OBJECTIVE:To describe early and late outcomes of segmental resection and graft replacement of the inferior vena cava (IVC) for malignant disease over three decades. METHODS:All patients who had IVC resection with graft replacement from 1990 to 2024 at a single institution were retrospectively reviewed. Patients with tangential excision and primary or patch venorrhaphy were excluded. End points were early (<30 days) mortality, major adverse events, graft-related complications, primary patency, overall survival, and freedom from local recurrence. RESULTS:One hundred sixty-seven patients (54% female; mean age at operation 55 ±14 years) had IVC resection and graft replacement. Primary IVC leiomyosarcoma occurred in 69 patients (41%) and other secondary malignancies in 97 (58%). Preoperative performance status (Eastern Cooperative Oncology Group) was good or excellent in 153 patients (92%). Resection of multiple IVC segments was required in 94 patients (56%), 41 who needed renal vein reconstruction or implantation (25%) and 6 (3.6%) who had hepatic vein implantation. Graft replacement was with ringed polytetrafluoroethylene in 163 patients (98%). Two patients died of intraoperative hemorrhage. Six others died within 4 months; three were procedure-related. One or more major adverse events occurred in 28 patients (17%). Intra-abdominal hemorrhage requiring transfusion was the most common complication, occurring in 10 patients (5.9%). Only one patient developed permanent renal or liver failure. Two patients (1.2%) had asymptomatic subsegmental pulmonary emboli. Over a mean follow-up of 5.5 ± 5.8 years (median 3.2 [1.2, 7.5] years), 10 patients experienced graft occlusion (5.9%). Two occlusions were within 1 month of graft placement, two were within 1 year, and 6 were over 1 year, with one at 23 years postoperatively. Four patients had stents placed to treat asymptomatic high-grade stenoses, one early and three late. There were four graft infections, all related to small bowel leaks. The median overall survival was 52% and 36% at 5 and 10 years, respectively (range, 0-27 years). Freedom from local recurrence was 85%, 71%, and 54% at 1, 5, and 10 years, respectively. Kaplan-Meier estimates of IVC graft primary patency were 96%, 95%, and 88% at 1, 5, and 10 years, respectively. CONCLUSIONS:IVC resection and graft replacement for malignant disease are safe and durable, and provide excellent local control of the tumor, offering a chance for long-term survival in select patients.

For more than 2000 years, control of battlefield hemorrhage relied on compressive dressings. Added to this were the use of cautery, styptics, boiling oil, and a variety of other partially effective adjuncts. In Rome 2000 years ago, Galen advocated ligature of bleeding vessels. However, this was lost during the Dark Ages, and it was not until the 16th century that Ambroise Paré “reinvented” ligature of bleeding vessels when he ran out of boiling oil. Paré was also one of the first to devise instruments, including the bec de corbin to grasp bleeding vessels to assist with the ligature. At the turn of the 20th century, the development of clinical and experimental concepts related to vascular surgery progressed, and during the Korean War (1950–1953) successful repair of injured arteries and veins was accomplished consistently in the treatment of battlefield casualties. Over the past 50 years, additional advances in managing vascular trauma have been made in both civilian and military practices. These have included experiences with endovascular procedures, particularly over the past decade, transferring civilian experience to the management of battlefield casualties by coalition forces in Afghanistan and Iraq.

