Introduction Transportation databases have limited data regarding injury severity of pedestrian versus automobile patients. To identify opportunities to reduce injury severity, transportation and trauma databases were integrated to examine the differences in pedestrian injury severity at street crossings that were signalized crossings (SCs) versus nonsignalized crossings (NSCs). It was hypothesized that trauma database integration would enhance safety analysis and pedestrians struck at NSC would have greater injury severity. Methods Single-center retrospective review of all pedestrian versus automobile patients treated at a level 1 trauma center from 2014 to 2018 was performed. Patients were matched to the transportation database by name, gender, and crash date. Google Earth Pro satellite imagery was used to identify SC versus NSC. Injury severity of pedestrians struck at SC was compared to NSC. Results A total of 512 patients were matched (median age = 41 y [Q1 = 26, Q3 = 55], 74% male). Pedestrians struck at SC (n = 206) had a lower injury severity score (ISS) (median = 9 [4, 14] versus 17 [9, 26], P < 0.001), hospital length of stay (median = 3 [0, 7] versus 6 [1, 15] days, P < 0.001), and mortality (21 [10%] versus 52 [17%], P = 0.04), as compared to those struck at NSC (n = 306). The transportation database had a sensitivity of 63.4% (55.8%-70.4%) and specificity of 63.4% (57.7%-68.9%) for classifying severe injuries (ISS >15). Conclusions Pedestrians struck at SC were correlated with a lower ISS and mortality compared to those at NSC. Linkage with the trauma database could increase the transportation database's accuracy of injury severity assessment for nonfatal injuries. Database integration can be used for evidence-based action plans to reduce pedestrian morbidity, such as increasing the number of SC.

Subclavian steal syndrome results from subclavian artery stenosis that results in retrograde blood flow through the ipsilateral vertebral artery. Rarely, this retrograde flow can affect the vertebrobasilar junction and cause vertebrobasilar insufficiency, ischemia, and even aneurysm formation. We describe a unique presentation of a vertebrobasilar aneurysm presenting with subarachnoid hemorrhage in the setting of subclavian steal syndrome. The subclavian stenosis was endovascularly managed, with complete resolution of both retrograde flow and the dissection itself. Re-establishment of native flow mechanics in the subclavian artery may treat aneurysms at the vertebrobasilar junction, potentially eliminating the need for further interventions.

Objectives: To assess outcomes of carotid body tumors (CBTs) managed with active surveillance. Methods: Retrospective chart review of CBTs managed with active surveillance from 2001 to 2019. Results: A total of 115 cases were identified during chart review. Sixty-five of these patients were managed with active surveillance, and 11 patients had bilateral tumors for a total of 76 tumors. Follow-up records with symptomatic outcomes were available for 51 patients, and 47 tumors had follow-up imaging. Thirty-one (66%) actively surveilled CBTs remained stable or decreased in size while 16 (34%) increased in size. Patients undergoing active surveillance developed symptoms in 12 cases, 6 of these patients underwent surgical intervention. Nine CBTs managed with active surveillance (18%) were ultimately resected. The majority of patients who did not undergo surgical intervention never developed symptoms (36/42, 86%). Conclusions: Active surveillance may be a reasonable approach for a subset of CBTs.

Objective: A novel transdermal arterial gasotransmitter sensor (TAGS) has been tested as a diagnostic tool for lower limb microvascular disease in individuals with and without diabetes mellitus (DM). Methods: The TAGS system noninvasively measures hydrogen sulfide (H2S) emitted from the skin. Measurements were made on the forearm and lower limbs of individuals from three cohorts, including subjects with DM and chronic limb -threatening ischemia, to evaluate skin microvascular integrity. These measurements were compared with diagnosis of peripheral artery disease (PAD) using the standard approach of the toe brachial index. Other measures of vascular health were made in some subjects including fasting blood glucose, hemoglobin A1c, plasma lipids, blood pressure, estimated glomerular filtration, and body mass index. Results: The leg:arm ratio of H2S emissions correlated with risk factors for microvascular disease (ie, high-density lipo-protein levels, estimated glomerular filtration rate, systolic blood pressure, and hemoglobin A1c). The ratios were signif-icantly lower in symptomatic DM subjects being treated for chronic limb-threatening ischemia (n = 8, 0.48 & PLUSMN; 0.21) compared with healthy controls (n = 5, 1.08 & PLUSMN; 0.30; P = .0001) and with asymptomatic DM subjects (n = 4, 0.79 & PLUSMN; 0.08; P = .0086). The asymptomatic DM group ratios were also significantly lower than the healthy controls (P = .0194). Using ratios of leg:arm transdermal H2S measurement (17 subjects, 34 ratios), the overall accuracy to identify limbs with severe PAD had an area under the curve of the receiver operating curve of 0.93. Conclusions: Ratios of transdermal H2S measurements are lower in legs with impaired microvascular function, and the decrease in ratio precedes clinically apparent severe microvascular disease and diabetic ulcers. The TAGS instrument is a novel, sensitive tool that may aid in the early detection and monitoring of PAD complications and efforts for limb salvage. (J Vasc Surg Cases Innov Tech 2023;9:101101.)

