Objective: Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair. Methods: All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves. Results: We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 6 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency. Conclusions: This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.

Endovascular repair of popliteal artery aneurysms is widely accepted, yet long-term limb-related outcomes and factors associated with failure are not available. All patients who underwent endovascular popliteal artery aneurysm repair at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event (MALE)-free survival and graft loss/occlusion were analyzed with multivariable Cox regression analysis and Kaplan-Meier curves. We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158.00 months). The average age was 73 ± 9.3 years. Thirty-two (29.1%) patients were symptomatic (claudication, rest pain, tissue loss or ruptured). The stent grafts crossed the knee joint in 91.4% of cases. The number of stent grafts used was one in 36.8% of cases, two in 41.0%, and more than two in 22.2%. Average arterial length covered was 196 ± 82 mm, with an average length of stent overlap of 27 ± 27 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had three-vessel runoff, 20.2% had two-vessel runoff, and 17% one-vessel runoff. Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. One- and 3-year primary patency rates were 88.2% and 72.6%, and 1- and 3-year MALE-free survival rates were 82% and 57.4%. One- and 3-year survival rates were 92.9% and 76.2%. On multivariable Cox regression, aneurysm size, one-vessel runoff and coverage below the knee were associated with decreased 3-year MALE-free survival (Table). Coverage below the knee was also associated with reduced 3-year MALE-free survival (Fig). Other anatomic or technical details were not associated with limb-related events (Table) or patency. This is the largest single-center study to describe long-term outcomes following popliteal artery aneurysm repair. One vessel tibial runoff adversely affects outcomes while the ability to keep stent coverage above the knee is associated with better results.TableMultivariate Cox regression model for 3-year major adverse limb event (MALE)-free survivalVariablesHR95% CIP valueRunoff (1 runoff vessel)a3.011.07-8.48.037Popliteal segments (P2 & P3 or P1 & P2 & P3)b20.162.21-183.87.008Diameter of aneurysm1.061.02-1.10.003Number of stents (multiple stents)c1.200.35-4.05.764Diameter of small stent1.200.92-1.56.166Tapered stentsd1.170.45-3.01.735Total length of coverage (≥197 mm)e0.920.29-2.91.899Length of overlap (≥27 mm)f0.580.19-1.74.332Symptomaticg0.940.34-2.60.911Boldface entries indicate statistical significance.aReference group ≥2 runoff vessels.bReference group P1&P2.cReference group single stent.dReference group not tapered or single stent.eReference group <197 mm.fReference group <27 mm.gReference group asymptomatic. Open table in a new tab

Carbon monoxide (CO) is anti-inflammatory and protective in models of disease. Its actions in vitro are short-lived but are sustained in vivo. We hypothesize that systemic CO can mediate prolonged phenotype changes in vivo, with a focus on macrophages (Mφs). Mφs isolated from CO treated rats responded to lipopolysaccharide (LPS) with increased IL6, IL10 and iNOS expression but decreased TNF. Conditioned media (CM) collected from peritoneal Mφs isolated from CO treated rats stimulated endothelial cell (EC) proliferation versus CM from Mφs from air treated rats. This effect was mediated by Mφ released VEGF and HMGB1. Inhaled CO reduced LPS induced Mφ M1 inflammatory phenotype for up to 5 days. Mitochondrial oxygen consumption in LPS treated Mφs from CO treated mice was preserved compared to LPS treated Mφs from control mice. Finally, transient reduction of inflammatory cells at the time of inhaled CO treatment eliminated the vasoprotective effect of CO in a rodent carotid injury model. Thus, inhaled CO induces a prolonged mixed phenotype change in Mφs, and potentially other inflammatory cells, that contribute to vasoprotection. These findings demonstrate the ability of inhaled CO to modify Mφs in a sustained manner to mediate its therapeutic actions, supporting the translational potential of inhaled CO.