Neurogenic thoracic outlet syndrome (nTOS) is a complex clinical entity subject to variable diagnostic regimens. We hypothesized that patients with a positive response, defined as relief of symptoms, following local muscle block of the anterior scalene muscle were more likely to demonstrate benefit following decompression of the thoracic outlet. Patients who underwent surgical decompression for nTOS from 2009 to 2019 at a single institution were identified. Perioperative data were collected to include symptomatology, diagnostic evaluation, intraoperative findings, and postoperative changes in functionality, symptom relief, and recurrence. Groups were then stratified based on the receipt of preoperative local anesthetic block. Univariate analysis was used to assess the impact of demographic and clinical characteristics and response to block on the likelihood of developing persistent or recurrent symptoms and need for reoperation. To explore long-term efficacy, patients were surveyed with regard to symptom relief, symptom recurrence, functionality since surgery, and overall satisfaction with operative outcome. We evaluated 45 patients (49 limbs) who underwent surgical decompression for nTOS between 2009 and 2019; 38.8% (19/49) of these cases were preceded by a scalene muscle block. The patients were predominantly female, 77.8% (35/45) with a mean age of 33.0 ± 11.3 years, and an average age at symptom onset of 25 years. The survey response rate was 68.9% with 31 of 45 patients responding. On postoperative follow up, 91.8% (45/49) of operative limbs were clinically noted to have improvement in function. Survey results demonstrated an average overall preoperative level of functionality of 4.5 ± 2.4 and postoperative level of functionality of 8.1 ± 1.9 (1 = little/no function, 10 = total/high function). NoTably, the population operated on following a positive response to preoperative scalene muscle block reported poorer preoperative functionality of the affected limb than those not screened by this protocol, 2.7 versus 5.4 (P = .0082). Postoperative functionality reported by the two groups was similar, 8.0 versus 8.1 (P = .45). Approximately half of survey respondents reported some degree of symptom recurrence after surgery, with an average time to recurrence of 2 months (range, 1-96 months). There was no difference in symptom recurrence (P = .74) or need for reintervention 4 of 49 cases (P = .80) between block and nonblock groups. Patients operated on following positive response to muscle block reported a lower long-term postoperative pain rating (2.9 vs 3.3), as well as more relief from nTOS symptoms (8.0 vs 7.7), though neither of these differences reached significance. The majority of patients undergoing surgical decompression for relief of nTOS symptoms report improvement in pain and related symptomatology, though some degree of recurrence continues to occur in nearly half of patients. The institution of a preoperative screening protocol involving temporary muscle block selects a patient population with more severe preoperative symptoms. While block protocols may provide another data point to guide patient selection, this study does not demonstrate a statistically significant difference in clinical outcomes in an initial patient group following protocol institution. Further study as additional patients are accrued under the protocol is ongoing.

External iliac arteriopathy, a full-thickness disease process in high-performance athletes as a result of repetitive trauma, is manifested as claudication with extreme exercise. We present findings here from the largest series in the United States, with attention to optimal preoperative evaluation and the characterization of reintervention. Patients who underwent operative intervention for external iliac arteriopathy at a single institution from 2004 to 2019 were evaluated. Preoperative evaluation consisted of resting and exercise ankle-brachial index (percentages) as well as neutral and provocative arteriography, all studies done on strict protocols. Univariate analysis was used to assess the influence of demographic and clinical characteristics on the later likelihood for development of persistent or recurrent symptoms requiring operative reintervention. There were 75 patients (26 male, 49 female) identified, with an average age of 40.4 years (range, 22.3-56.1 years) at the time of index operation. In total, 102 (53 left, 49 right) limbs were treated operatively, with 27 patients (26.4%) undergoing bilateral intervention. In the overall series, the majority of interventions were interposition grafts, which represented 56 (54.9%) of the interventions, with patch angioplasty performed in 30 (29.4%). Patch angioplasty was performed more frequently (60%) from 2004 to 2010; since then, the majority of reconstructions (78%) have been interposition grafts. Of the 102 limbs, 25 (24.5%) required reintervention, at an average interval of 16.6 months from the index operation. Intimal hyperplasia, predominantly distal, accounted for 15 (60%) of these limbs and kinking for 9 (36%). Initial operative approach, sex, and age at initial presentation had no statistically significant impact on the likelihood of reoperation. These findings contrast with our earlier study. Three-quarters of the patients in this 15-year series achieved symptom relief and did not require revision. Success remains elusive for a quarter of these patients as mild to moderate degrees of restenosis or kinking may be clinically symptomatic and significant for these physically active athletes. The ideal reconstructive technique for each patient has not yet been determined.