Background: Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma.Methods: A single-center retrospective review of all consecutive patients who sustained trau-matic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clin-ical outcomes.Results: A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 & PLUSMN; 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial ves-sels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher pro-portion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS inter-vened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more com-mon in the TS group (38% vs. 15%, P = 0.04).Conclusions: Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popli-teal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).

Between 2009 and 2019, pedestrian fatalities in the U.S. increased 51.0% while all other traffic fatalities increased 0.4%. To mitigate pedestrian safety issues, practitioners increasingly use police-reported data to identify and treat locations that experience either serious or fatal injuries. We investigated how many and which types of pedestrian injuries were misclassified by police-reported data in New Mexico between 2014 and 2018 by matching pedestrian-vehicle crash victims reported in New Mexico Department of Transportation (NMDOT) crash data to patients treated at University of New Mexico Health-Science Center, an American College of Surgeons-certified level 1 trauma center (n = 3097 pedestrians in NMDOT data; n = 512 matched pedestrians). Findings suggest that injuries involving older pedestrians, males, alcohol, more serious injuries, and those that occur at night are more likely to match to the hospital data. Of the non-fatally injured pedestrians who police estimated as seriously-injured (n = 207), 21.7% were no more than minorly-injured (n = 45) (KABCO A and ISS < 9). Of pedestrians who police estimated as minorly-injured (n = 239), 55.6% were seriously-injured (n = 133) (KABCO B,C,O and ISS > 9). Of pedestrians with true serious injuries (n = 295) (ISS > 9), 45.1% were underestimated by police (n = 133) (KABCO B,C,O and ISS > 9) whereas 29.8% of pedestrians with true minor injuries (n = 151) (ISS < 9) were over-estimated by police (n = 45) (KABCO A and ISS < 9). Minorly-injured pedestrians who were over-estimated by police (KABCO A and ISS < 9) were more likely to have lower extremity injuries (62.2% vs 42.5%, p-value = 0.013) compared to minorly-injured pedestrians whose injury severities were estimated correctly (KABCO B,C,O and ISS < 9). Seriously-injured pedestrians who were underestimated (KABCO B,C,O and ISS > 9) were less likely to have injuries to the head (39.8% vs. 55.6%, p-value = 0.003), spine (30.1% vs. 50.0%, p-value < 0.001), thorax (53.4% vs. 66.7%, p-value = 0.0139), or abdomen (18.8% vs. 32.1%, p-value = 0.005) compared to seriously-injured pedestrians whose injury severities were estimated correctly (KABCO A and ISS > 9). This research illustrates the importance of linking police and health outcome databases to provide a more complete understanding of traffic safety.

Evaluate the utility of whole-body computed tomography (WBCT) imaging in detecting clinically significant findings in patients who have undergone extracorporeal membrane oxygenation (ECMO) cannulation for cardiac arrest (extracorporeal cardiopulmonary resuscitation or "eCPR"). Single-center retrospective review of 52 consecutive patients from 2017 to 2019 who underwent eCPR and received concomitant WBCT imaging. WBCT images were reviewed for clinically significant findings (compression-related injuries, cannulation-related complications, etiology of cardiac arrest, incidental findings, and evidence of hypoxic brain injury) as well as the frequency of interventions performed as a direct result of such findings. Thirty-eight patients met inclusion criteria for analysis. Clinically significant WBCT findings were present in 37/38 (97%) of patients with 3.3 ± 1.7 findings per patient. An intervention as a direct result of WBCT findings was performed in 54% (20/37) of patients with such findings. Evidence of hypoxic brain injury on WBCT was associated with clinical brain death as compared with those without such findings (10/15 [67%] vs 1/22 [4%], P < 0.001), respectively. WBCT scan after eCPR frequently detects clinically significant findings which commonly prompt an intervention directly affecting the patient's clinical course. We advocate for protocolized use of WBCT imaging in all eCPR patients.

