Cynthia K. Shortell

Revision of the venous clinical severity score: Venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group

In response to the need for a disease severity measurement, the American Venous Forum committee on outcomes assessment developed the Venous Severity Scoring system in 2000. There are three components of this scoring system, the Venous Disability Score, the Venous Segmental Disease Score, and the Venous Clinical Severity Score (VCSS). The VCSS was developed from elements of the CEAP classification (clinical grade, etiology, anatomy, pathophysiology), which is the worldwide standard for describing the clinical features of chronic venous disease. However, as a descriptive instrument, the CEAP classification responds poorly to change. The VCSS was subsequently developed as an evaluative instrument that would be responsive to changes in disease severity over time and in response to treatment. Based on initial experiences with the VCSS, an international ad hoc working group of the American Venous Forum was charged with updating the instrument. This revision of the VCSS is focused on clarifying ambiguities, updating terminology, and simplifying application. The specific language of proven quality-of-life instruments was used to better address the issues of patients at the lower end of the venous disease spectrum. Periodic review and revision are necessary for generating more universal applicability and for comparing treatment outcomes in a meaningful way.

Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum.

Thomas F. O’Donnell Jr, MD, Marc A. Passman, MD, William A. Marston, MD, William J. Ennis, DO, Michael Dalsing, MD, Robert L. Kistner, MD, Fedor Lurie, MD, PhD, Peter K. Henke, MD, Monika L. Gloviczki, MD, PhD, Bo G. Eklof, MD, PhD, Julianne Stoughton, MD, Sesadri Raju, MD, Cynthia K. Shortell, MD, Joseph D. Raffetto, MD, Hugo Partsch, MD, Lori C. Pounds, MD, Mary E. Cummings, MD, David L. Gillespie, MD, Robert B. McLafferty, MD, Mohammad Hassan Murad, MD, Thomas W. Wakefield, MD, and Peter Gloviczki, MD

An evaluation of new methods of expressing aortic aneurysm size: Relationship to rupture

The diameter of aortic aneurysms were standardized to measures of patient size and normal aortic size in an effort to define indexes that might be more predictive of aneurysm rupture than raw aneurysm diameter alone. Normal aortic diameters were measured in 100 patients undergoing abdominal CT scans for other reasons, and an average infrarenal aortic diameter of 2.10 +/- 0.05 cm was observed. Normal aortic diameter was dependent on both age and sex, ranging from 1.71 +/- 0.06 cm in women below age 40 years to 2.85 +/- 0.04 cm in men above age 70 years. Overall, 11 (5.1%) of the ruptures occurred in aneurysms less than 5 cm in diameter, and four (1.9%) occurred in aneurysms less than 4.0 cm in diameter. When the CT scans of 100 patients undergoing elective aneurysm resection were compared with those of 36 patients with ruptured aneurysms, no threshold diameter value accurately discriminated between the two groups. However, standardization of the aneurysm diameter to the transverse diameter of the third lumbar vertebral body as an index of patient body size produced an accurate predictor of rupture when a threshold ratio of 1.0 was used. No aneurysm ruptured below this ratio, but 29% of elective aneurysms were smaller than the vertebral body diameter. Receiver operating characteristic curve analysis confirmed the superiority of the aneurysm to vertebral body diameter ratio as a discriminator of ruptured aneurysms. It appears that aneurysm diameter alone is not sufficiently predictive of rupture to be used as the sole indication for elective resection.

Intracerebral hemorrhage after carotid endarterectomy: Incidence, contribution to neurologic morbidity, and predictive factors

PURPOSE With a diminishing rate of cardiac and neurologic events after carotid endarterectomy, intracerebral hemorrhage is gaining increasing importance as a cause of perioperative morbidity and mortality. To date, information has been largely anecdotal, and there has been no comparison with a control group of patients. METHODS The records of all patients experiencing symptomatic intracerebral hemorrhage after carotid endarterectomy were reviewed and compared with data from 50 randomly selected patients who did not experience intracranial bleeding. Univariate analyses were performed, using the Fisher exact test for dichotomous data and the Student t test for continuous data. RESULTS During a 6-year period, symptomatic intracranial hemorrhage developed in 11 (0.75%) of 1471 patients undergoing carotid endarterectomy, accounting for 35% of the 31 total perioperative neurologic events. Hemorrhage occurred a median of 3 days postoperatively (range, 0 to 18 days). Signs and symptoms included hypertension in all 11 patients, headache in 7 conscious patients (64%), and bradycardia in 6 patients (55%). Massive hemorrhage with herniation and death occurred in 4 patients (36%). Moderate hemorrhage developed in 5 patients (45%); 3 of these patients had partial recovery, and 2 had complete recovery. Petechial hemorrhage occurred in the remaining 2 patients (18%), 1 with partial and 1 with complete recovery. In comparison with the control group, there were no differences in respect to sex, indication for operation, smoking or diabetic history, and antiplatelet therapy or perioperative heparin management. Patients with intracranial hemorrhage were, however, younger, more frequently hypertensive, had a higher degree of ipsilateral and contralateral carotid stenosis, and had a higher rate of contralateral carotid occlusion. CONCLUSION Intracranial hemorrhage occurs with notable frequency after carotid endarterectomy and accounts for a significant proportion of neurologic morbidity and mortality. Younger patients, hypertensive patients, and patients with severe cerebrovascular occlusive disease appear to be at greatest risk for the complication.