Aortic graft infections (AGIs) represent one of the more challenging clinical problems for the vascular surgeon. The purpose of this study was to describe clinical characteristics and outcomes for the management of open and endovascular AGIs at a single center. The institutional clinical data repository was queried using International Classification of Diseases codes to identify patients diagnosed with AGIs between 2001 and 2017. Preoperative variables and treatment strategies and outcomes were compared between open and endovascular AGIs. Time-to-event analysis was performed for the primary outcomes of survival and patency after AGI repair. Forty-three patients with AGIs were identified, 36 of whom underwent initial open graft and 7 endografting. Infection after initial surgery but preceding AGI was present in 58.1% of the entire cohort. AGIs developed in endovascular patients at significantly shorter intervals after initial surgery (28 ± 44 months vs 55 ± 48 months; P < .05). Pain (47.6%) and fever (37.2%) were the most common presentations, whereas 23.3% presented in extremis and 14 had aortoenteric erosions or fistulas (32.6%). Pathogens did not differ between the two groups. At time of AGI, there was no difference in age between the groups, but more endovascular patients had congestive heart failure (28.6% vs 2.8%; P = .01) and were immunosuppressed (14.3% vs 0%; P = .02). Open patients required repair at significantly shorter intervals from AGI diagnosis (15 ± 25 days vs 27 ± 25 days; P < .05). Management strategy with extra-anatomic or in situ bypass did not differ between the groups. Synthetic conduits (n = 37) predominated over vein (n = 4; 88.1% vs 9.5%). Estimated blood loss was significantly higher for endovascular AGI repairs (2.3 ± 1.6 L vs 1.1 ± 0.9 L; P < .05). Major morbidity within 30 days and after 30 days did not differ between the groups. Six patients required amputation during the study period (14.0%). Reinterventions for patency and reinfection did not differ between the two groups. Eight patients showed evidence of infection at last follow-up (18.6%). Patency and overall survival did not differ between the open and endovascular groups. Endovascular AGIs present earlier than open AGIs but require less urgent repair. Morbidity and mortality remain high, but durable patency and survival can be achieved for some patients. Further studies should combine multiple institution outcomes to better define the natural course of these difficult-to-treat patients.

: Although multiple sources chronicle the practice of vascular surgery in the North African, Mediterranean, and European theaters of World War II, that of the Pacific campaign remains undescribed. Relying on primary source documents from the war, this article provides the first discussion of the management of vascular injuries in the island-hopping battles of the Pacific. It explains how the particular military, logistic, and geographic conditions of this theater influenced medical and surgical care, prompting a continued emphasis on ligation when surgeons in Europe had already transitioned to repairing arteries.

The aim of the study was to conduct a retrospective chart review of patients who underwent betadine/bacitracin continuous irrigation (BBCI) for vascular graft infections (VGIs) to review its use as a treatment option. A retrospective chart review from 2013 to 2017 was conducted of patients with VGIs that were treated with BBCI postremoval of the infected graft. The BBCI is a continuous infusion of 0.25% betadine in normal saline at 0.3 mL/kg/h for 48 hours then followed by bacitracin infusion with a concentration of 50,000 units bacitracin/per liter normal saline at 0.3 mL/kg/h for 72 hours. Descriptive statistics were used to describe the sample. The nine adult patients who received postoperative BBCI had an age range of 30-81 years, with average age of 58.8 years. Five of the subjects were females with four males. A total of nine patients with groin infections were identified, with two aortobifemoral bypasses, two axillofemoral bypasses, three femoral-femoral bypasses, one femoral artery pseudoaneurysm repair with Dacron patch, and one common femoral endarterectomy with Dacron patch. VGIs were identified from 10 days up to 72 months from the original vascular procedure. Six patients had negative wound cultures, while two had wound cultures positive for methicillin-resistant Staphylococcus aureus and one patient had positive culture for Escherichia coli. The length of time of BBCI ranged from 48 to 84 hours with average of 57.6 hours (standard deviation [SD] = 12.7 hours). The length of time of the bacitracin irrigation ranged from 30 to 72 hours with average of 48.4 hours (SD = 14.9 hours). All patients healed their groin wounds except for an 81-year-old patient with aortobifemoral bypass graft who developed ischemic bowel and expired. Patients received at least 6 weeks of intravenous antibiotics followed by oral antibiotic suppression therapy for life. VGIs are a devastating complication associated with a high morbidity. BBCI provides an option for antiseptic irrigation of the vascular graft site postgraft removal to promote wound closure.