We have described the utility of a three-dimensionally (3D) printed model in the surgical repair of an extensive mycotic superior mesenteric artery (SMA) aneurysm. A 62-year-old woman with no pertinent medical history had presented with a 2-week history of fever, abdominal pain, and diarrhea. Laboratory analysis demonstrated leukocytosis. Computed tomography angiography (CTA) revealed an SMA mycotic aneurysm with degeneration along its entire length and endometrial/myometrial inflammation. After obtaining blood cultures, endometrial biopsy, and initiating broad-spectrum antibiotics, the patient was scheduled for urgent aneurysm repair because of the risk of rupture.

Background: Percutaneous arteriovenous fistulas have recently proven successful alternatives to surgical arteriovenous fistulas with encouraging initial results. The Ellipsys Endovascular Arteriovenous Fistula System utilizing ultrasound and thermal energy has recently received approval for use in the United States. At the University of New Mexico, we developed an integrated service between Vascular Surgery, Interventional Radiology, and Interventional Nephrology for percutaneous arteriovenous fistulas utilizing Ellipsys. Methods: We performed a retrospective chart review of the initial 6 months (January 1st 2019 to July 1st 2019) of 18 percutaneous arteriovenous fistula placements to evaluate our initial technical success rate, the number of arteriovenous fistulas meeting maturation characteristics or use in dialysis, and to identify areas for quality improvement. Results: Initial technical success was achieved in 17 out of 18 arteriovenous fistulas (94.4%). Three patients did not report for any follow-up at the end of the initial 6 months. Of the remaining patients, 7 out of 15 were using their arteriovenous fistulas or meeting maturation characteristics at the end of the study (46.7%). Patient loss to follow-up/no-show (16.7%), patient not yet requiring hemodialysis (27.8%), and poor post-surgical maturation and/or need for additional maturation procedures (55.6%) were the predominate reasons for non-use. We identified improved coordination of care, early intervention, and outpatient dialysis center education as the primary areas of focus for quality improvement. Conclusion: Initial technical success rate of percutaneous arteriovenous fistulas placement was comparable to published studies. Early and aggressive secondary angiographic interventions of arteriovenous fistulas failing to meet cannulation requirements, improved coordination of post-operative care, and outpatient dialysis center education appear to be the primary targets for quality improvement.

Background Metastatic melanoma to the colon is rarely diagnosed with an incidence of only 0.3% and more than 95% of cases identified post-mortem. Survival for patients with metastatic melanoma to the colon is poor, with 5-year survival rates of 26.5%. Nonetheless, surgical resection of the colonic metastatic melanoma lesions is recommended as it is associated with improved survival. Additionally, surgical resection is also indicated for palliative reasons, as symptom resolution is achieved in 90% of such patients. Use of the surgical robot has increased dramatically in the past decades, especially in the field of colorectal surgery. Furthermore, recent studies have demonstrated comparable outcomes between patients undergoing either laparoscopic or robotic-assisted colorectal surgery for cancer. Here, we describe the first case, to the authors knowledge, of a robot-assisted sigmoid colectomy for metastatic melanoma. Case presentation A 72-year-old male with a history of metastatic melanoma diagnosed in 2015 with a favorable response to immunotherapy presented to the emergency department with symptomatic lower gastrointestinal bleeding (LGIB). Endoscopy demonstrated a friable melanotic lesion of the sigmoid colon with biopsy demonstrating histopathologic evidence of metastatic melanoma. After further evaluation, the patient consented for an elective robot-assisted segmental colectomy for palliative intent. Diagnostic laparoscopy identified no evidence of further intra-abdominal metastatic disease. After identifying the metastatic lesion in the sigmoid colon, the mesentery of involved segment of sigmoid colon adjacent to the lesion was divided using the bipolar electrosurgical vessel sealer device. The colon was divided both proximal and distal to the lesion using a robotic stapler and a tension-free colo-colonic anastomosis was created intracorporeally. Postoperatively, the patient had an unremarkable course and was discharged home on post-operative day 3. On follow-up, the patient was doing well with resolution of preoperative LGIB. Conclusion This case highlights a rare presentation of metastatic melanoma to the colon in a patient presenting with LGIB. Furthermore, this case demonstrates the feasibility of the minimally invasive robotic-assisted approach for an uncommon pathology.