An Endoluminal Method of Hemorrhage Control and Repair of Ruptured Abdominal Aortic Aneurysms

Purpose: To report our initial experience with endovascular grafting to treat ruptured abdominal aortic aneurysms (AAAs). Methods: Three consecutive patients with severe comorbid illnesses and symptoms of aneurysm rupture and hemodynamic instability were treated with aortomonoiliac grafts. The Z-stent—based devices were implanted with the assistance of an occlusion balloon placed in the distal descending thoracic aorta. Results: All patients survived the procedure with successfully excluded AAAs. Two patients had relatively short hospital stays (4 and 14 days), while the third required prolonged treatment for pre-existing conditions. All patients required blood transfusions; 2 developed significant coagulopathies. Definitive management was delayed significantly by imaging protocols and graft construction. Conclusions: Endovascular repair of ruptured aortic aneurysms is feasible. Proximal aortic control is readily attainable with the use of an aortic occlusion balloon placed through the left axillary artery. The absence of a laparotomy, extensive retroperitoneal dissection, and aortic cross-clamping likely contributes to patient survival; however, the delay in operative therapy to obtain adequate imaging and construct an endograft could be a hindrance to the ultimate success of this approach. The concepts of alternative aortic imaging techniques and endograft design, construction, and storage must be addressed.

Vascular disease in the antiphospholipid syndrome: A comparison with the patient population with atherosclerosis

The antiphospholipid syndrome was diagnosed in 19 of 1078 patients treated between 1987 and 1991. All patients with antiphospholipid syndrome had either anticardiolipin antibody (16/19) or lupus anticoagulant (10/19); three patients had thrombocytopenia, eight patients had a prolonged partial thromboplastin time, and 10 patients had an elevated erythrocyte sedimentation rate. The most common site of involvement was the cerebral circulation (nine patients), manifested by transient ischemic attacks or stroke. Eight patients had upper extremity disease, characterized by symptoms of Raynauds phenomenon, with angiographic lesions involving the brachial, radial, ulnar, and/or digital arteries. Lower extremity disease occurred in seven patients, with clinical presentations similar to those of atherosclerosis and varying angiographic patterns. In comparison with the population having atherosclerosis, patients with arterial manifestations of antiphospholipid syndrome were more likely to be women (13 of 19 versus 411 of 1078, p less than 0.02), were significantly younger (46.2 years versus 63.6 years, p less than 0.0001), did not smoke (1 of 19 patients versus 700 of 1078, p less than 0.0001), had a higher percentage of upper extremity involvement (8 of 18 versus 13 of 1078, p less than 0.0001), and had a higher incidence of early graft failure (9 of 12 grafts versus 13 of 371 grafts, p less than 0.0001). The syndrome is associated with the repetitive failure of vascular reconstructions and occlusion of native vessels. Antiphospholipid syndrome should therefore be suspected in young, female, nonsmokers with vascular disease, especially those with involvement of the upper extremity, cerebrovascular disease with normal findings on extracranial carotid angiography, and premature graft failure.

The impact of race and insurance type on the outcome of endovascular abdominal aortic aneurysm (AAA) repair

BACKGROUND Although mortality and complication rates for abdominal aortic aneurysm (AAA) have declined over the last 20 years, operative complication rates and perioperative mortality are still high, specifically for repair of ruptures. The goal of this study was to determine the influence of insurance type and ethnicity while controlling for the influences of potential confounders on procedure selection and outcome following endovascular AAA repair (EVAR). METHODS Using the Nationwide Inpatient Sample (NIS) database, we identified patients who underwent EVAR repair of ruptured and elective infrarenal AAA, between 1990 and 2003. Insurance type and ethnicity were analyzed against the primary outcome variables of mortality and major complications. The potential confounders of age, gender, operative location, diabetes, and Deyo index of comorbidities, were controlled. RESULTS Bivariate analyses demonstrated significant differences between insurance types and ethnicity and mortality and complications. Patients who were self pay had adverse outcomes in comparison to Private insurance. Whites encountered less perioperative mortality and postoperative complications than Blacks and Hispanics. CONCLUSIONS After controlling for previously identified associative factors for AAA outcome, ethnicity and insurance type does influence EVAR surgical outcome. Subsequent studies that break down emergent repair vs elective surgery and that longitudinally stratify delay in surgery, or time to admission may be useful.