OBJECTIVE:In 2009, the Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) to define the therapeutic benchmarks in critical limb ischemia (CLI) based on outcomes from randomized trials of lower extremity bypass (LEB). Current performance relative to these benchmarks in both LEB and infrainguinal endovascular intervention (IEI) remains unknown. The objective of this study was to determine whether LEB and IEI performed for CLI in a contemporary national cohort met OPG 30-day safety thresholds. METHODS:SVS OPG criteria were applied to 11,043 revascularizations for CLI performed from 2011 to 2015 in the National Surgical Quality Improvement Program (NSQIP) vascular targeted modules. Primary 30-day safety OPGs including major adverse cardiovascular events (MACEs), major adverse limb events (MALEs), and amputation were calculated for the NSQIP LEB (n = 3833) and IEI (n = 3526) cohorts as well as for subgroups at "high anatomic risk" (infrapopliteal revascularization) and "high clinical risk" (age >80 years and tissue loss). These were compared with SVS OPG benchmarks using χ2 comparisons. RESULTS:Compared with the SVS OPG cohort, both the NSQIP LEB and IEI cohorts had fewer patients at high anatomic risk (LEB, 51%; IEI, 27%; SVS OPG, 60%; both P < .0001). The LEB cohort had fewer patients with high clinical risk than the SVS OPG cohort (LEB, 11%; SVS OPG, 16%; P < .0001). The 30-day MALE was significantly higher in the NSQIP LEB (9.0% [8.7%-9.2%]) and IEI (9.7% [9.4%-10.0%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-9.0%]; both P ≤ .007), including significantly higher rates of amputation. MACE was significantly lower in the NSQIP LEB (4.2% [4.1%-4.3%]) and IEI (3.1% [3.0%-3.2%]) cohorts compared with the SVS OPG cohort (6.1% [4.7%-8.1%]; both P ≤ .013). Among patients at high anatomic risk, 30-day MALE was significantly higher after LEB (9.5% [9.1%-9.8%]) and IEI (11.1% [10.4-11.8%]) compared with the SVS OPG cohort (6.1% [4.2%-8.6%]; P ≤ .002). Among patients with high clinical risk, IEI was associated with lower MACE compared with the SVS OPG cohort, with similar limb-related outcomes. CONCLUSIONS:In contemporary real-world practice, LEB and IEI for CLI failed to meet SVS OPG limb-related 30-day safety benchmarks for the entire CLI cohort as well as for the patients at high anatomic risk. Additional investigation using SVS OPGs as consistent end points is required to determine why limb-related outcomes after revascularization for CLI remain suboptimal. LEB and IEI surpassed OPG benchmarks for 30-day cardiovascular morbidity and mortality. OPGs for cardiovascular morbidity in patients undergoing revascularization for CLI deserve re-evaluation using contemporary data.

Objective: Dementia represents a major risk factor for medical complications and has been linked to higher rates of complication after surgery. Given the systemic nature of vascular disease, medical comorbidities significantly increase cost and complications after vascular surgery. We hypothesize that the presence of dementia is an independent predictor of increased postoperative complications and higher health care costs after vascular surgery. Methods: The Vascular Quality Initiative database was queried for all patients undergoing vascular surgery at a single academic medical center from 2012 to 2017. All modules were included (open abdominal aortic aneurysm, suprainguinal bypass, lower extremity bypass, amputation, carotid endarterectomy, endovascular aortic aneurysm repair, thoracic endovascular aortic aneurysm repair, and peripheral endovascular intervention). An institutional clinical data repository was queried to identify patients with International Classification of Diseases, Ninth Revision diagnosis codes for dementia as well as total hospital cost and long-term survival using Social Security records from the Virginia Department of Health. Hierarchical logistic and linear regression models were fit to assess risk-adjusted predictors of any complication and inflation-adjusted cost. Kaplan-Meier and Cox proportional hazards models were used for survival analysis. Results: A total of 2318 patients underwent vascular surgery and were captured by the Vascular Quality Initiative during the past 5 years, with 88 (3.8%) having a diagnosis of dementia. Patients with dementia were older and had higher rates of medical comorbidities, and the most common procedure was major amputation. In addition, dementia patients had a significantly higher rate of any complication (52% vs 16%; P < .0001) and increased 90-day mortality (14% vs 4.8%; P = .0002). Furthermore, dementia was associated with significant resource utilization, including preoperative length of stay (LOS), postoperative LOS, intensive care unit LOS, and inflation-adjusted total hospital cost (all P < .0001). Hierarchical modeling demonstrated that dementia was the strongest preoperative predictor for any complication (odds ratio, 8.64; P < .0001) and had the largest risk-adjusted impact on total hospital cost ($22,069; P < .0001). Finally, survival analysis demonstrated that dementia is independently associated with reduced survival after vascular surgery (hazard ratio, 1.37; P = .018). Conclusions: This study demonstrated that dementia is one of the strongest predictors of any complication and increased hospital cost after vascular surgery. Given the high risk of clinical and financial maladies, patients with dementia should be carefully considered and counseled before undergoing vascular surgery.

