Teamwork, endurance, perseverance, accepting feedback, maintaining composure through successes and setbacks – these are all parallels between the fields of medicine and soccer. Allow me to paint you a picture, from my position of goalkeeper. Logan D. Cho

INTRODUCTION:Major disparities in outcomes by race are present throughout vascular surgery, yet little has been published on iliac vein stent outcomes by race. This retrospective study assessed iliac vein stent outcomes by patient race.METHODS:Patients who underwent iliac vein stenting at a single institution for chronic venous insufficiency (CVI) from 2011 to 2021 were reviewed. Demographic, preoperative, perioperative, and postoperative data were collected. Self-reported race groups included Asian, Black, Hispanic, and White. Univariate differences were analyzed using χ2 tests for categorical variables and 1-way ANOVA for continuous variables. Outcomes included change in Venous Clinical Severity Score (VCSS) at interval timepoints relative to a preoperative baseline and reinterventions. Logistic regression models were used to determine the unadjusted and adjusted odds ratio (OR) of any minor and major reintervention. Multivariate regression models controlled for demographic and comorbidity characteristics.RESULTS:A total of 827 patients were included. Asian patients were younger and had a greater proportion of male patients, lower Body mass index (BMI), less smoking history, and fewer comorbidities. White patients were more likely to have a history of deep vein thrombosis (DVT). White patients presented with the most severe CVI symptoms as defined by both Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification and preoperative VCSS composite scores. There were no differences in acute DVT, number of stents deployed, and bilateral versus unilateral stent placement. Black patients had the longest average days of follow-up, followed sequentially by Hispanic, White, and Asian. Black patients had the most reinterventions, while Asian patients had the fewest. Asian patients were less likely to have a major reintervention. No differences in VCSS composite or change in VCSS were observed.CONCLUSIONS:In patients with CVI, Asian patients presented younger and healthier, while White patients presented with the most severe symptoms. No differences were observed in VCSS outcomes, though Black patients had the most reinterventions.

BACKGROUND AND OBJECTIVES:Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA. METHODS:Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ 2 -tests and student t -tests. For those factors with a P -value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors. RESULTS:A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak ( P < .01), postoperative diabetes insipidus (DI) ( P < .01), increased surgery duration ( P = .01), and elevated maximal tumor dimension ( P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression. CONCLUSION:Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.

Introduction: Pituitary adenomas (PA) are the most common intrasellar tumor and have a prevalence of a prevalence of 17%, and transsphenoidal surgical approach (TSA) is the most common surgical treatment. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). The aim of this study was to identify demographic and clinical factors associated with PLOS following TSA for PA.

Value-based care initiatives require accurate quantification of resource utilization. This study explores hospital resource documentation performance for total knee and hip arthroplasty (TKA, THA) implants and how this may differ between hospitals. This retrospective study utilized the Premier discharge database, years 2006 to 2020. TKA/THA cases were categorized into 5 tiers based upon the completeness of implant component documentation: Platinum, Gold, Silver, Bronze, Poor. Correlation between TKA and THA documentation performance (per-hospital percentage of Platinum cases) was assessed. Logistic regression analyses measured the association between hospital characteristics (region, teaching status, bed size, urban/rural) and satisfactory documentation. TKA/THA implant documentation performance was compared to documentation for endovascular stent procedures. Individual hospitals tended to have very complete (Platinum) or very incomplete (Poor) documentation for both TKA and THA. TKA and THA documentation performance were correlated (correlation coefficient = .70). Teaching hospitals were less likely to have satisfactory documentation for both TKA ( P = .002) and THA ( P = .029). Documentation for endovascular stent procedures was superior compared to TKA/THA. Hospitals’ TKA and THA-related implant documentation performance is generally either very proficient or very poor, in contrast with often well-documented endovascular stent procedures. Hospital characteristics, other than teaching status, do not appear to impact TKA/THA documentation completeness.