Objective: Endovascular popliteal artery aneurysm repair (EPAR) is increasingly used over open surgical repair (OPAR). The purpose of this study was to analyze the available literature on their comparative outcomes. Methods: The PubMed and Embase databases were searched to identify studies comparing OPAR and EPAR. Studies with only one treatment and fewer than five patients were excluded. Demographics and outcomes were collected. Bias risk was assessed using a modified version of the Newcastle-Ottawa Scale. Results were computed from random-effects meta-analyses using the DerSimonian-Laird algorithm. Results: A total of 14 studies were identified encompassing 4880 popliteal artery aneurysm repairs (OPAR, 3915; EPAR, 1210) during the last decade. OPAR patients were younger (standard mean difference, -0.798 [-0.798 to -1.108]; P < .001) and more likely to have worse tibial runoff (odds ratio [OR], 1.949 (1.15-3.31); P = .013) than EPAR patients. OPAR had higher odds of wound complications (OR, 5.182 [2.191-12.256]; P < .001) and lower odds of thrombotic complications (OR, 0.362 [0.155-0.848]; P <. 001). OPAR had longer length of stay (standardized mean difference, 2.158 [1.225-3.090]; P < .001) and fewer reinterventions (OR, 0.275 [0.166-0.454]; P < .001). Primary patency was better for OPAR at 1 year and 3 years (relative risk, 0.607 [P = .01] and 0.580 [P = .006], respectively). There was no difference in secondary patency at 1 year and 3 years (0.770 [P = .458] and 0.642 [P = .073], respectively). Conclusions: EPAR has a lower wound complication rate and shorter length of hospital stay compared with OPAR. This comes at the cost of inferior primary patency but not secondary patency out to 3 years. Studies reporting long-term outcomes are lacking and necessary.

Introduction: Carbon monoxide (CO) has potent vasoproective effects in vivo through changes in macrophage (MΦ) function. Because of these marked changes, we examined the vagal cholinergic anti-inflammatory pathway in regulating the actions of inhaled CO. We previously showed that vagotomy inhibited the ability of inhaled CO to prevent intimal hyperplasia following arterial injury in rats. We now hypothesize that the anti-inflammatory effects of inhaled CO can be blocked through pharmacologic vagal inhibition. Methods: Sprague-Dawley rats (3 rats/group) were treated with inhaled CO (250 parts per million) for 1 hr or remained in room air. Some were injected with atropine (0.05 mg/kg SQ) 1 hr prior to and just prior to inhaled CO treatment. Peritoneal macrophages (MΦ) were collected 1 hr after CO treatment or comparable time period in control rats and were cultured overnight under standard conditions. Media from these cells were collected for Western blot analysis for high mobility box group 1 (HMGB1) and VEGF. Results: MΦ isolated from CO treated rats released increased levels of HMGB1 and VEGF into the media compared to MΦs from air treated rats (1.7 and 4 fold increase, respectively; Fig.). These molecules mediate the proendothelial actions of inhaled CO. MΦs isolated from atropine treated rats showed a mild reduction of HMGB1 and VEGF secretion. In contrast, MΦ from atropine and CO treated rats showed a significant inhibition of HMGB1 release (P<0.01 vs. all other treatment groups) and a trend toward significance in the reduction in VEGF release (Fig.). Conclusions: Inhaled CO activates vagal signaling to mediate changes in MΦ behavior. Inhibition of vagal signaling with atropine blocked the changes in MΦ induced by inhaled CO, confirming the importance of the vagus nerve in mediating the vasoprotective actions of CO. These findings suggest the potential ability to reproduce the therapeutic actions of CO through pharmacologic vagal stimulation.

