010 were identified in a prospectively maintained database. The primary outcome of failure was defined as patency loss detected by duplex ultrasonography, with or without clinical failure. Analysis included univariate and multivariate Cox regression models, as well as RE-based analysis including product life-cycle models and Weibull failure plots. Early failures were distinguished using the RE principle of "basic rating life," and multivariate models identified independent risk factors for early failure.Results: From 2005 to 2010, 434 primary endovascular peripheral interventions were performed for claudication (51.8%), rest pain (16.8%), or tissue loss (31.3%). Fifty-five percent of patients were aged >= 75 years; 57% were men. Failure was noted after 159 (36.6%) interventions during a mean follow-up of 18 months (range, 0-71 months). Using multivariate (Cox) regression analysis, rest pain and tissue loss were independent predictors of patency loss, with hazard ratios of 2.5 (95% confidence interval, 1.6-4.1; P < 0.001) and 3.2 (95% confidence interval, 2.0-5.2, P < 0.001), respectively. The distribution of failure times for both claudication and critical limb ischemia fit distinct Weibull plots, with different characteristics: interventions for claudication demonstrated an increasing failure rate (beta = 1.22, theta = 13.46, mean time to failure = 12.603 months, index of fit = 0.99037, R-2 = 0.98084), whereas interventions for critical limb ischemia demonstrated a decreasing failure rate, suggesting the predominance of early failures (beta = 0.7395, theta = 6.8, mean time to failure = 8.2, index of fit = 0.99391, R-2 = 0.98786). By 3.1 months, 10% of interventions failed. This point (90% reliability) was identified as the basic rating life. Using multivariate analysis of failure data, independent predictors of early failure (before 3.1 months) included tissue loss, long lesion length, chronic total occlusions, heart failure, and end-stage renal disease.Conclusions: Application of a RE framework to the assessment of clinical outcomes after peripheral interventions is feasible, and potentially more informative than traditional techniques. Conceptualization of interventions as "products" permits application of product life-cycle models that allow for empiric definition of "early failure" may facilitate comparative effectiveness analysis and enable the development of individualized surveillance programs after endovascular interventions.

Late complications of retrievable inferior vena cava (IVC) filters resulting from IVC perforation and erosion into adjacent structures is an increasingly frequent phenomena. We describe six cases of open filter explantation for IVC penetration and offer a novel technique for open filter removal without the need for an extensive cavotomy. All patients had radiographic evidence of filter erosion into pericaval structures requiring open surgical filter explant. Four of the six patients underwent minimal cavatomy filter extraction, eliminating the need for caval reconstruction.

Endovascular aneurysm repair (EVAR) has become the standard treatment of abdominal aortic aneurysms (AAA) and is also commonly used for treatment of aortoiliac aneurysms. However, treatment of aortoiliac aneurysms involving the iliac bifurcation often requires hypogastric artery sacrifice during EVAR, which may result in ischemic complications and buttock claudication. We hypothesized that aneurysmal involvement of the iliac arteries also has a negative effect on the durability of EVAR and sought to determine what fraction of these patients could be candidates for internal iliac artery preservation with an iliac branch graft device (IBG). A review of 632 patients who underwent EVAR at a single institution between 2001 and 2010 was performed. Patients were divided into two groups: group 1 included patients who underwent EVAR for treatment of aneurysms that did not involve the iliac bifurcation, and group 2 included patients with aortoiliac aneurysms that involved the iliac bifurcation (diameter >22 mm). Operative details and outcomes were compared between the groups and preprocedural computed tomography (CT) scans of patients in group 2 were used to determine if anatomy was suitable for IBG. Of 632 patients, 586 (522 group 1, 64 group 2) had data available for analysis with a mean follow-up of 26 months. During EVAR, 60 patients (94%) in group 2 underwent coil embolization and coverage of the internal iliac artery. In group 2 patients, the 5-year endoleak-free survival was significantly lower (57% ± 10% vs 72 ± 5%; P = .018), incidence of distal iliac artery attachment site (type Ib) endoleak was significantly higher (0.7% vs 7.8%, P < .001), and reintervention-free survival was significantly lower (68% ± 11% vs 77 ± 4%, P = .027). Anatomy in 42 patients (66%) was deemed suitable for use of iliac branched grafts, and presence of a hypogastric artery aneurysm was the most frequent reason restricting iliac branched grafts candidacy. Patients with aneurysms involving the iliac bifurcation usually require internal iliac artery sacrifice during EVAR and have worse long-term outcomes, with significantly higher rates of endoleak and reintervention. The anatomy in >50% of these patients is suitable for internal iliac preservation with an iliac branched graft, which could improve long-term outcomes after EVAR in patients with iliac involvement.