Background Given the rapid deployment of telemedicine at the onset of the COVID - 19 pandemic, updated assessment methods are needed to study and characterize telemedicine programs. We developed a novel semi - structured survey instrument to systematically describe the characteristics and implementation processes of telemedicine programs in primary care. Methods In the context of a larger study aiming to describe telemedicine programs in primary care, a survey was developed in 3 iterative steps: 1) literature review to obtain a list of telemedicine features, facilitators, and barriers; 2) application of three evaluation frameworks; and 3) stakeholder engagement through a 2-stage feedback process. During survey refinement, items were tested against the evaluation frameworks while ensuring it could be completed within 20–25 min. Data reduction techniques were applied to explore opportunity for condensed variables/items. Results Sixty initially identified telemedicine features were reduced to 32 items / questions after stakeholder feedback. Per the life cycle framework, respondents are asked to report a month in which their telemedicine program reached a steady state, i.e., “maturation”. Subsequent questions on telemedicine features are then stratified by telemedicine services offered at the pandemic onset and the reported point of maturation. Several open - ended questions allow for additional telemedicine experiences to be captured. Data reduction techniques revealed no indication for data reduction. Conclusion This 32-item semi-structured survey standardizes the description of primary care telemedicine programs in terms of features as well as maturation process. This tool will facilitate evaluation of and comparisons between telemedicine programs across the United States, particularly those that were deployed at the pandemic onset.

PURPOSE The need to rapidly implement telemedicine in primary care during the coro-navirus disease 2019 (COVID-19) pandemic was addressed differently by various practices. Using qualitative data from semistructured interviews with primary care practice leaders, we aimed to report commonly shared experiences and unique perspectives regarding tele -medicine implementation and evolution/maturation since March 2020.METHODS We administered a semistructured, 25-minute, virtual interview with 25 primary care practice leaders from 2 health systems in 2 states (New York and Florida) included in PCORnet, the Patient-Centered Outcomes Research Institute clinical research network. Questions were guided by 3 frameworks (health information technology evaluation, access to care, and health information technology life cycle) and involved practice leaders' perspectives on the process of telemedicine implementation in their practice, with a specific focus on the process of maturation and facilitators/barriers. Two researchers conducted inductive coding of qualitative data open-ended questions to identify common themes. Transcripts were electronically generated by virtual platform software.RESULTS Twenty-five interviews were administered for practice leaders representing 87 primary care practices in 2 states. We identified the following 4 major themes: (1) the ease of telemedicine adoption depended on both patients' and clinicians' prior experience using virtual health platforms, (2) regulation of telemedicine varied across states and differen-tially affected the rollout processes, (3) visit triage rules were unclear, and (4) there were positive and negative effects of telemedicine on clinicians and patients.CONCLUSIONS Practice leaders identified several challenges to telemedicine implementa-tion and highlighted 2 areas, including telemedicine visit triage guidelines and telemedi-cine-specific staffing and scheduling protocols, for improvement.

Objective/Introduction Increased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following EVAR in AAA patients. Methods Patients who underwent elective EVAR between 2004 and 2018 were reviewed. Thoracic tortuosity index (TTI) was measured using 3D reconstruction software. Patients were dichotomized across the median TTI into high tortuosity [HT] (TTI >1.27, Figure1(a) ) and low tortuosity [LT] (TTI ≤1.27, Figure 1(b) ) groups. Perioperative complications, postoperative outcomes, and CT-based features of thoracic aortic wall degeneration ( Figure 1(c)-(e) ) were collected and analyzed. Results 136 patients underwent treatment: 70 HT patients, including 54 males and 16 females (mean age: 77 years), and 66 LT patients, including 62 males and 4 females (mean age: 70 years) (age; P < .001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P = .045, P = .01). Presence of degenerative aortic wall markers was greater in HT patients (P = .045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P = .002). Frequency of AAA rupture/dissection was 4.3% for HT and 1.5% for LT (P = .339). A trend was observed in all cause 30-day mortality in the HT group (P = .061). Other perioperative complications and postoperative outcomes were similar between groups. Conclusion High TTI was associated with older age at time of EVAR, greater prevalence of degenerative markers in the descending thoracic aortic wall, and widespread aorto-iliac dilation. While not predictive of EVAR outcomes, TTI can provide valuable information regarding aneurysm pathophysiology.

Background: Comorbidity scales for outcome prediction in traumatic brain injury (TBI) include the 5-component modified Frailty Index (mFI-5), the 11-component modified Frailty Index (mFI-11), and the Charlson Comorbidity Index (CCI). Objective: To compare the accuracy in predicting clinical outcomes in TBI of mFI-5, mFI-11, and CCI. Methods: The National Trauma Data Bank (NTDB) of the American College of Surgeons (ACS) was utilized to study patients with isolated TBI for the years of 2017 and 2018. After controlling for age and injury severity, individual multivariable logistic regressions were conducted with each of the 3 scales (mFI-5, mFI-11, and CCI) against predefined outcomes, including any complication, home discharge, facility discharge, and mortality. Results: All 3 scales demonstrated adequate internal consistency throughout their individual components (0.63 for mFI-5, 0.60 for CCI, and 0.56 for mFI-11). Almost all studied complications were significantly more likely in frail patients. mFI-5 and mFI-11 had similar areas under the curve (AUC) for all outcomes, while CCI had lower AUCs (0.62-0.61-0.53 for any complication, 0.72-0.72-0.52 for home discharge, 0.78-0.78-0.53 for facility discharge, and 0.71-0.70-0.52 for mortality, respectively). Conclusion: mFI-5 and mFI-11 demonstrated similar accuracy in predicting any complication, home discharge, facility discharge, and mortality in TBI patients across the NTDB. In addition, CCI's performance was poor for the aforementioned metrics. Since mFI-5 is simpler, yet as accurate as the 2 other scales, it may be the most practical both for clinical practice and for future studies with the NTDB.