Objective: The purpose of this study was to evaluate contemporary practice and outcomes of open repair (OR) or endovascular repair (ER) for popliteal artery aneurysms (PAAs).Methods: Consecutive patients with PAA treated at one institution from January 2006 to March 2014 were reviewed under an Institutional Review Board-approved protocol. Demographics, indications, anatomic characteristics, and outcomes were collected. Standard statistical methods were used.Results: A total of 186 PAAs were repaired in 156 patients (110 ORs, 76 ERs) with a mean age of 71 6 11 years, and most were male (96%). Mean follow-up was 34.9 +/- 28.6 months for OR and 28.3 +/- 25.8 months for ER (P = .12). Comorbidities were similar between groups. OR was used in more patients with PAA thrombosis (41.8% vs 5.3%; P <.001), acute ischemia (24.5% vs 9.2%; P = .010), and ischemic rest pain (34.5% vs 6.6%; P <.001). Mean tibial (Society for Vascular Surgery) runoff score was 5.0 for OR vs 3.3 for ER (P = .006). OR was associated with increased 30-day complications (22% vs 2.6%; P <.001) and mean postoperative stay (5.8 vs 1.6 days; P <.001). There was no difference in 30-day mortality (OR, 1.8%; ER, 0%; P = .56) or major amputation rate (OR, 3.7%; ER, 1.3%; P = .65). Primary, primary assisted, and secondary patency rates were similar at 3 years (OR, 79.5%, 83.7%, and 85%; ER, 73.2%, 76.3%, and 83%; P = NS). Among 130 patients presenting electively without acute ischemia or thrombosed PAA (63 ORs and 67 ERs), OR had better 3-year primary patency (88.3% vs 69.8%; P = .030) and primary assisted patency (90.2% vs 73.5%; P = .051) but similar secondary patency (90.2% vs 82%; P = .260). ER thrombosis was noted in 8 of 24 patients treated in 2006-2008 (33%; mean time to failure, 49 months) but in only 4 of 51 patients treated in 2009-2013 (7.8%; mean time to failure, 30 months), suggesting a steep learning curve.Conclusions: ER is a safe and durable option for PAA, with lower complication rates and a shorter length of stay. OR has superior primary patency in patients treated electively but no difference in midterm secondary patency and amputations.

Alter, Begleiterkrankungen, Raucherstatus und Medikamentengebrauch, bis auf die Verwendung von Clopidogrel, waren für beide Gruppen vergleichbar. Die OR wurde häufiger bei thrombosierten PAAs (41,8% vs. 5,3%), akuter Ischämie (24,5% vs. 9,2%) und ischämischen Ruheschmerzen (34,5% vs. 6,6%) angewandt. Unterschiede in PAA-Größe und muralen Thromben fanden sich nicht. Der modifizierte Run-Off-Score war signifikant schlechter für OR (8,8±6,0) als für ER (3,6±3,0; p<0,001). Rupturierte PAA fanden sich in dieser Untersuchung selten (OR 1,0%, ER 3,9%; p=0,31).

Leake, Andrew E. MD; Lee, Ghee R.; Aggarwal, Ankur MD; Zuckerbraun, Brian S. MD, FACS; Tzeng, Edith MD, FACS Author Information