Medical therapy for mycotic aortic aneurysms (MAA) is almost universally fatal, while surgical and endovascular repair carry high morbidity and mortality. The purpose of this study was to compare outcomes between patients receiving treatment for MAA. Records were obtained and patients with MAA were stratified by intervention: endovascular repair, open surgery, and medical therapy. Primary outcomes were aneurysm-related mortality and survival. Risk-adjusted associations with mortality were assessed using time-to-event analysis. Thirty-eight patients were identified (median age, 67). Twenty-one underwent endovascular repair,10 had open surgery and 7 received medical therapy alone. Overall mortality was 47% (n = 18), with 94% aneurysm related. Median survival was significantly longer in the endovascular group (747.0 [161-1249]) vs open surgery and medical therapy (507.5 [34-806] and 66 [13-146] days, respectively; P = .02). The endovascular group had significantly fewer perioperative complications (43% vs 80%, P < .01). However, 4 endovascular patients experienced reinfection versus no open surgery patients. Mortality risk factors included medical therapy (hazard ratio [HR]: 5.3, P < .01) and aneurysm size (HR: 1.4 per 1-cm increase in diameter, P = .03). Endovascular repair of MAA was associated with the best long-term survival and lowest perioperative complication rate, although it is associated with greater reinfection. These tradeoffs should be considered when selecting which procedure is best for a patient.

Background: The decision to proceed with vascular surgical interventions requires evaluation of cardiac risk. Recently, several online risk calculators were created to predict outcomes and to lead to a more informed conversation between surgeons and patients. The objective of this study was to compare and further validate these online calculators with actual adverse cardiac outcomes at a single institution. Methods: All patients from January 2011 through December 2015 undergoing carotid endarterectomy (CEA), infrainguinal lower extremity bypass, open abdominal aortic aneurysm (AAA) repair, and endovascular aneurysm repair (EVAR) on the vascular surgical service were included using the Society for Vascular Surgery Vascular Quality Initiative database at our health system. Additional information was collected through retrospective chart review. Each patient was entered through three online risk calculators: (1) the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) estimates the risk of cardiac arrest and myocardial infarction (MI); (2) the Revised Cardiac Risk Index (RCRI) estimates risk of MI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block; and (3) the Vascular Study Group of New England (VSGNE) Cardiac Risk Index estimates risk of postoperative MI only. Observed adverse cardiac events (ACEs) were compared with expected values for each calculator using a chi(2) goodness-offit test. Institutional Review Board exemption was obtained. Results: A total of 856 cases were included: 350 CEAs, 210 infrainguinal bypasses, 77 open AAA repairs, and 219 EVARs. For CEA, no risk calculator showed statistically significant variation from the observed values (NSQIP, P = .45; RCRI, P = .17; VSGNE, P = .24). For infrainguinal bypass, NSQIP slightly underpredicted adverse events (P = .054), RCRI strongly underpredicted (P = .002), and VSGNE showed no difference (P = .42). For open AAA repair, NSQIP (P = .51) and VSGNE (P = .98) were adequate predictors, but RCRI strongly underpredicted the adverse events (P <= .0001). Finally, EVAR cardiac outcomes showed greater adverse events than predicted by all three calculators (NSQIP, P = .02; RCRI, P = .0002; and VSGNE, P = .025). Pooled data for the entire group documented that the VSGNE proved an accurate tool for prediction (P = .34), whereas ACEs were underpredicted by NSQIP (P = .0055) and RCRI (P <= .001). Conclusions: Although online cardiac risk calculators of adverse surgical events are easy to use and to reference in broad surgical decision-making, there is significant variability in their predictability at the procedure and institutional level. Our data suggest that ACEs often occur at a higher rate than expected on the basis of calculated risks profiles, thus creating a platform for future discussion about preoperative evaluation and postoperative care decision-making models.