Introduction. Telemedicine was rapidly deployed at the onset of the COVID-19 pandemic. Little has been published on telemedicine in musculoskeletal care prior to the COVID-19 pandemic. This study is aimed at characterizing trends in telemedicine for musculoskeletal care preceding the COVID-19 pandemic. Methods. This retrospective study used insurance claims from the Truven MarketScan database. Musculoskeletal-specific outpatient visits from 2014 to 2018 were identified using the musculoskeletal major diagnostic category ICD-10 codes. Telemedicine visits were categorized using CPT codes and Healthcare Common Procedure Coding Systems. We described annual trends in telemedicine in the overall dataset and by diagnosis grouping. Multivariable logistic regression modeling estimated the association between patient-specific and telemedicine visit variables and telemedicine utilization. Results. There were 36,672 musculoskeletal-specific telemedicine visits identified (0.020% of all musculoskeletal visits). Overall, telemedicine utilization increased over the study period (0% in 2014 to 0.05% in 2018). Orthopedic surgeons had fewer telemedicine visits than primary care providers (OR 0.57, 95% CI 0.55-0.59). The proportion of unique patients utilizing telemedicine in 2018 was higher in the south (OR 2.28, 95% CI 2.19-2.38) and west (OR 5.58, 95% CI 5.36-5.81) compared to the northeast. Those with increased comorbidities and lower incomes and living in rural areas had lower rates of telemedicine utilization. Conclusions. From 2014 to 2018, there was an increase in telemedicine utilization for musculoskeletal visits, in part due to insurance reimbursement and telemedicine regulation. Despite this increase, the rates of telemedicine utilization are still lowest in some of the groups that could derive the most benefit from these services. Establishing this baseline is important for assessing how the roll-out of telemedicine during the pandemic impacted how/which patients and providers are utilizing telemedicine today.

Cancer has been reported as a significant risk factor for deep vein thrombosis. Little research has been done that directly studies cancer as a risk factor in iliac vein stenting. We undertook the present study comparing patients with cancer to patients without cancer in iliac vein stent placement.

Objective: An active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU-). Methods: A single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU-) VLUs. Results: A total of 872 patients (71 VLU+ and 801 VLU-) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio,1.94; 95% confidence interval,1.01-3.52; P- .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio,1.17; 95% confidence interval, 0.55-2.40; P= .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU- cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P- .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6,12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%,19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years. Conclusions: Patients with active VLU5 who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

INTRODUCTION: Both unfractionated heparin (UH) and low-molecular weight heparin (LMWH) are routinely used prophylactically after traumatic brain injury (TBI) to prevent deep vein thrombosis. Their comparative risk for intracranial hemorrhage (ICH) development or worsening necessitating cranial decompression after prophylaxis initiation is unclear. Furthermore, the absence of a specific antidote for LMWH may lead to UH being used more often for high-risk patients. METHODS: We compared the incidence of delayed cranial decompression occurring after initiation of prophylactic UH vs. LMWH using the National Trauma Data Bank. Cranial decompression procedures included craniotomy, craniectomy, and external ventricular drain placement. Multiple imputation was utilized for missing data. To account for selection bias between UH and LMWH, we conducted propensity score matching using factors that were significantly different between the two groups. The matched UH and LMWH groups were then compared using logistic regression for the primary outcome of post-prophylaxis cranial decompression. RESULTS: A total of 218,594 TBI patients were included, with 61,998 (28.3%) receiving UH and 156,596 (71.7%) receiving LMWH as DVT prophylaxis. The UH group had significantly higher patient age, BMI, comorbidity rates, injury severity score, and worse motor Glasgow coma scale. After matching the UH and LMWH groups for these factors, logistic regression demonstrated lower rates of post-prophylaxis cranial decompression for the LMWH group (OR 0.13, 95% CI 0.11-0.16, P < 0.001). CONCLUSION: Despite the absence of a specific antidote, LMWH was associated with substantially lower rates of post-DVT-prophylaxis cranial decompression. This indicates that UH may not be the safer alternative in TBI patients at high risk for intracranial hemorrhagic complications.