OBJECTIVE:Dialysis access-associated steal syndrome (DASS) complicates arteriovenous access surgery. We describe a 10-year experience with the surgical management of DASS.METHODS:DASS operations were retrospectively reviewed from July 2003 to July 2013 from a single academic institution. Demographics, symptoms, surgical details, and outcomes were collected.RESULTS:A total of 201 patients had 218 episodes of DASS. Mean age was 65 years, and 62% were women. DASS was caused by 175 arteriovenous fistulas (80%), 41 upper extremity prosthetic grafts (19%), and two thigh grafts (1%); 87% were brachial artery based. A portion (22%) were referred for DASS from outside practices. All patients had grade 2 (48%) or grade 3 (52%) DASS; 92% (185) were available for follow-up, with a median time to first follow-up of 23 days. Surgical procedures included ligation (73), distal revascularization with interval ligation (DRIL) (59), revision using distal inflow (RUDI) (21), banding (38), proximalization of arterial inflow (12), and distal radial artery ligation (13). There were no differences in preoperative comorbidities between treatment groups. The 30-day complications included continued steal, thrombosis, bleeding, infection, and mortality. Ligation and DRIL were performed most often for grade 3 steal. Ligation and banding were performed most acutely (median time to intervention after access creation of 39 and 24 days vs DRIL and RUDI at 97 and 100 days). Fistula preservation was 0% for ligation, 100% for DRIL, 95% for RUDI, and 89% for banding (P < .01). Improvement of symptoms ranged from 75% (banding) to 98% (DRIL) (P = .005). Women were less likely to have DRIL but more likely to have ligation (P = .001). Complications were highest in the banding (49%) and RUDI (37%) groups. Average mortality was 3.5%, with no significant differences among groups. During the study period, 3287 access procedures were performed, and access volume steadily increased (2003-2008, 1312 access creations; 2008-2013, 1975). Percentage of fistulas (79% vs 86%), incidence of steal (4% vs 6%), and percentage of DRILs (25% vs 28%) were consistent across the two study periods.CONCLUSIONS:DRIL and ligation were performed in patients with the most severe symptoms. Compared with ligation, DRIL has equal symptom resolution, no increase in complications, and fistula preservation. Compared with banding, DRIL resulted in superior fistula preservation and fewer complications. DRIL should be considered the preferred procedure for management of DASS in patients with a functioning autologous fistula who can tolerate a major operation.

Long-term outcomes after distal revascularization and interval ligation (DRIL) for the management of dialysis access associated steal syndrome were evaluated. Patients undergoing a DRIL procedure were retrospectively reviewed from July 2003 to July 2014. Patency and mortality were estimated using Kaplan-Meier survival analysis, and Cox proportional regression models were generated for predictors of mortality (Table). Seventy-nine patients underwent a DRIL with a mean age of 63 years. Most were Caucasian (75%) and female (52%). Hypertension (91%), coronary artery disease (58%), peripheral vascular disease (56%), and hyperlipidemia (52%) were prevalent. Access was an autologous fistula (96%), had brachial inflow (95%) and occurred >30 days after access placement (79%) with grade 2 or 3 symptoms (95%). Most (81%) were performed under general anesthesia. Bypass conduit was great saphenous vein (72%) or upper extremity vein (27%). Clinical improvement occurred in 94% of patients, with a median increase in finger pressures of 40 ± 12 mm Hg. The complication rate was 19% and included continued steal (6%), hematoma (5%), and infection (8%). There were no 30-day thrombotic access or fistula complications. Four patients died within 30 days. Mean follow-up was 44 months. There was one bypass thrombosis, requiring no secondary interventions. Multivariable predictors of mortality were age (hazard ratio (HR), 1.27 per 5 years, 95% confidence interval [CI], 1.06-1.51; P = .01), male gender (HR, 3.24; 95% CI, 1.40-7.55; P = .006), and loss of primary access patency (HR, 2.37; 95% CI, 1.01-5.65; P = .05). DRIL achieves excellent clinical and objective improvement in hand perfusion, with full access preservation. However, patients with steal have limited survival, and DRIL should be reserved for patients with a long life expectancy.TableFive-year distal revascularization and interval ligation (DRIL) bypass patency and patient survivalTimeBypass patency (%)Overall survival (%)PrimaryPrimary assisted1 year86.988.977.73 years84.688.947.65 years72.588.928.8 Open table in a new tab

Dialysis access-related ischemic steal syndrome is a well-recognized dialysis access complication. When severe, manifestations include rest pain, hand dysfunction, and tissue loss. Dialysis access attempts on the affected extremity are usually abandoned after a diagnosis of steal syndrome, and patients are often left catheter-dependent. Prophylactic distal revascularization with interval ligation has been described in patients at high-risk for steal syndrome. We present our experience with prophylactic distal revascularization with interval ligation performed simultaneously with arteriovenous fistula creation to prevent the recurrence in five patients and review the current body of literature supporting its use.