OBJECTIVE:Compare the effects of preoperative embolization for carotid body tumor resection on surgical outcomes to carotid body tumor resections without preoperative embolization.METHODS:Single-center retrospective review of all consecutive patients who underwent carotid body tumor resection from 2001 to 2019. Surgical outcomes with emphasis on operative time (estimated blood loss and cranial nerve injury) of patients undergoing carotid body tumor resection following preoperative embolization were compared to those undergoing resection alone using unpaired Student's t-test and Fisher's exact test.RESULTS:Forty-six patients (15% male, mean age 50 ± 15 years) underwent resection of 49 carotid body tumors. Patients undergoing preoperative embolization (n = 20 (40%)) had larger mean tumor size (4.0 ± 0.7 vs 3.2 ± 1 cm, p = 0.006), increased Shamblin II/III tumor classification (18 (90%) vs 22 (76%), p < 0.001), operative time (337 ± 195 vs 199 ± 100 min, p = 0.004), and cranial nerve injuries overall (8 (40%) vs 2 (10%), p = 0.01) compared to patients undergoing resection without preoperative embolization (n = 29 (60%)). In subgroup analysis of Shamblin II/III classification tumors (n = 40), preoperative embolization (n = 18) was associated with increased tumor size (4.1 ± 0.6 vs 3.5 ± 0.9 cm, p = 0.01), operative time (351 ± 191 vs 244 ± 105 min, p = 0.02), and cranial nerve injury overall (8 (44%) vs 2 (9%), p = 0.03) compared to resections alone (n = 19). In further subgroup analysis of large (⩾ 3 cm) tumors (n = 37), preoperative embolization (n = 18) was associated with increased operative time (350 ± 191 vs 198 ± 99 min, p = 0.006) and cranial nerve injury overall (8 (44%) vs 2 (11%), p = 0.03) compared to resections alone (n = 19). There were no significant differences in estimated blood loss, transfusion requirement, or hematoma formation between any of the embolization and non-embolization subgroups.CONCLUSION:After controlling for tumor Shamblin classification and size, carotid body tumor resections following preoperative embolization were associated with increased operative time and inferior surgical outcomes compared to those tumors undergoing resection alone. Nonetheless, such results remain susceptible to the confounding effects of individual tumor characteristics often used in the decision to perform preoperative embolization, underscoring the need for prospective studies evaluating the utility of preoperative embolization for carotid body tumors.

Background: Recently, there has been an abundance of encouraging data regarding the creation of percutaneous arteriovenous fistulas. Despite promising data regarding their clinical maturation, a paucity of data exists which provides direct comparison between percutaneously created AVFs (pAVF) and open surgically created AVFs (sAVF). This study has 2 primary objectives: First, to compare clinical outcomes of pAVFs to sAVFs, with emphasis on clinical maturation and frequency of postoperative interventions to facilitate maturation. Second, to contribute toward the evidence-based incorporation of the pAVF procedure into the hemodialysis access algorithm. Methods: A single-center retrospective review was performed on all consecutive patients undergoing surgically created brachiocephalic arteriovenous fistula (BC-AVF, sAVF group) from January 1, 2018 to December 31, 2018 and Ellipsys-created percutaneous arteriovenous fistula (pAVF group) from January 1, 2019 to December 31, 2019. Comparative analysis between groups was performed. Results: A total of 24 patients underwent Ellipsys-created pAVF with mean age of 56.7 +/- 22.6 years (12 males [50%], 12 females [50%]) and 62 patients underwent surgically created BC-AVF with mean age of 62.5 +/- 13.2 years (32 males [52%], 30 females [48%]). Both the pAVF and sAVF groups had comparable mean operating times (60 +/- 40 vs. 56 +/- 25 min, P = 0.67) and frequency of procedural technical success (23 [96%] vs. 62 [100%], P = 0.28), respectively. The pAVF group had a lower clinical maturation rate (12 [52%] vs. 54 [87%], P = 0.003) and a higher primary failure rate (9 [39%] vs. 6 [10%], P = 0.003) when compared to the sAVF group. The pAVF group had an increased overall rate of undergoing a postoperative intervention (18 [78%] vs. 13 [21%], P < 0.001), as well as an increased number of total postoperative interventions (1.1 +/- 0.9 vs. 0.3 +/- 0.6 interventions, P < 0.001) compared to the sAVF group. Percutaneous transluminal angioplasty of the juxta anastomotic segment was the most prevalent postoperative intervention performed in the pAVF group and occurred at a significantly increased frequency when compared to the sAVF group rate (13 [57%] vs. 5 [8%], P < 0.001). Conclusions: In our single-center retrospective review, patients undergoing Ellipsys-created pAVF in the first year following introduction of percutaneous endovascular had inferior rates of clinical maturation and underwent more postoperative interventions when compared to historical patients undergoing surgically created BC-AVF. Outcome discrepancies compared to previously reported Ellipsys data demonstrate a need for further studies examining the practical translatability of the pAVF.