Active venous leg ulcers (VLUs) caused by lower extremity venous insufficiency indicate a high disease burden and risk of infection. Our objective was to compare the clinical outcomes and need for reoperation after iliac vein stenting for patients with VLU vs those without VLU (non-VLU). A single-institution database of patients who had undergone iliac vein stenting from August 2011 to June 2021 was analyzed. The symptoms were quantified using the venous clinical severity score (VCSS) and clinical assessment score. The patients in the VLU cohort had had an active VLU at the initial iliac vein stent procedure. Major reoperation was defined as any procedure using venography. Minor reoperations were defined as endovenous laser ablation and sclerotherapy. Among 784 patients, we identified 67 (8.5%) with a VLU and 717 (90.4%) without a VLU. The VLU cohort had a higher prevalence of hypertension (74.6% vs 48.4%; P = .001), coronary artery disease (30.6% vs 10.2%; P < .001), and smoking history (35.8% vs 19.8%; P = .038) compared with the non-VLU cohort. The VLU cohort was older (mean age, 67.1 vs 61.0 years; P = .001) and were more likely to be men (55.2% vs 41.7%; P = .031). Ethnicity also differed significantly between these two cohorts (P < .001; Table). On univariable analysis, the VLU cohort was more likely to have undergone a major reoperation (odds ratio, 1.98; 95% confidence interval, 1.03-3.63; P = .032). However, on multivariable analysis, this difference was not significant (odds ratio, 1.28; 95% confidence interval, 0.59-2.65; P = .521). Additionally, the VLU cohort had required a significantly higher mean number of total reoperations (1.4 vs 1.0; P = .012) compared with the non-VLU cohort. Comparatively, for patients who had undergone at least one reoperation, the difference in the mean total number of reoperations was even larger for the VLU cohort (2.6 vs 1.8; P = .001). The log-rank test revealed no differences in the intervention-free survival time (P = .44). Changes in the VLU clinical assessment score at postoperative follow-up of 30 days, 90 days, and 6 months are listed in the Table. Although many patients had experienced resolution of VLUs after iliac vein stenting, this cohort was more likely to undergo major reoperation and, on average, had required more total reoperations.TableDemographics, comorbidities, perioperative details, and outcomes of iliac vein stenting stratified by VLUVariableVLU (n = 67)No VLU (n = 717)P valueDemographics and comorbidities Age, years67.1 ± 13.261.0 ± 13.1.001 Male sex34 (56.7)298 (41.7).045 Ethnicity<.001Asian20 (29.9)571 (79.7)Black8 (11.9)33 (4.6)Hispanic7 (10.4)49 (6.8)Other8 (11.9)23 (3.2)White24 (35.8)40 (5.6) DM23 (34.3)150 (20.9).017 HTN50 (74.6)347 (48.4)<.001 CAD19 (30.6)67 (10.2)<.001 Smoking history24 (35.8)142 (19.8).004 Cancer history17 (26.6)68 (10.0)<.001 BMI, kg/m228.2 ± 7.626.2 ± 5.3.039 DVT history19 (28.4)99 (13.8).003Perioperative details VCSS composite18.1 ± 4.69.9 ± 3.1<.001 Intraoperative DVT found22 (32.8)188 (26.2).305 Stent position.004Unilateral37 (55.2)261 (36.4)Bilateral30 (44.8)456 (63.6) Stents placed, No.1.9 ± 1.02.3 ± 1.0.001Postoperative outcomes Follow-up, days801.1 ± 776.7764.3 ± 671.3.701 Interval to reoperation, days393.5 ± 501.7303.0 ± 365.4.167 Total reoperations, No.1.4 ± 1.91.0 ± 1.3.012 Reoperations for patients with ≥1 reoperation2.6 ± 1.81.8 ± 1.2.001 Univariate OR, major operation1.98 (1.03-3.63).032 Multivariate OR, major operation1.79 (0.93-3.35).072 30-Day postoperative VLU CASFull resolution11 (26.8)NASignificant change8 (19.5)NAMild change7 (17.1)NANo change13 (31.7)NAWorse2 (4.9)NA 90-Day postoperative VLU CASFull resolution12 (31.6)NASignificant change13 (34.2)NAMild change9 (23.7)NANo change3 (7.9)NAWorse1 (2.6)NA 6-Month postoperative VLU CASFull resolution10 (26.3)NASignificant change12 (31.6)NAMild change6 (15.8)NANo change7 (18.4)NAWorse3 (7.9)NABMI, Body mass index; CAD, coronary artery disease; CAS, clinical assessment score; DVT, deep vein thrombosis; HTN, hypertension; NA, not applicable; VCSS, venous clinical severity score; VLU, venous leg ulcer.Data presented as mean ± standard deviation or number (%). Open table in a new tab