Objective: Arteriovenous fistulas (AVFs) are associated with improved long-term outcomes but longer maturation times and higher primary failure rates compared with arteriovenous grafts (AVGs). The Fistula First Breakthrough Initiative has recently emphasized tunneled dialysis catheter (TDC) avoidance. We sought to characterize the relationship of AVFs and AVGs to the use of TDCs as well as secondary procedures.Methods: Using the United States Renal Data System(USRDS) database, we identified incident hemodialysis (HD) patients in 2005 that started HD with a TDC and survived at least 1 year. We then monitored them through 2008. Access creation, TDC removal, TDC placement, and secondary procedures were identified by Current Procedural Terminology codes (American Medical Association, Chicago, Ill). Multivariate logistic regression was used to identify risk factors for the primary end points.Results: In 2005, HD was initiated in 56,495 patients, 74% with a TDC. Of these, 6286 had an access procedure <= 3 months and 1 year of follow-up (AVF, 4634; AVG, 1652). Mean age was 67.7 years (AVF, 67.3; AVG, 68.7 years; P < .001), 53.3% were men (AVF, 58.1%; AVG, 40.5%; P < .001), and 33.8% were obese (AVF, 33.6%; AVG, 34.4%; P = not significant). AVG placement was associated with a higher TDC removal at 1 (7.9% vs 3.1%; P < .001), 3 (47.8% vs17.8%; P < .001), and 6 (60.6% vs 47.2%; P < .001) months. There was no difference at 9 months (AVG, 64.9% vs AVF, 62.3%; P = .06). The median time to TDC removal was lower in the AVG group (70 days vs 155 days; P < .001). Multivariable model found AVFs were associated with decreased odds of TDC removal at 3 (odds ratio, 0.22; P < .001) and 6 months (odds ratio, 0.54; P < .001). AVGs required more secondary procedures than AVFs at all time points up to 1 year and specifically had increased thrombectomy procedures (39.8% vs 11.5%; P < .001).Conclusions: In patients starting dialysis with a TDC, AVGs are associated with increased TDC removal and fewer catheter days compared with AVFs at up to 6 months. However, AVGs require more secondary procedures at all time points up to 1 year.

Arteriovenous fistula (AVF) is associated with improved long-term outcomes but longer maturation periods than arteriovenous graft (AVG). The Fistula First Breakthrough Initiative has recently emphasized tunneled dialysis catheter (TDC) avoidance. We sought to characterize the relationship of AVF and AVG to the utilization of TDCs as well as secondary procedures, defined as surgical revision, fistulogram, and thrombectomy. Using the US Renal Data System (USRDS) database, we identified incident hemodialysis (HD) patients in 2005 who started HD with a TDC and survived at least 1 year. Access creation, TDC placement and secondary procedures were identified by Current Procedural Terminology codes. Multivariate logistic regression was used to identify risk factors for TDC placement or secondary procedures. In 2005, 56,839 patients started HD, 73% with a TDC. Of those patients, 6286 had an access procedure ≤3 months and had at least 1 year of follow-up available (AVF, 4,634; AVG, 1,652). Mean age was 67.7 years (AVF, 67.4; AVG, 68.7; P < .001), 53.3% were male (AVF, 57.9%; AVG, 40.5%; P < .001), and 33.9% were obese (AVF, 33.6%; AVG, 34.6%; P = NS). Multivariate logistic regression demonstrates that AVG is associated with more secondary procedures (odds ratio, 1.403; P < .001) but significantly lower TDC use (odds ratio, 0.845; P = .006). Lower body mass index, white race, older age, and male gender also protect against TDC placement (Table). Lower body mass index, male gender, white race, and younger age are protective against secondary procedures. In patients starting HD with TDC, AVG is associated with increased secondary procedures but lower TDC placement at 1 year.