The objectives of this study were to define variables that predict failure of femoral access for mesenteric arterial intervention. We evaluated the relationship between anatomical and mural characteristics of the mesenteric vessels to determine the optimal access site for successful percutaneous intervention. A prospective database identified all patients who underwent an endovascular mesenteric intervention from 2005-2010. Patient demographics, lesion characteristics and operative details were analyzed. All angiograms were reviewed for mesenteric vessel angulation, tortuosity, lesion severity, and calcium score to determine the necessary access site for intervention. All patients had an initial attempt made through femoral access (F), followed by brachial access (B) if technical success was not achieved. 142 mesenteric arteries in 125 patients were reviewed. Of these, 83 vessels underwent endovascular treatment (50 Celiac, 33 SMA). The majority of these patients were female (n=57). 22 lesions were treated for aneurysm (15 celiac, 7 SMA) and 61 for CMI (12% CTO). 58 lesions were treated with F, while 24 required B. Mean angulation of the mesenteric arteries requiring F access was 48 degrees +/− 15 and 40 +/− 18 for brachial (P=0.03). Calcification at the origin did not impact access site (22% F- severe calcium score; 14% B; P=.5). Presence of CTO predicted brachial route (24% B vs 3.4% F, P=.008). Complication rates (arterial repair, hematoma) were higher in the B group (16% B vs 4% F, P=.05). Severe angulation and CTO are associated with technical failure for mesenteric intervention via transfemoral route. This is the first study to define factors where brachial access is the optimal approach for a successful endovascular intervention.Tabled 1CTO (%)Mesenteric Vessel Angulation (Degree)Severe Calcification at Origin (%)Primary Patency Rate(%) - 12 monthsSecondary Patency Rate(%) - 12 monthsDiabetes (%)Tobacco (%)Female Gender (%)Femoral Access3.448224979244869Brachial Access2440147888164068P Value.008.03.5.1.2.37.63.8 Open table in a new tab

Retrievable inferior vena cava (IVC) filters were introduced to provide protection from pulmonary emboli (PE) in patients with short-term PE risk, with the option to be removed once the PE risk subsides. However, many filters are not removed and there are increasing reports describing complications from retrievable filters including IVC perforation, erosion into adjacent structures, migration, and filter fracture. Importantly, the frequency of these complications is likely to increase as greater numbers of IVC filters are being placed and we describe our experience with open filter explantation for IVC perforation. We describe 5 cases of open filter explantation for IVC perforation by retrievable IVC filters following unsuccessful endovascular retrieval. Five patients underwent successful laparotomy and explantation of retrievable IVC filters. Three filters were placed for PE prophylaxis in high-risk patients prior to elective surgical intervention. Two others were placed in patients with PE and contraindications to anticoagulation. All patients had radiographic evidence of cava penetration by the filter. 4 patients had symptoms attributed to erosion into adjacent bowel, including one patient with endoscopic evidence of duodenal penetration. One patient was asymptomatic but had radiographic evidence of aortic penetration by a filter leg. All patients had improvement in symptoms and uncomplicated recoveries following explantation. This is the largest case series to date describing the open explantation of IVC filters for IVC perforation and erosion into adjacent structures. We advocate early endovascular retrieval of IVC filters as soon as PE risk subsides to avoid long-term complications of retrievable IVC filters. In cases of IVC perforation open removal of IVC filters can be performed safely with minimal risk when endovascular retrieval is unsuccessful.

Objectives: Advanced age is a significant risk factor that has traditionally steered patients away from open aneurysm repair and toward expectant management. Today, however, the reduced morbidity and mortality of aortic stent grafting has created a new opportunity for aneurysm repair in patients previously considered too high a risk for open surgery. Here we report our experience with endovascular aneurysm repair (EVAR) in nonagenarians.Methods: Retrospective chart review identified all patients >90-years-old undergoing EVAR over a 9-year period at our institution. Collected data included preoperative comorbidities, perioperative complications, endoleaks, reinterventions, and long-term survival.Results: 24 patients underwent EVAR. The mean age was 91.5 years (range 90-94) among 15 (63%) males and 9 (37%) females. Mean abdominal aortic aneurysm diameter was 6.3 +/- 1.1 cm. Eight patients (33%) were symptomatic (pain or tenderness). There were no ruptures. Fourteen patients (58%) had general anesthesia while 10 (42%) had local or regional anesthesia. Mean postoperative length of stay was 3.2 +/- 2.4 days (2.8 +/- 1.9 days for asymptomatic vs 4.1 +/- 3.2 days for symptomatic, P = .29). There was one perioperative mortality (4.2%). There were two local groin seromas (8.3%) and six systemic complications (25%). One patient required reintervention for endoleak (4.2%). There were no aneurysm related deaths beyond the 30-day postoperative period. Mean survival beyond 30 days was 29.7 +/- 18.0 months for patients expiring during follow-up. Cumulative estimated 12, 24, and 36-month survival rates were 83%, 64%, and 50%, respectively. Linear regression analysis demonstrated an inverse relationship between the number of preoperative comorbidities and postoperative survival in our cohort (R-2 = 0.701), with significantly decreased survival noted for patients presenting with >5 comorbidities. Those still alive in follow-up have a mean survival of 36.1 +/- 16.0 months.Conclusion: This is the largest reported EVAR series in nonagenarians. Despite their advanced age, these patients benefit from EVAR with low morbidity, low mortality, and mean survival exceeding 2.4 years. Survival appears best in those patients with <= 5 comorbidities. With or without symptoms, patients over the age of 90 should be considered for EVAR. (J Vase Surg 2010;52:1140-6.)