Background: Online patient reviews influence a patient's choice of a vascular surgeon. The aim of this study is to examine underlying factors that contribute to positive and negative patient reviews by leveraging sentiment analysis and machine learning methods. Methods: The Society of Vascular Surgeons publicly accessible member directory was queried and cross-referenced with a popular patient-maintained physician review website, healthgrades.com. Sentiment analysis and machine learning methods were used to analyze several parameters. Demographics (gender, age, and state of practice), star rating (of 5 stars), and written reviews were obtained for corresponding vascular surgeons. A sentiment analysis model was applied to patient-written reviews and validated against the star ratings. Student's t-test or one-way analysis of variance assessed demographic relationships with reviews. Word frequency assessments and multivariable logistic regression analyses were conducted to identify common and determinative components of written reviews. Results: A total of 1,799 vascular surgeons had public profiles with reviews. Female gender of surgeon was associated with lower star ratings (male = 4.19, female = 3.95, P < 0.01) and average sentiment score (male = 0.50, female = 0.40, P < 0.01). Younger physician age was associated with higher star rating (P = 0.02) but not average sentiment score (P = 0.12). In the Best reviews, the most commonly used one-words were Care (N = 999), Caring (N = 767), and Kind (N = 479), while the most commonly used two-word pairs were Saved/Life (N = 189), Feel/Comfortable (N = 106), and Kind/Caring (N = 104). For the Worst reviews, the most commonly used one-words were Pain (N = 254) and Rude (N = 148), while the most commonly used two-word pairs were No/One (N = 27), Waste/Time (N = 25), and Severe/Pain (N = 18). In a multiple logistic regression, satisfactory reviews were associated with words such as Confident (odds ratio [OR] = 8.93), Pain-free (OR = 4.72), Listens (OR = 2.55), and Bedside Manner (OR = 1.70), while unsatisfactory reviews were associated with words such as Rude (OR = 0.01), Arrogant (OR = 0.09), Infection (OR = 0.20), and Wait (OR = 0.48). Conclusions: Female surgeons received significantly worse reviews and younger surgeons tended to receive better reviews. The positivity and negativity of reviews were largely related to words associated with the patientedoctor experience and pain. Vascular surgeons should focus on these 2 areas to improve patient experiences and their own reviews.

BackgroundIncreased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following endovascular aneurysm repair (EVAR) in abdominal aortic aneurysm patients.MethodsPatients who underwent elective EVAR between 2004 and 2018 were reviewed. The thoracic tortuosity index (TTI) was measured using three-dimensional reconstruction software. Patients were dichotomized across the median TTI into high tortuosity (HT) (TTI >1.27; Figure, A) and low tortuosity (LT) (TTI ≤1.27; Figure, B) groups. Perioperative complications, postoperative outcomes, and computed tomography-based features of thoracic aortic wall degeneration (Figure, C-E) were collected and analyzed.ResultsThere were 136 patients who underwent treatment: 70 HT patients, including 54 males and 16 females (mean age, 77 years), and 66 LT patients, including 62 males and 4 females (mean age, 70 years) (age; P < .001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P = .045 and P = .01, respectively). Presence of degenerative aortic wall markers was greater in HT patients (P = .045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P = .002). Frequency of abdominal aortic aneurysm rupture/dissection was 4.3% for HT and 1.5% for LT (P = .339). A trend was observed in all-cause 30-day mortality in the HT group (P = .061). Other perioperative complications and postoperative outcomes were similar between groups.Conclusions BackgroundIncreased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following endovascular aneurysm repair (EVAR) in abdominal aortic aneurysm patients. Increased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following endovascular aneurysm repair (EVAR) in abdominal aortic aneurysm patients. MethodsPatients who underwent elective EVAR between 2004 and 2018 were reviewed. The thoracic tortuosity index (TTI) was measured using three-dimensional reconstruction software. Patients were dichotomized across the median TTI into high tortuosity (HT) (TTI >1.27; Figure, A) and low tortuosity (LT) (TTI ≤1.27; Figure, B) groups. Perioperative complications, postoperative outcomes, and computed tomography-based features of thoracic aortic wall degeneration (Figure, C-E) were collected and analyzed. Patients who underwent elective EVAR between 2004 and 2018 were reviewed. The thoracic tortuosity index (TTI) was measured using three-dimensional reconstruction software. Patients were dichotomized across the median TTI into high tortuosity (HT) (TTI >1.27; Figure, A) and low tortuosity (LT) (TTI ≤1.27; Figure, B) groups. Perioperative complications, postoperative outcomes, and computed tomography-based features of thoracic aortic wall degeneration (Figure, C-E) were collected and analyzed. ResultsThere were 136 patients who underwent treatment: 70 HT patients, including 54 males and 16 females (mean age, 77 years), and 66 LT patients, including 62 males and 4 females (mean age, 70 years) (age; P < .001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P = .045 and P = .01, respectively). Presence of degenerative aortic wall markers was greater in HT patients (P = .045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P = .002). Frequency of abdominal aortic aneurysm rupture/dissection was 4.3% for HT and 1.5% for LT (P = .339). A trend was observed in all-cause 30-day mortality in the HT group (P = .061). Other perioperative complications and postoperative outcomes were similar between groups. There were 136 patients who underwent treatment: 70 HT patients, including 54 males and 16 females (mean age, 77 years), and 66 LT patients, including 62 males and 4 females (mean age, 70 years) (age; P < .001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P = .045 and P = .01, respectively). Presence of degenerative aortic wall markers was greater in HT patients (P = .045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P = .002). Frequency of abdominal aortic aneurysm rupture/dissection was 4.3% for HT and 1.5% for LT (P = .339). A trend was observed in all-cause 30-day mortality in the HT group (P = .061). Other perioperative complications and postoperative outcomes were similar between groups. Conclusions