Dialysis access-associated steal syndrome (DASS) complicates arteriovenous (AV) access surgery. We describe our 10-year experience with DASS. DASS operations were retrospectively reviewed from July 2003 to July 2013. Demographics, symptoms, surgical details, and outcomes were collected. IRB approval was secured, and a P < .05 was considered significant. A total of 201 patients had 218 episodes of DASS. Mean age was 65 years, 62% were female. DASS was caused by 175 AV fistulas (80%), 41 prosthetic grafts (19%) and two thigh grafts (1%); 87% were brachial artery based. Twenty-two percent were referred for DASS from other practices. All patients had grade 2 (48%) or 3 (52%) DASS. Ninety-two percent (185) were available for follow-up, with a median follow-up of 23 days. There were no differences in preoperative comorbidities. Surgical managements, omitting thigh grafts due to low numbers, were compared (Table). The 30-day complications included continued steal, thrombosis, bleeding, infectious, or mortality. During the study period, access volume increased from 1312 access creations for 2003-2008 to 1975 for 2008-2013. Percentage of fistulas (79% vs 86%), incidence of steal (4% vs 6%), and percentage of distal revascularization-interval ligation (DRIL) procedures (25% vs 28%) was consistent across study periods. DRIL and ligation were performed in the most severe patients. Compared with ligation, DRIL has equal symptom resolution, no increase in complications, and fistula preservation. Compared with banding, DRIL resulted in superior fistula preservation and fewer complications. DRIL should be considered the gold standard management for DASS.TableDialysis access-associated steal syndrome (DASS) surgical outcomesProcedureNo.Grade 3 steal (%)Time to intervention (days)Native AVF (%)Fistula preserved (%)Improvement of steal symptoms (%)30-day complications (%)Ligation736739a64a0a9310Distal revascularization & interval ligation (DRIL)5964210971009814Revision using distal inflow (RUDI)2119a72100958937Banding3832a24a71a8975a49aProximalization of arterial inflow (PAI)1233928310010044Radial artery ligation (RAL)13391991001001000Total216527280649022aP < 0.05 vs DRIL. Open table in a new tab

Leake, Andrew E. MD; Hong, Guiying; Zettel, Kent R. MD; Ramadan, Mostafa H. MBCHB; Tzeng, Edith MD, FACS Author Information

Introduction: Carbon monoxide (CO) has potent anti-inflammatory and pro-healing properties. We have previously shown that CO enhances endothelial cell (EC) angiogenic behavior in vitro. More striking, however, is that conditioned medium (CM) from macrophages isolated from CO treated rats can promote angiogenesis indirectly. We sought to examine the mechanism of this indirect angiogenic effect of CO. Methods: Peritoneal macrophages were collected from rats after inhaled CO treatment (250 PPM for 1 hr) or air treatment. Macrophages were cultured overnight and CM was collected to treat human umbilical vein ECs (HUVECs). VEGF and eNOS expression was assessed by Western blot. Results: CM from macrophages isolated from CO treated rats (CO) showed a 3-fold increase in VEGF vs Air CM (Ratio CO/Air=2.96, Range 1.6-4.2) (Figure). VEGF levels were similar between the macrophages from CO or air treated rats (CO/Air=0.89). HUVECs treated with CO or Air CM also showed no difference in VEGF levels (CO/Air=1.07). However, eNOS expression was significantly increased in HUVECs treated with CO CM vs. Air CM (CO/Air=26.4, Range 20-32; p=0.004). HUVECs cultured in a CO chamber or a standard incubator exhibited no change in eNOS expression (CO/Air, 1.38 p=0.11). Conclusion: In vivo CO promotes macrophage secretion of VEGF. These cells can promote angiogenic behavior in ECs through this VEGF and other secreted products. These macrophage products upregulate eNOS but not VEGF expression in HUVECs. The effect of the CO CM on eNOS expression in HUVECs could not be reproduced by direct CO treatment of the cells. Future studies will further characterize the phenotypic change of the macrophages induced by inhaled CO that favors angiogenesis and healing.