Objective: The objective of this study was to evaluate the efficacy of protocolized use of catheter-directed thrombolysis and echocardiography in submassive pulmonary embolism patients. Methods: A retrospective study at a single institution of 28 patients that presented with submassive pulmonary embolism from July 2016 to September 2019 was performed. All patients were diagnosed using chest computed tomography demonstrating a pulmonary embolism and abnormal right ventricular to left ventricular ratio. Patients with severe right heart dysfunction (right ventricular to left ventricular ratio ⩾1.4) were protocolized to receive catheter-directed thrombolysis via EkoSonic catheters (EKOS Corporation, Bothell, WA, United States). Transthoracic echocardiogram was performed after 24 hours to assess right ventricular function and determine the need to continue thrombolysis. Patients after discharge then received follow-up echocardiograms at 6 weeks to determine new post-treatment baseline. Results: The mean patient age was 54.6 years, mean body mass index was 35.0, and mean right ventricular to left ventricular ratio on admission computed tomography imaging was 1.70. Interval mean right ventricular to left ventricular ratio on echocardiography during thrombolysis therapy was 1.01 (p < 0.00001). Patients were tachycardic on admission (mean heart rate 102.2 beats per minute) with improvement by completion of thrombolysis (mean heart rate 72.9 beats per minute) (p < 0.00001). There was a 0% incidence of periprocedural complications. Overall 30-day complication rate was 7.1% (n = 1 arrhythmia, n = 1 delayed intracranial hemorrhage). At 6-week follow-up, 91% of the patients who received echocardiography had normal right ventricular function. Conclusion: This retrospective study demonstrates the effectiveness of protocolized use of catheter-directed thrombolysis and echocardiography in reversing severe right heart dysfunction in submassive pulmonary embolism patients.

Objective: Treatment of massive pulmonary embolism (MPE) is controversial, with mortality rates ranging from 25% to 65%. Patients commonly present with profound shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used as a form of acute cardiopulmonary support in critically ill patients. We reviewed our institution's pulmonary embolism response team experience using VA-ECMO for patients presenting with advanced shock and/or cardiac arrest from MPE. Methods: From March 2017 to July 2019 we retrospectively reviewed 17 consecutive patients at our institution with MPE who were placed on VA-ECMO for initial hemodynamic stabilization. Results: The mean patient age and body mass index was 55.8 years and 31.8, respectively. Ten of 17 patients (59%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All patients had evidence of profound shock with a mean initial lactate of 8.95 mmol/L, a mean pH of 7.10, and a mean serum creatinine of 1.78 mg/dL. Seventeen of 17 cannulations (100%) were performed percutaneously, with 41% (n = 7) of patients placed on VA-ECMO while awake and using local analgesia. Five of 17 patients (29%) required reperfusion cannulas, with 0% incidence of limb loss. Overall survival was 13 of 17 patients (76%), with causes of death resulting from anoxic brain injury (n = 2), septic shock (n = 1), and cardiopulmonary resuscitation-induced hemorrhage from liver laceration (n = 1). In survivors, 12 of 13 patients (92%) were discharged without evidence of neurologic insult. The median duration of the VA-ECMO run for survivors was 86 hours (range, 45-218 hours). In survivors, the median length of time from ECMO cannulation to lactate clearance (<2.0 mmol/L) was 10 hours and the median length of time from ECMO cannulation to freedom from vasopressors was 6 hours. Three of 13 patients (23%) required concomitant percutaneous thrombectomy and catheter-directed thrombolysis to address persistent right heart dysfunction, with the remaining survivors (77%) receiving VA-ECMO and anticoagulation alone as definitive therapy for their MPE. The median intensive care and hospital length of stay for survivors was 9 and 13 days, respectively. Conclusions: VA-ECMO was effective at salvaging highly unstable patients with MPE. Survivors had rapid reversal of multiple organ failure with ECMO as their primary therapy. The majority of survivors required ECMO and anticoagulation alone for definitive therapy of their MPE.

