Inferior vena cava filters are medical devices used as an alternative method in the prevention of pulmonary thromboembolism in patients with deep vein thrombosis. Though generally regarded as safe alternatives, these devices do carry a risk of associated complications. Presented is a case of a 32-year-old female who developed a duodenal perforation after undergoing the removal of a retrievable inferior vena cava (IVC) filter. She required placement of the IVC filter during her second pregnancy due to multiple thrombotic events. The patient underwent nonoperative conservative therapy and ultimately had a favorable outcome. When managing patients with known IVC filter placement experiencing acute-onset abdominal pain, there should be a high clinical suspicion of IVC filter perforation of an organ.

Operating room cancellation rates, defined as cancellation ≤24 hours of planned surgery, have been reported to be as high as 14% to 17.4%. In the United Kingdom, this cancellation rate average is 8.1%. One large metropolitan hospital system in the United States has chosen 6% as a target mandatory cancellation rate. Procedures in the fields of vascular and transplant surgery fall well outside this benchmark, particularly ones involving arteriovenous access (AVA). PubMed was searched to determine the reported cancellation rates for patients undergoing AVA surgery. Interestingly, there were no clearly defined studies or published rates of AVA procedure cancellation in the English language literature. Using an operating room quality assurance database, we analyzed the 1-year cancellation rate of AVA procedures by Current Procedural Terminology (CPT) code. Analysis included the number of cases cancelled and the reasons stated for case cancellation. Among 191 cases booked, encompassing CPT codes 36,819, 36,821, 36,830, and 36,831, 88 (46%) were cancelled ≤24 hours. Cancellations by surgical type were 36,819 (55%), 36,821 (46%), 36,830 (43%), and 36,830 (25%). The reasons for cancellation were as follows: 44% attributed to practice conditions, including scheduling issues, insurance verification, and attending schedule; 31% based on patient factors; and 25% listed as lack of medical clearance. A cancellation rate of 14% is generally reported, and accepted, for elective general surgery cases. This percentage is largely attributed to patient comorbidities and the disease process. However, the cancellation rate for patients undergoing AVA procedures is notably higher, at 46%. We believe that by minimizing practice-related and preoperative assessment variables, the AVA cancellation rate can be reduced to a percentage closer to the 14% for elective general surgery.

Debate exists about the outcomes and relative benefits of endovascular vs surgical treatment of infrainguinal arterial disease. We evaluated the 30-day instances of unplanned reoperations following primary revascularization procedures in these two groups. Primary revascularization procedures were identified from the 2011 to 2012 ACS American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Unplanned reoperations following these procedures were then categorized by procedure type. Appropriate statistical tests were used to compare demographics and surgical outcomes. Among 8687 patients who underwent infrainguinal revascularization, 5489 surgical (63%) and 3198 endovascular (37%) procedures were performed. Patients in the surgical group had significantly higher American Society of Anesthesiologists class, were more likely to have a diagnosis of critical limb ischemia, and more often had a history of previous revascularization or amputation. The overall rate of unplanned reoperation within 30 days was 18.1% in the surgical group and 11.1% in the endovascular group (P < .001). When unplanned reoperations were categorized by procedure type, the surgical group had significantly higher rates of unplanned reoperations for wound related complications (4.3% vs 1.1%; P < .001) and bleeding related complications (1.1% vs 0.3%; P < .001). No differences between the two groups were seen in rates of amputations (5.2% vs 4.4%; P = .10), secondary revascularization procedures (5.9% vs 6.2%; P = .53), and nonvascular-related procedures (1.1% vs 1.2%; P = 1.0). Although the overall rate of unplanned reoperations within 30 days of primary revascularization for infrainguinal arterial disease is significantly higher following surgical treatment compared with endovascular treatment, the differences are largely attributable to inherent wound- and hemostasis-related complications. Surgical and endovascular groups are equivalent in terms of amputation and revascularization procedures.TableUnplanned reoperation within 30 days of surgical and endovascular treatment infrainguinal arterial diseaseUnplanned reoperationsOverall (N = 8687)Surgical (n = 5489)Endovascular (n = 3198)P valueNo. (%)No. (%)No. (%)All unplanned reoperations1346 (15.5)991 (18.1)355 (11.1)<.001 First unplanned reoperation1111 (12.8)815 (14.8)296 (9.3)<.001 Second unplanned reoperation235 (2.7)176 (3.2)59 (1.8)<.001Amputation within 30 days430 (4.9)288 (5.2)142 (4.4).101 AKA75 (0.9)53 (1.0)22 (0.7).188 BKA105 (1.2)64 (1.2)41 (1.3).684 TMA170 (2.0)113 (2.1)57 (1.8).422 Toe amputation80 (0.9)58 (1.1)22 (0.7).102All revascularizations447 (5.1)324 (5.9)199 (6.2).543 Surgical365 (4.2)299 (5.1)142 (4.4).043 Endovascular82 (0.9)25 (0.5)57 (1.8)<.001Wound-related procedures270 (3.1)236 (4.3)34 (1.1)<.001 Débridement158 (1.8)136 (2.5)22 (0.7)<.001 Wound closure31 (0.4)26 (0.5)5 (0.2).015 Wound infection81 (0.9)74 (1.3)7 (0.2)<.001Hemostasis70 (0.8)62 (1.1)8 (0.3)<.001Fasciotomy16 (0.2)13 (0.2)3 (0.1).194Angiography13 (0.1)5 (0.1)8 (0.3).084Nonvascular related100 (1.2)63 (1.1)37 (1.2)1.000AKA, Above-knee amputation; BKA, below-knee amputation; TMA, transmetatarsal. Open table in a new tab