Objectives: This study aimed to determine the role of the body mass index (BMI) in iliofemoral vein stent placement among patients who were normal weight, overweight, and obese.Methods: A clinical registry of 624 patients who underwent iliofemoral vein stenting for chronic proximal venous outflow obstruction (PVOO) was retrospectively analyzed.The patients were divided into three groups according to their BMI: normal (n ¼ 250; BMI, $18.5 but <25 kg/m 2 ), overweight (n ¼ 249, BMI, $25 but <30 kg/m 2 ), and obese (n ¼ 125; BMI $30 kg/m 2 ).Major interventions were defined as any subsequent interventions that include venography.Univariate differences were analyzed using the c 2 or Fisher exact test for categorical variables and one-way analysis of variance for continuous variables.Logistic regression models were used to determine the unadjusted and adjusted odds ratio (OR) for any reintervention.A log-rank test was used to assess for differences in reintervention-free survival.Results: Among patients with PVOO undergoing vein stent placement, the prevalence of obesity was 20.0% (n ¼ 125) and overweight was 39.9% (n ¼ 249) with a mean BMI of 35.3 kg/m 2 and 27.0 kg/m 2 , respectively.Diabetes (normal weight, 16.0%; overweight, 22.5%; obese, 40.8%;P < .001),hypertension (normal weight, 40.8%; overweight, 75.2%; obese, 52.6%; P < .001),coronary artery disease (normal weight, 7.6%; overweight, 26.2%; obese, 9.3%; P < .001),cancer history (normal weight, 10.4%; overweight, 19.2%; obese, 9.6%; P ¼ .017),and mean CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class (normal weight, 3.4; overweight, 3.7; obese, 3.5; P ¼ .017)differed significantly across the three groups (Table I).Univariate logistic regression showed that obesity was associated with an increased risk of major reintervention (OR, 1.88; 95% confidence interval [CI], 1.13-3.06;P ¼ .013;Table II).After controlling for age, gender, coronary artery disease, race/ethnicity, and diabetes status, the association between obesity and major reintervention was no longer significant (OR, 1.06; 95% CI, 0.50-2.17;P ¼ .882;Table II).The log-rank test results also showed no difference in reintervention-free survival for major or minor reoperations among those with a normal, overweight, or obese BMI (P ¼ .40).Improvement in the mean composite venous clinical severity scores from preoperatively to postoperatively (P ¼ .802),at 1-year follow-up (P ¼ .111),and at 5-year follow-up (P ¼ .44)showed no differences across the three BMI groups.Conclusions: Overweight and obesity were prevalent among vein stent patients.Despite the greater comorbid conditions, after controlling for these risk factors, obese patients benefited as much as patients with a normal BMI from iliac vein stent placement for PVOO, as reflected in a similar improvement in the composite venous clinical severity scores.