Identify risk factors and develop a predictive model for cannula-associated limb ischemia requiring distal perfusion cannula (DPC) placement in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. Single-center retrospective review of all consecutive patients who underwent peripheral VA-ECMO from 2016 to 2019. Patients were excluded if ECMO duration was <24 hours or if they underwent prophylactic DPC placement during time of cannulation. Clinical factors including laboratory shock markers, abnormal postcannulation computed tomography angiogram (CTA), limb near infrared spectroscopy (NIRS) discrepancy, and limb examination discrepancy were compared between patients requiring DPC placement to those who did not. Laboratory shock markers were defined as initial lactate ≥4 mmol/L and pH ≤7.2. Abnormal postcannulation CTA was defined as diminished or absent arterial contrast opacification distal to the arterial cannula. Limb NIRS discrepancy was defined as ≥25% rSO2 saturation discrepancy relative to contralateral limb. Limb examination discrepancy was defined as two or more abnormal physical examination findings (absent dorsalis pedis signal, absent posterior tibial signal, capillary refill of >2 seconds, edema, motor deficit, sensory deficit, or pallor) not present in contralateral limb. Fifty-four patients were included for analysis (35 males, 19 females; mean age, 55.9 ± 13 years), of whom 17 (32%) underwent DPC placement. Thirty-three patients (61%) survived VA-ECMO and 27 (50%) survived to discharge. Using selective DPC placement, there was a 0% incidence of limb amputation. One patient (1.8%) developed cannula-associated limb ischemia with persistent ischemic changes despite DPC placement; however, the patient did not survive ECMO. Patients with positive laboratory shock markers (n = 22) were significantly more likely to undergo DPC placement compared to those without (n = 32) (11 [50%] vs 6 [19%]; P = .0198). Patients with abnormal postcannulation CTA (n = 4) were significantly more likely to undergo DPC placement compared to those without (n = 25) (4 [100%] vs 2 [8%]; P = .006). All patients with unilateral limb NIRS discrepancy (n = 4) underwent DPC placement, whereas all patients without limb NIRS discrepancy (n = 15) did not undergo DPC placement (4 [100%] vs 0 [0%]; P = .0003). Patients with limb examination discrepancy (n = 15) were significantly more likely to undergo DPC placement compared to those without (n = 39) (15 [100%] vs 2 [5%]; P < .0001). Using the above clinical factors, we have derived the Cannula-associated limb ischemia severity score (CALIS score), to predict VA-ECMO patients that will benefit from selective DPC placement (Table). Cannula-associated limb ischemia requiring DPC placement can be predicted with high-fidelity using the CALIS score and was associated with no limb loss in our study.TableCannula-associated limb ischemia severity score (CALIS score)CategoryDefinitionPointsLaboratory shock markersLaboratory markers during VA-ECMO cannulation with lactate ≥4mmol/L and pH ≤ 7.21Abnormal postcannulation CTACTA obtained after VA-ECMO cannulation demonstrating diminished or absent arterial contrast opacification distal to arterial cannula2Limb NIRS discrepancyNIRS discrepancy in which there is ≥25% rSO2 saturation discrepancy relative to contralateral limb2Limb examination discrepancyLimb exam with ≥2 abnormal physical examination findings (absent dorsalis pedis signal, absent posterior tibial signal, capillary refill >2 seconds, edema, motor deficit, sensory deficit, or pallor) not present on contralateral limb2Scoring: 0 points: Low probability for cannula-associated limb ischemia. No need for DPC placement. 1 point: Intermediate probability for cannula-associated limb ischemia. Have low threshold for DPC placement. ≥2 points: High probability for cannula-associated limb ischemia. Recommend DPC placement.CTA, Computed tomography angiography; DPC, distal perfusion catheter; VA-ECMO, venoarterial extracorporeal membrane oxygenation. Open table in a new tab