Background. While it is anticipated that decubitus ulcers are detrimental to outcomes after vascular operations, the contemporary influence of perioperative decubitus ulcers in vascular surgery remains unknown.Methods. Using the National Impatient Survey, all adult patients who underwent vascular operation were selected. Patients were stratified by the presence or absence (non decubitus ulcers) of decubitus ulcer. Case-mix adjusted hierarchical mixed-models examined in-hospital mortality, the occurrence of any complication, and discharge disposition.Results. A total of 538,808 cases were analyzed. Decubitus ulcers were most prevalent among Caucasian male Medicare beneficiaries (P < .001). Decubitus ulcer patients also underwent more nonelective vascular operations (P < .001). Wound, infectious, and procedural complications were more common in patients with decubitus ulcers (P < .001). Failure to rescue, defined as mortality after any complication, was more than doubled in decubitus ulcers (non decubitus ulcers: 1.5 %, decubitus ulcers: 3.2%, P < .001). Similarly, unadjusted mortality was also doubled in patients undergoing vascular operation with decubitus ulcers (non decubitus ulcers: 3 %, decubitus ulcers: 6%, P < .001). After risk adjustment among all patients, neither the presence of a decubitus ulcer nor specific ulcer staging increased the adjusted odds of death. Having a decubitus ulcer increased the adjusted odds of discharge to an intermediate care facility (odds ratio 2.9, P < .001). These patients also had 1.6 times the total charges compared to their non decubitus ulcer cohort (non decubitus ulcers: $49,460 +/- $281 vs decubitus ulcers: $81,149 +/- $5,855, P < .001).Conclusion. Contrary to common perception, perioperative decubitus ulcer does not adversely affect mortality after vascular operation in patients proceeding to operative intervention. Patients with decubitus ulcers are, however, at higher risk for complications and incur sizeable additional charges.

Objective: Studies from large administrative databases have demonstrated associations between institutional case volume and outcomes after lower extremity bypass (LEB). We hypothesized that increased institutional and surgeon volume would be associated with improved outcomes after LEB. Using a national, prospectively collected clinical database, the objective of this study was to determine the effects of both surgeon and institutional volume on outcomes after LEB. Methods: The Vascular Quality Initiative (VQI) was queried to identify all LEBs for critical limb ischemia or claudication between 2004 and 2014. Average annual case volume was calculated by dividing an institution's or surgeon's total LEB volume by the number of years they reported to the VQI. Institutional and surgeon volumes were analyzed as continuous variables to determine the impact of volume on major adverse cardiac events (MACEs), major adverse limb events (MALEs), graft patency, and amputation-free survival. Hierarchical regression models were used with cases clustered by surgeon and center. Time-dependent outcomes were evaluated with multivariable shared frailty Cox proportional hazards models. Results: From 2004 to 2014, there were 14,678 LEB operations performed at 114 institutions by 587 surgeons. Average annual institutional volume ranged from 1.0 to 137.5 LEBs per year, with a median of 26.9 (interquartile range, 14-45.3). Average annual surgeon volume ranged from 1 to 52 LEBs per year with a median of 5.7 (interquartile range, 2.5-9.3). Institutional LEB volume was not associated with MACEs or MALEs or with loss of patency. However, average annual surgeon volume was independently associated with reduced MALEs and improved primary patency. Institutional and surgeon volume did not predict MACEs. Conclusions: In contradistinction to previous studies, there was no relationship in this study between institutional LEB volume and outcomes after LEB. However, greater average annual surgeon volume was associated with improved primary patency and decreased risk of MALEs. Open LEB remains a safe and effective procedure for limb salvage. Limb-related outcomes in critical limb ischemia and claudication will be optimized if surgeons maintain adequate volume of LEB.