Mechanical versus Chemical Thrombolysis: An In Vitro Differentiation of Thrombolytic Mechanisms

PURPOSE To assess differing mechanisms of thrombolysis determining time to reperfusion, completeness of thrombus dissolution, and embolic potential. MATERIALS AND METHODS An in vitro perfusion model designed to mimic arterial flow conditions was created. Bifurcated limbs allowed continuous flow through one channel and the placement of radiolabeled (iodine-125) thrombus housed in a 5-cm segment of polytetrafluoroethylene graft in the other. The three experimental groups consisted of a standard continuous urokinase infusion, a pulsed pressurized injection of saline, and a similar injection with urokinase. A continuous infusion of 5% dextrose served as a control group. Time to reflow (as assessed with ultrasonic flow monitoring), completeness of thrombus dissolution (I-125 liberated into solution), and the number and size of embolic particles produced (detected by a series of graduated filter sizes) were analyzed. RESULTS Time to reflow was significantly faster for both groups when pressurized injections were used (P < .001). There was no reflow in the control arm at 90 minutes. Completeness of thrombus dissolution was higher when a continuous infusion of urokinase was used in comparison to either of the power injection groups or the control (P < .05). The amount of embolic debris produced was significantly lower with a continuous infusion of urokinase compared with either of the power lysis groups (P < .05), but significantly greater than the control arm (P < .001). The size of the embolic particles in the power pulsed lysis groups was significantly decreased by the addition of urokinase (P < .05). CONCLUSIONS Reflow is more rapidly established by the use of mechanical means. However, a less complete dissolution of thrombus in conjunction with a greater amount of embolic debris is achieved with this approach. The size of the embolic particles produced is reduced by the addition of a thrombolytic agent.

Regional versus general anesthesia for carotid endarterectomy: The American College of Surgeons National Surgical Quality Improvement Program perspective

BACKGROUND The ideal anesthetic technique for carotid endarterectomy remains a matter of debate. This study used the American College of Surgeons National Surgical Quality Improvement Program to evaluate the influence of anesthesia modality on outcomes after carotid endarterectomy. METHODS Postoperative outcomes were compared for American College of Surgeons National Surgical Quality Improvement Program patients undergoing carotid endarterectomy between 2005 and 2009 with either general or regional anesthesia. A separate analysis was performed on a subset of patients matched on propensity for undergoing carotid endarterectomy with regional anesthesia. RESULTS For the entire sample of 24,716 National Surgical Quality Improvement Program patients undergoing carotid endarterectomy and the propensity-matched cohort of 8,050 patients, there was no difference in the 30-day postoperative composite stroke/myocardial infarction/death rate based on anesthetic type. Within the matched cohort, the rate of other complications did not differ (2.8% regional vs. 3.6% general anesthesia; P = .07), but patients receiving regional anesthesia had shorter operative (99 ± 36 minutes vs 119 ± 53 minutes; P < .0001) and anesthesia times (52 ± 29 minutes vs. 64 ± 37 minutes; P < .0001) and were more likely to be discharged the next day (77.0% vs 64.4%; P < .0001). CONCLUSION Anesthesia technique does not impact patient outcomes after carotid endarterectomy, but may influence overall cost of care.

Femoral-infrapopliteal bypass with prosthetic grafts

BACKGROUND Patients who require prosthetic infrapopliteal of the lower extremity have historically had dismal long-term results. This study examined the outcome of patients undergoing femoral-distal arterial bypass with expanded polytetrafluoroethylene (ePTFE) grafts. METHODS Femoral to infrapopliteal artery bypasses with ePTFE performed between 1990 and 1997 were reviewed. Graft patency, limb salvage, and survival rates were calculated by actuarial analysis. Different anastomotic adjuncts (direct end-to-side anastomosis, vein patch anastomosis, and arteriovenous fistula [AVF] anastomosis) were compared with the log-rank test. RESULTS Seventy-four femoral-infrapopliteal bypasses with ePTFE were performed in 67 patients for limb salvage. At 24 months the primary patency, assisted primary patency, and secondary patency rates were 40% +/- 10% (SEMAI), 48% +/- 11%, and 52% +/- 11%, respectively. Limb salvage was successful in 62 % +/- 10% of the bypasses at 24 months. Forty-six percent of the bypasses were performed with an AVF; 35% were performed with direct end-to-side anastomosis, and 19% were performed with a vein patch anastomosis. Apparent trends in favor of the AVF group did not attain statistical significance with 24-month patency rates of 65% +/- 19%, 44% +/- 16%, and 35% +/- 20%, respectively, in the 3 subgroups. Limb salvage rates were similar (64% +/- 17%, 56% +/- 15%, and 76% +/- 22%, respectively) at 24 months. CONCLUSIONS Patency and limb salvage rates are sufficient to justify the use of ePTFE grafts in infrapopliteal bypass when adequate autogenous material is unavailable.