BackgroundWe observed that a history of deep vein thrombosis (DVT) was more prevalent than expected among patients undergoing iliofemoral vein stent placement for nonthrombotic iliac vein lesion (NIVL), of which May-Thurner syndrome is the most common. We undertook this study to understand how prior DVT affects perioperative outcomes among these patients.MethodsThis retrospective analysis included 873 iliac vein stent placements for NIVL at a single institution from 2013 to 2021. Patients with a known history of DVT were identified. Focal stenosis in the common iliac vein or external iliac vein on venography and intravascular ultrasound examination was considered a result of compression whereas a diffuse common iliac vein or external iliac vein stenosis was considered postphlebitic vascular change (PPVC) from a remote DVT. CEAP and Venous Clinical Severity Score were collected preoperatively and postoperatively. Major reintervention defined any reoperation with venography. Multivariate regression models calculated the odds ratio of major re-interventions while χ2 tests compared categorical variables. Multivariate models controlled for demographics and comorbidities.ResultsOf these 873 patients, DVT was present in 33.2%: 15.1% had a known history of DVT, 26.7% with intraoperative findings of PPVC, and 8.6% with both. In patients with intraoperative PPVC, 67.8% occurred without a known history of DVT. Comorbid conditions were higher in DVT patients, including diabetes (29.7% vs 18.2%; P < .001), hypertension (58.6% vs 47.0%; P = .002), coronary artery disease (16.1% vs 9.4%; P = .007), and cancer (16.0% vs 8.3%; P = .001). More DVT patients had C4-C6 CEAP classifications than non-DVT patients (42.0% vs 33.7%; P = .031). Improvement in the Venous Clinical Severity Score was lower among DVT patients postoperatively, after 1 year, and after 2 years (3.0 vs 4.0; P < .001; 3.7 vs 4.5; P = .04; 3.0 vs 4.4; P = .003). The odds of a major reintervention were lower for those without DVT than with DVT (odds ratio, 0.61).ConclusionsDVT, by history and by intraoperative findings, is more prevalent among these NIVL patients than recognized. Patients with DVT are more likely to have comorbid conditions, greater severity in disease before and after the operation, and re-interventions. Many DVT are clinically silent to the patient. Two concurrent obstructions, one from compression and a second from PPVC, may contribute to symptom severity, known or unknown to the patient. BackgroundWe observed that a history of deep vein thrombosis (DVT) was more prevalent than expected among patients undergoing iliofemoral vein stent placement for nonthrombotic iliac vein lesion (NIVL), of which May-Thurner syndrome is the most common. We undertook this study to understand how prior DVT affects perioperative outcomes among these patients. We observed that a history of deep vein thrombosis (DVT) was more prevalent than expected among patients undergoing iliofemoral vein stent placement for nonthrombotic iliac vein lesion (NIVL), of which May-Thurner syndrome is the most common. We undertook this study to understand how prior DVT affects perioperative outcomes among these patients. MethodsThis retrospective analysis included 873 iliac vein stent placements for NIVL at a single institution from 2013 to 2021. Patients with a known history of DVT were identified. Focal stenosis in the common iliac vein or external iliac vein on venography and intravascular ultrasound examination was considered a result of compression whereas a diffuse common iliac vein or external iliac vein stenosis was considered postphlebitic vascular change (PPVC) from a remote DVT. CEAP and Venous Clinical Severity Score were collected preoperatively and postoperatively. Major reintervention defined any reoperation with venography. Multivariate regression models calculated the odds ratio of major re-interventions while χ2 tests compared categorical variables. Multivariate models controlled for demographics and comorbidities. This retrospective analysis included 873 iliac vein stent placements for NIVL at a single institution from 2013 to 2021. Patients with a known history of DVT were identified. Focal stenosis in the common iliac vein or external iliac vein on venography and intravascular ultrasound examination was considered a result of compression whereas a diffuse common iliac vein or external iliac vein stenosis was considered postphlebitic vascular change (PPVC) from a remote DVT. CEAP and Venous Clinical Severity Score were collected preoperatively and postoperatively. Major reintervention defined any reoperation with venography. Multivariate regression models calculated the odds ratio of major re-interventions while χ2 tests compared categorical variables. Multivariate models controlled for demographics and comorbidities. ResultsOf these 873 patients, DVT was present in 33.2%: 15.1% had a known history of DVT, 26.7% with intraoperative findings of PPVC, and 8.6% with both. In patients with intraoperative PPVC, 67.8% occurred without a known history of DVT. Comorbid conditions were higher in DVT patients, including diabetes (29.7% vs 18.2%; P < .001), hypertension (58.6% vs 47.0%; P = .002), coronary artery disease (16.1% vs 9.4%; P = .007), and cancer (16.0% vs 8.3%; P = .001). More DVT patients had C4-C6 CEAP classifications than non-DVT patients (42.0% vs 33.7%; P = .031). Improvement in the Venous Clinical Severity Score was lower among DVT patients postoperatively, after 1 year, and after 2 years (3.0 vs 4.0; P < .001; 3.7 vs 4.5; P = .04; 3.0 vs 4.4; P = .003). The odds of a major reintervention were lower for those without DVT than with DVT (odds ratio, 0.61). Of these 873 patients, DVT was present in 33.2%: 15.1% had a known history of DVT, 26.7% with intraoperative findings of PPVC, and 8.6% with both. In patients with intraoperative PPVC, 67.8% occurred without a known history of DVT. Comorbid conditions were higher in DVT patients, including diabetes (29.7% vs 18.2%; P < .001), hypertension (58.6% vs 47.0%; P = .002), coronary artery disease (16.1% vs 9.4%; P = .007), and cancer (16.0% vs 8.3%; P = .001). More DVT patients had C4-C6 CEAP classifications than non-DVT patients (42.0% vs 33.7%; P = .031). Improvement in the Venous Clinical Severity Score was lower among DVT patients postoperatively, after 1 year, and after 2 years (3.0 vs 4.0; P < .001; 3.7 vs 4.5; P = .04; 3.0 vs 4.4; P = .003). The odds of a major reintervention were lower for those without DVT than with DVT (odds ratio, 0.61). ConclusionsDVT, by history and by intraoperative findings, is more prevalent among these NIVL patients than recognized. Patients with DVT are more likely to have comorbid conditions, greater severity in disease before and after the operation, and re-interventions. Many DVT are clinically silent to the patient. Two concurrent obstructions, one from compression and a second from PPVC, may contribute to symptom severity, known or unknown to the patient. DVT, by history and by intraoperative findings, is more prevalent among these NIVL patients than recognized. Patients with DVT are more likely to have comorbid conditions, greater severity in disease before and after the operation, and re-interventions. Many DVT are clinically silent to the patient. Two concurrent obstructions, one from compression and a second from PPVC, may contribute to symptom severity, known or unknown to the patient.