Objective: Autologous vein is the preferred conduit for lower extremity bypass. However, it is often unavailable because of prior harvest or inadequate for bypass owing to insufficient caliber. Cryopreserved cadaveric vessels can be used as conduits for lower extremity revascularization when autogenous vein is not available and the use of prosthetic grafts is not appropriate. Many studies have shown that donor characteristics influence clinical outcomes in solid organ transplantation, but little is known regarding their impact in vascular surgery. The purpose of this study was to examine the effects donor variables have on patients undergoing lower extremity bypass with cryopreserved vessels. Methods: The tissue processing organization was queried for donor blood type, warm ischemia times (WITs), and serial numbers of cryopreserved vessels implanted at a single center from 2010 to 2016. The serial numbers were then matched with their respective patients using the institutional Clinical Data Repository and patient data were obtained from the Clinical Data Repository and chart review. Primary outcomes were primary patency of the bypass conduits and limb salvage. Time to loss of patency was evaluated using Kaplan-Meier methods and a Cox proportional hazards model determined risk-adjusted predictors of patency and limb salvage. Results: Sixty patients underwent lower extremity bypass with 65 cryopreserved vessels (23 superficial femoral arteries, 41 saphenous veins, 1 femoral vein). Thirty-eight procedures were reoperations. There were 21 inflow, 44 outflow, and 44 infrainguinal procedures. Preexisting comorbidities did not differ significantly between those who lost patency and those who did not. The mean WIT among the entire cohort was 892.3 +/- 389.1 minutes (range, 158.0-1434.0 minutes). The median follow-up was 394 days. Kaplan-Meier analysis demonstrated an overall 1-year primary patency rate of 51%. Primary patency at 1 year was 67% and 41% for inflow and outflow procedures, respectively, and did not differ significantly between the two groups (P = .15). Donor-to-recipient ABO incompatibility was not associated with loss of primary patency. The 1-year amputation-free survival was 74%. Primary patency significantly decreased with each hourly increase in WIT on risk-adjusted analysis (hazard ratio, 1.1; P = .02). Conclusions: Higher cryopreserved vessel WIT was associated with increased risk-adjusted loss of primary patency in this cohort. At 1 year, the overall primary patency was 51% and amputation-free survival was 74%. Vascular surgeons should be aware that WIT may affect outcomes for lower extremity bypass.

PURPOSE: The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery. DESIGN: Retrospective, descriptive study. METHODS: We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; χ2 was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%. RESULTS: We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008). CONCLUSION: We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

PURPOSE: The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery. DESIGN: Retrospective, descriptive study. METHODS: We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; &khgr;2 was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%. RESULTS: We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008). CONCLUSION: We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

Background: Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay.Methods: The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS <= 1 day and > 1 day.Results: Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05).Conclusions: Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.

Vascular surgery in World War II has long been defined by DeBakey and Simeone's classic 1946 article describing arterial repair as exceedingly rare. They argued ligation was and should be the standard surgical response to arterial trauma in war. We returned to and analyzed the original records of World War II military medical units housed in the National Archives and other repositories in addition to consulting published accounts to determine the American practice of vascular surgery in World War II. This research demonstrates a clear shift from ligation to arterial repair occurring among American military surgeons in the last 6 months of the war in the European Theater of Operations. These conclusions not only highlight the role of war as a catalyst for surgical change but also point to the dangers of inaccurate history in stymieing such advances.