Introduction: It has been suggested that preemptive renal transplantation can reduce the incidence and severity of peripheral vascular disease (PVD) and improve limb salvage. Immunosuppressed transplant patients may have a decreased incidence of in-stent restenosis. This study compared limb salvage and patency rates after endovascular interventions among patients with chronic renal insufficiency (CRI), functional and failed renal transplants (RT), and normal renal (NR) function. Methods: A database of 1567 treated lesions from 2004 to 2009 was cross-referenced with the RT registry for the same period (n = 2283) to select three treated patient groups: NR, 1172; CRI (creatinine >1.2 mg/dL), 349 (end-stage renal disease, 92); RT, 46 (25 functional, 21 failed). Comorbidities and indications, and primary, secondary patencies, and limb salvage at 6, 12, 18, 24 months were assessed. P was calculated by log-rank analysis. Results: Indications for interventions were similar for CRI and RT, comprising claudication, 28 (39%); rest pain, 14 (4%); and tissue loss, 58 (57%). The NR group had more claudicant patients (52%) and less tissue loss (34%; P < .0001). RT patients were younger than CRI patients and had lower rates of heart failure. NR patients had a significantly lower incidence of diabetes than CRI and RT patients (P < .002). Primary patency for NR (78% at 6 months; 50% at 24 months) was significantly better than for CRI (P = .019 at 6 months; P = .002 at 24 months). Primary and secondary patencies at 6 and 24 months were significantly worse for the RT group than for the NR group (P < .001). Similarly, limb salvage at 24 months for RT (67%) was significantly worse than for NR (87%, P < .0001) but did not reach statistical significance for CRI (73%, P = .058). There was a nonsignificant trend towards improved patency results in patients with functional vs failed RT. Conclusions: As anticipated, endovascular outcomes for patency and limb salvage in patients with CRI were significantly worse than in patients with NR. Restoration of renal function by transplantation does not appear to reverse these outcomes despite the postulated beneficial effect of systemic immunosuppression.

BackgroundDigital subtraction angiography (DSA) is the gold standard for diagnosing lower extremity (LE) arterial lesions. However, duplex ultrasound (DUS) is a widely used, safe, and noninvasive method of detecting LE lesions. The purpose of this study was to establish DUS criteria for detecting and grading de novo stenotic lesions in the femoropopliteal arterial segment.MethodsA prospective database was established including all patients who underwent LE endovascular interventions between 2004 and 2009. Patients with de novo stenotic lesions in the femoropopliteal segment were selected. DUS and DSA data pairs ≤30 days apart were analyzed. Peak systolic velocity (PSV; cm/s), velocity ratio (Vr), and DSA stenosis were noted. Linear regression and receiver operator characteristic (ROC) curves were used.ResultsTwo hundred seventy-five lesions in 200 patients were analyzed. Indications were claudication (50.5%), rest pain (12.5%), and tissue loss (37.0%). Mean time interval between DUS and DSA was 24 days. Both PSV (R = .80, R2 = .641; P < .001) and Vr (R = .73, R2 = .546; P < .001) showed strong correlation with the degree of angiographic stenosis. ROC analysis showed that to detect ≥70% stenosis, a PSV of 200 cm/s had 89.2% sensitivity and 89.7% specificity, and a Vr of 2.0 had 88.7% sensitivity and 90.2% specificity. Similarly, to differentiate between <50% and ≥50% stenosis, PSV of 150 cm/s and Vr of 1.5 were highly specific and predictive. Combining PSV 200 cm/s and Vr 2.0 for ≥70% stenosis gave 79.0% sensitivity, 99.0% specificity, 99.0% positive predictive value, and 85.0% negative predictive value.ConclusionDUS shows a strong agreement with angiography and has good accuracy in detecting femoropopliteal lesions. We propose DUS criteria of PSV 200 cm/s and Vr 2.0 to differentiate between <70% and ≥70% de novo stenosis in the femoropopliteal arterial segment.

The management of chronically occluded lower extremity (LE) arteries is one of the more challenging issues for endovascular therapy. Not only is the procedure more complicated, the long-term patency has been a concern. We reviewed our prospectively maintained database to evaluate the long-term effectiveness of the endovascular treatment of chronic total occlusions (CTOs).