We present a case of an 87-year-old female with new-onset hoarseness of unclear etiology. Imaging demonstrated a penetrating aortic ulcer (PAU) in the proximal descending thoracic aorta with an associated pseudoaneurysm that enlarged to a depth of 32 mm over 2 years. This patient was diagnosed with hoarseness being secondary to left recurrent laryngeal nerve (LRLN) palsy, a variant of Ortner syndrome. Patient was treated with endovascular stent-grafting successfully covering of the PAU and pseudoaneurysm with zone 3 proximal landing zone. The patient had moderate improvement in hoarseness after 1 year of follow-up. Endovascular repair is indicated for symptomatic patients with PAUs complicated by enlarging pseudoaneurysms or rupture. Endovascular treatment is effective with low procedural morbidity and mortality. In this case, the PAU and associated pseudoaneurysm at the level of the ligamentum arteriosum caused compression on the LRLN, resulting in a nerve palsy and hoarseness. This case highlights the importance of vascular imaging for patients presenting with unclear etiology of hoarseness or other signs of LRLN palsy. Therefore, aortic arch abnormalities, a variant of Ortner syndrome, even though rare, should be on the differential diagnosis of new onset hoarseness.

Despite the promising initial results regarding the creation of percutaneous arteriovenous fistulas (pAVFs), a paucity of data exists providing a direct comparison between percutaneously created AVFs and open surgically created AVFs (sAVFs). The present study compared the clinical outcomes of pAVFs and sAVFs, with an emphasis on clinical maturation and the frequency of postoperative interventions. A single-center retrospective review was performed of all consecutive patients who had undergone treatment with a surgically created brachiocephalic AVF (BC-AVF; sAVF group) during 2018 (Fig 1) and Ellipsys (Avenu Medical, San Juan Capistrano, Calif) percutaneously created AVFs (pAVF group) during 2019 (Fig 2). A comparative analysis between the two groups was performed. A total of 24 patients had undergone pAVF creation and 62 patients had undergone surgically created BC-AVF (Table). Both the pAVF and sAVF groups had comparable mean operating times (60 ± 40 vs 56 ± 25 minutes; P = .67) and rates of technical success (n = 23 [96%] vs n = 62 [100%]; P = .28), respectively. The pAVF group had a lower clinical maturation rate (n = 12 [52%] vs n = 54 [87%]; P = .003) and greater primary failure rate (n = 9 [39%] vs n = 6 [10%]; P = .003) compared with the sAVF group. The pAVF group had an increased overall rate of requiring a postoperative intervention (n = 18 [78%] vs n = 13 [21%]; P < .001) and an increased number of postoperative interventions (1.1 ± 0.9 vs 0.3 ± 0.6 interventions; P < .001) compared with the sAVF group. Percutaneous transluminal angioplasty of the juxta-anastomotic segment was the most prevalent postoperative intervention performed in the pAVF group and occurred at a significantly increased frequency compared with the rate for the sAVF group (n = 13 [57%] vs n = 5 [8%]; P < .001). Patients undergoing Ellipsys-created pAVF had inferior rates of clinical maturation and underwent more postoperative interventions than did patients undergoing surgically created BC-AVF in our single-center retrospective review. These outcome discrepancies compared with previously reported Ellipsys data demonstrate the need for further studies examining the real-world translatability of the pAVF device.TableComparison of pAVF and sAVF groupsVariablepAVF group (n = 24)sAVF group (n = 62)P valueAge, years56.7 ± 22.662.5 ± 13.2.15Preoperative hemodialysis14 (58)41 (66).62Operating time, minutes60 ± 4056 ± 25.67Technical success23 (96)62 (100).28Clinical maturation12 (52)54 (87).003Postoperative intervention (any)18 (78)13 (21)<.001No. of postoperative interventions1.1 ± 0.90.3 ± 0.6<.001Complication (any)3 (13)7 (11)>.99Follow-up duration, months6.1 ± 4.02.7 ± 2.6<.001Categorical data presented as number (%) and continuous variables as mean ± standard deviation. Boldface P values represent statistical significance. Open table in a new tab Fig 2Percutaneous arteriovenous fistulas (AVFs).View Large Image Figure ViewerDownload Hi-res image Download (PPT)