INTRODUCTION: As the first generation of integrated (0 + 5) vascular surgery (VS) residents enter the job market, this survey sought to understand how the surgical community perceives this training paradigm.METHODS: An anonymous online survey was e-mailed to surgery chairpersons (n = 193) and Society for Vascular Surgery (SVS) members (n = 2193) in the United States/Canada with 26% (n = 38) and 14% (n = 309) response rates, respectively. Respondents were asked about their practice background, residency program, hiring patterns, and perceptions of the 0 + 5 training.RESULTS: Response rates were 26% (n = 38) and 14% (n = 309) for surgery chairpersons and SVS members, respectively. SVS respondents were from academic (62%) and private (38%) practices and included staff surgeons (62%), program directors (15%), and division chiefs (22%). Only 33% had a 0 + 5 program, and 57% had a VS fellowship. Overall, 94% were likely to hire a new vascular surgeon in the next 5 years. In some categories, SVS respondents believed 0 + 5 residents would be less prepared than 5 + 2 residents. Only 32% thought that 0 + 5 residents have the same level of surgical maturity, and 36% thought that they have the same level of open operative skills as 5 + 2 trainees. Another 34% thought 0 + 5 residents will need additional fellowship training in open surgery. However, there was also a general perception from SVS respondents that 0 + 5 residents would be prepared for clinical practice (67%) and would have equal endovascular skills to 5 + 2 trainees (92%). The chairpersons had similar perceptions as SVS members. Both SVS members (88%) and chairpersons (86%) would consider interviewing a 0 + 5 graduate for faculty position; 83% and 72%, respectively, would consider hiring. Moreover, 93% of SVS respondents who currently have a 0 + 5 program and 86% of SVS respondents who do not would consider hiring a 0 + 5 graduate. Both SVS members (62%) and chairpersons (50%) believed the 0 + 5 paradigm is essential for the advancement of VS.CONCLUSIONS: Overall perceptions of 0 + 5 graduates were positive and indicated their likely acceptance into the VS workforce. Although there were some reservations regarding the 0 + 5 graduates' maturity level and open operative skills, the surgical community was willing to interview and hire these trainees for staff positions. Further follow-up will be required to evaluate their performance in clinical practice. Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery

BACKGROUND:The Kidney Disease Outcomes and Quality Initiative (K/DOQI) has developed guidelines from available data suggesting that arteriovenous fistulas (AVF) be performed in the majority of patients. Patient demographics were not included nor suggested in their recommendations. The purpose of this study is to analyze the outcomes of elderly patients, age greater than 70, undergoing first-time permanent access surgery.METHODS:A retrospective review of consecutive patients undergoing new, first time access procedures from January 2005 through December 2005 was performed. Patients with previous attempts at permanent Arteriovenous (AV) access were removed from analysis. Standard statistical methods were used and patency was determined with Kaplan-Meier curves.RESULTS:One hundred and sixty eight patients underwent first time AVF, 48 of whom were older than 70 years of age. Comparing elderly patients to younger ones, the 12 month primary assisted patency was 35% and 67%, respectively (p=0.002) and secondary patency was 36% and 67%, respectively (p=0.004). Of the 48 elderly patients, 48% had died in the subsequent follow up period as compared to just 20% of the 120 patients younger than 70. The 18-month survival for the elderly group was 50% versus 74% for the younger patients (p=0.004). Of the elderly group who died, the average time to death was 13.1 months and only 8 AVF were able to be accessed. Similar intervention rates per year were seen in both groups.DISCUSSION:With an aging population, more patients older than 70 are being evaluated for permanent vascular access. This group poses a difficult dilemma for surgeons attempting to adhere to K/DOQI guidelines. In light of the increased mortality and decreased patency of AVF, this data questions which form of permanent access should be first-line treatment in this subgroup of patients.CONCLUSION:This data suggest in the elderly patients, autogenous fistulas may not be the best option for this set of patients.