BACKGROUND:Medical compression stocking (MCS) therapy remains a core treatment for chronic venous disease, particularly in patients with lower extremity edema. This study investigated the impact of postoperative MCS adherence on patients with moderate to severe edema who underwent iliac vein stenting (IVS). METHODS:Patients at a large tertiary care center who underwent IVS from August 2011 to June 2021 were analyzed. Symptoms were quantified using the venous clinical severity score (VCSS) and clinical assessment score (CAS). The criterion for inclusion was moderate or severe lower extremity edema at the time of IVS. Patients were stratified into two cohorts: complete postoperative compression therapy compliance (MCS+) and no postoperative compression therapy use (MCS-). RESULTS:Among 376 patients fitting our study criteria, we identified 168 MCS+ and 208 MCS- patients. The VCSS edema score did not significantly differ between groups (P = 0.179). Postoperatively, the mean changes in VCSS edema at the first postoperative visit, the one-year follow-up, and the two-year follow-up were not significantly different between the MCS+ and MCS- cohorts (P = 0.123, 0.296, and 0.534, respectively). An analysis of CAS for edema revealed that the MCS+ cohort had a modestly better improvement in edema at the 90-day follow-up visit versus the MCS- cohort (P = 0.018), but this difference was not observed in the 30-day (P = 0.834) or six-month follow-up visit (P = 0.755). A multivariate analysis revealed no difference in the need for major intervention (OR 0.93, 95% CI 0.44 to 1.50, P = 0.504). A Kaplan-Meier analysis via log-rank test revealed no difference in reintervention-free survival between groups (P = 0.77). CONCLUSIONS:Many patients with moderate to severe lower extremity edema experience a reduction in their edema after IVS. In our study, compression stocking compliance after surgery had a little impact on edema relief in this population.

Patients undergoing iliac vein stent placement (IVS) for chronic proximal venous outflow obstruction are observed to have two types of stenosis: a more focal stenosis from external compression, also known as nonthrombotic iliac vein lesions (NIVL), or more diffuse stenosis suggestive of post-thrombotic syndrome (PTS) from a remote deep venous thrombosis (DVT). We assessed the influence of PTS on the outcomes of IVS.