Lower extremity bypass (LEB) has traditionally been the gold standard in the treatment of critical limb ischemia (CLI). Over the past 2 decades, infrainguinal endovascular intervention (EI) has gained widespread acceptance and is now more commonly performed than LEB. Intuitively, EI should have the advantage of lower procedural risk in the complex critical limb population with multiple medical comorbidities. However, data directly comparing LEB and EI remains sparse. In addition, in many studies the heterogeneity of patients included and procedures performed along with a lack of standardization in the outcomes reported have rendered careful comparison of LEB and EI for CLI difficult. The Society for Vascular Surgery objective performance goals (OPGs) provide standardized metrics for expected outcomes after lower extremity revascularization which allow for comparison of LEB and EI in the CLI population. Included among the most important OPG outcomes are major adverse limb events (MALE) and major adverse cardiovascular events (MACE). There is very little data examining MALE and MACE after EI. Furthermore, there are no direct comparisons of LEB and EI using these important end points. The National Surgical Quality Improvement Program (NSQIP) provides a national sampling of cases with complete 30-day follow-up. The recently developed vascular-targeted modules have been added to the existing annual participant use file since 2011, providing additional vascular-specific variables and outcomes including limb and cardiovascular events. The primary purpose of this study was to compare rates of MALE and MACE after LEB and EI in a propensity-matched, national cohort of patients with CLI. The NSQIP vascular-targeted participant use file (2011-2014) for both lower extremity open and lower extremity endovascular were merged to obtain a representative national dataset. Details on the accruement methods and validity of the ACS-NSQIP have been documented. Patients with CLI were defined as having an indication of ischemic rest pain and/or tissue loss for revascularization. To account for potential confounders, specifically nonrandom allocation to LEB or EI, we matched patients on a 1:1 basis for propensity to undergo LEB or EI. Appropriate parametric and nonparametric statistical tests were used to compare LEB and EI. The primary outcomes were MALE and MACE within 30 days. MALE was defined as either untreated loss of patency of the revascularization, reintervention on the revascularization, or major amputation of the revascularized limb. MACE was defined as stroke, myocardial infarction (MI), or death. Secondary outcomes included untreated loss of patency of the revascularization, reintervention on the revascularization, major amputation, stroke, MI, and death. Within the propensity matched cohort multivariate logistic regression was then used to identify independent predictors of MALE and MACE. Statistical significance was set to an α value of 0.05. All statistical analyses were performed using SAS v 9.4 (SAS Institute, Cary, NC). A total of 13,294 LEB and EI were identified in the 2011-2014 NSQIP vascular- targeted modules. There were 8066 cases performed for CLI defined as rest pain or tissue loss. All procedures for claudication or asymptomatic peripheral vascular disease, as well as emergencies were excluded. After propensity matching for LEB vs EI was performed 3848 cases (1924 LEB and 1924 EI) were left for analysis. The median age of our matched cohort was 69 years, and 58.8% were male. There were no differences in preoperative variables between the propensity-matched LEB and EI groups (all P > .05) (Table). At 30 days, MALE was significantly lower in the LEB group (9.2% LEB vs 12.2% EI; P = .003; Table). This was driven primarily by a significantly higher rate of amputation in the EI group (4.2% LEB vs 6.8% EI; P = .0003). However, there was a higher rate of untreated loss of patency in the LEB group (2.7% LEB vs 1.7% EI; P = .03) with no difference in reintervention (4.8% LEB vs 5.5% EI; P = .38). On multivariate logistic regression, independent predictors of MALE included tibial bypass/tibial intervention (odds ratio [OR], 1.4; P = .01), and a history of prior bypass of currently revascularized segment (OR, 1.8; P < .0001). Antiplatelet therapy (OR, 0.8; P = .049), statin therapy (OR, 0.8; P = .04), bypass with single segment saphenous vein vs EI (OR, 0.7; P = .01), and bypass with alternative conduit (prosthetic/spliced vein/composite) vs EI (OR, 0.7; P = .04) were protective against MALE. A logistic model was also created for 30-day ipsilateral major amputation since it was the driving component for MALE outcomes. Independent predictors of amputation included black race (OR, 1.6; P = .003), dialysis dependence (OR, 1.8; P = .001), and prior bypass of current segment (OR, 1.8; P = .001). Antiplatelet therapy (OR, 0.7; P = .049) and bypass with single segment saphenous vein vs EI (OR, 0.5; P = .001) were protective against amputation. MACE at 30 days was not significantly different (4.9% LEB vs 3.7% EI; P = .07) between the groups (Table). Similarly rates of MI/cerebral vascular accident (2.8% LEB vs 2.1% EI; P = .14) and 30-day mortality (2.9% LEB vs 2.1% EI; P = .15) were not different between groups. On multivariate logistic regression, independent predictors of 30-day MACE included age (OR, 1.02; P = .01), steroid use (OR, 1.8; P = .03), congestive heart failure (OR, 1.7; P = .02), beta-blocker use (OR, 1.6; P = .01), dialysis dependence (OR, 2.3; P < .0001), totally dependent functional status (OR, 3.1; P = .02), and suboptimal conduit for LEB compared with EI (OR, 1.6; P = .02). Within this large, propensity-matched, national cohort, LEB was associated with lower 30-day MALE compared with EI. The increased MALE was driven by a higher rate of amputation in the EI group. Further risk adjustment with multivariate regression demonstrates that both optimal conduit (single segment saphenous vein) and suboptimal conduit (prosthetic/spliced vein/composite) independently reduce the risk of MALE compared with the EI approach. Other important predictors of decreased MALE are antiplatelet therapy and statin therapy, highlighting the importance of optimal medical management preoperatively. Factors identified that independently increase the risk of MALE include revascularization of infrageniculate targets, which are typically smaller with higher risk of failure, and prior bypass of the currently treated segment, demonstrating the poor prognosis for redo interventions. Because amputation was the driving factor for MALE outcomes, a multivariate regression was also modeled for these outcomes with many similar predictors of reduced amputation including antiplatelet therapy and optimal conduit compared with EI. Multivariate modeling did not have excellent discriminatory power to accurately predict MALE or amputation indicating other factors, such as vascular anatomy, likely have an important impact on these outcomes.