Endovascular access is difficult in the pediatric population given their small vessel size and propensity for vessel spams. As a result, more frequent and unique complications have been seen, including dissections, pseudoaneurysms, and ultimately, limb length discrepancies. A major risk factor for such complications is repeated endovascular access, which, unfortunately, is necessary in the management of many of the diseases addressed. We propose the creation of lower extremity arteriovenous fistulas as endovascular access sites in the pediatric population with the benefit of high flow, large caliber, and percutaneous access. We evaluated the feasibility of this concept in an animal model across several species with varying vessel caliber. Femoral artery and vein were used to create an end-vein to side-artery fistula. Fistulas were superficialized to provide percutaneous access. This was performed on leporine and canine models. Duplex ultrasonography was performed to demonstrate patency. Femoral vessels in the leporine model proved to be too small to accommodate the smallest sheath catheter (4F). Successful arteriovenous fistula was created and accessed in the canine model without complications. Patency was demonstrated by ultrasonography. This proof-of-concept pilot study was necessary to demonstrate the feasibility of lower extremity arteriovenous fistula creation and access in animal models. We now build upon this study and proceed with a survival model involving repeated endovascular access, increased catheterization time, and additional vascular imaging. The lower extremity arteriovenous fistula may be an ideal access site for endovascular procedures in the pediatric population.

Amputations are the terminal outcome of peripheral vascular disease and an indirect marker for the efficacy of revascularization procedures. They are associated with increased morbidity, mortality, and health care costs. We evaluated the risk factors for unplanned amputation within 30 days of infrainguinal revascularization. All patients who underwent unplanned above-knee, below-knee, transmetatarsal, and toe amputations within 30 days of infrainguinal revascularization were identified from the 2011 to 2012 American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. Appropriate statistical tests were used to compare demographics and surgical outcomes. Multivariate logistic regression was used to evaluate risk factors for unplanned amputation. Among 8726 patients who underwent infrainguinal revascularization, 421 (4.8%) underwent unplanned amputations within 30 days. The amputation group had significantly higher dependent functional status, American Society of Anesthesiologists class, comorbidities, including diabetes, end-stage renal disease, and critical limb ischemia, and was more likely to be non-Caucasian. Postoperatively, the amputation group had significantly higher rates of transfusion requirement, graft failure, and sepsis. On multivariate analysis, transfer from a chronic care facility was associated with the highest risk of unplanned amputations (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.5-6.0; P = .002), followed by preoperative systemic inflammatory response syndrome, sepsis, or septic shock (OR, 2.8; 95% CI, 1.4-5.5; P = .002), diabetes mellitus (OR, 2.4; 95% CI, 1.6-3.7; P < .001), and critical limb ischemia (OR, 1.8; 95% CI, 1.2-2.7; P = .006). The rate of unplanned amputation was not associated with whether the primary revascularization procedure was surgical or endovascular. Unplanned amputation occurring within 30 days of infrainguinal revascularization is associated with a number of variables. The results of our study provide a framework for identifying postrevascularization patients at highest risk for amputation.