Dean J. Arnaoutakis

Impact of body mass index and gender on wound complications after lower extremity arterial surgery

Objective: Wound complications (WCs) after lower extremity arterial surgery (LEAS) are common, resulting in readmissions and reinterventions. Whereas diabetes and obesity are known risk factors for WCs, gender‐specific variability in body fat distribution (android vs gynoid) may drive differential risks of WCs after LEAS. We analyzed the independent and synergistic effects of gender and body mass index (BMI) on WCs. Methods: We performed a retrospective review of prospectively collected data from a published, randomized, multicenter trial assessing the incidence of WCs (dehiscence, surgical site infections, seroma, and hematoma) after LEAS. Postoperative outcomes were compared between genders. A multivariable regression model assessed the impact of gender and BMI on WCs. Subanalysis focused on the synergy of gender and body habitus, groin‐only incisions, and clinical outcomes. Results: There were 502 patients who underwent LEAS between October 2010 and September 2013. The cohort was elderly (67.6 ± 10.5 years), mostly male (72%), and overweight (BMI, 27.6 ± 5.7); 225 (45%) patients had a groin‐only incision. In 171 patients (37.9%), a WC developed within 30 days, 85% of which were infectious in etiology. On multivariable regression, obesity (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.17‐3.77), morbid obesity (OR, 2.87; 95% CI, 1.32‐6.23), and female gender (OR, 1.17; 95% CI, 1.06‐2.75) were independent predictors of infectious WCs at 30 days. When stratified by groin‐only incision, BMI was no longer significant, but female gender (OR, 2.70; 95% CI, 1.24‐5.87) was predictive of infectious WCs at 30 days. There was no synergistic effect of BMI and gender on WCs. Conclusions: WCs are common after LEAS. BMI is an independent risk factor for the development of any WC. Female gender, a potential surrogate for high hip to waist ratio body habitus, is also an independent predictor of groin WCs, suggesting the clinical importance of gynoid vs android fat distribution.

Improved outcomes with proximal radial-cephalic arteriovenous fistulas compared with brachial-cephalic arteriovenous fistulas

Background Brachial‐cephalic arteriovenous fistulas (BCFs) are associated with high‐flow volumes, leading to potential risks such as arm swelling, steal syndrome, pseudoaneurysm (due to a pressurized access), and cephalic arch stenosis. We hypothesized that a proximal radial‐cephalic fistula (prRCF) configuration mitigates these risks because a lower flow state is created. Furthermore, we also hypothesized that despite these lower flows, patencies (primary, primary assisted, secondary) are sustained. Methods Leveraging a prospectively collected database supplemented with detailed medical record data, analyses of patients undergoing BCF and prRCF were completed (November 2008 through March 2016). Preoperative clinical and imaging characteristics, operative variables, and postoperative complications were reviewed. The primary end point was a composite of arm swelling, steal, and pseudoaneurysm at 2 years. Fistulograms and interventions (surgical revision, thrombectomy, endovascular treatment of cephalic arch stenosis) censored at 2 years were compared between configurations. Patencies were plotted using Kaplan‐Meier techniques and compared using Cox proportional hazards. Results During the study period, 345 arteriovenous fistulas and 72 prosthetic grafts were primarily placed; 56 patients underwent BCF and 50 patients underwent prRCF with a mean follow‐up of 1.8 ± 1.7 (standard deviation) years. Except for prRCF patients being older, there was no difference between the groups with regard to preoperative characteristics. The artery diameter used for anastomosis was significantly larger in the BCF group (4.0 ± 1.1 mm vs 2.6 ± 0.8 mm; P < .001), with higher flow volumes at 6‐week ultrasound examination (1060 ± 587 mL/min vs 735 ± 344 mL/min; P < .001). Complications (arm swelling, steal, pseudoaneurysm) were significantly more common in the BCF group (P = .02). There was a trend, albeit statistically insignificant, for the BCF group to require more cephalic arch stenosis interventions. Of those patients needing dialysis within 1 year, both BCF and prRCF were successfully used in the majority of patients (n = 27 [66%] vs n = 25 [63%]; P = 1.0). Unadjusted and adjusted primary, primary assisted, and secondary patency rates were similar between the groups. Conclusions prRCFs have fewer complications yet similar midterm durability compared with BCFs. When it is anatomically feasible, prRCFs should be constructed over BCFs because of their superior physiology and clinical outcomes.

Systematic identification and management of barriers to vascular surgery patient discharge time of day

Objective: Length of stay fails to completely capture the clinical and economic effects of patient progression through the phases of inpatient care, such as admission, room placement, procedures, and discharge. Delayed hospital throughput has been linked to increased time spent in the emergency department and postanesthesia care unit, delayed time to treatment, increased in‐hospital mortality, decreased patient satisfaction, and lost hospital revenue. We identified barriers to vascular surgery inpatient care progression and instituted defined measures to positively impact standardized metrics. Methods: The study was divided into three periods: preintervention, “wash‐in,” and postintervention. During the preintervention phase, barriers to patient flow were quantified by an interdisciplinary team. Suboptimal provider communication emerged as the key barrier. An enhanced communication intervention consisting of face‐to‐face and mobile application‐based education on key patient flow metrics, explicit discussion of individual patient barriers to progression at rounds and interdisciplinary huddles, and communication of projected discharge and potential barriers via e‐mail was developed with input from all stakeholders. Following a 4‐week wash‐in implementation phase, data collection was repeated. Results: The pre‐ and postintervention patient cohorts accounted for 244.3 and 238.1 inpatient days, respectively. Both groups had similar baseline demographic, clinical characteristics, and procedures performed during hospitalization. The postintervention group was discharged 78 minutes earlier (14:00:32 vs 15:18:37; P = .03) with a trend toward increased discharge by noon (94% vs 88%; P = .09). Readmission rates did not differ (P = .44). Conclusions: Implementation of a focused, interdisciplinary, frontline provider‐driven, enhanced communication program can be feasibly incorporated into existing specialty surgical workflow. The program resulted in improved timeliness of discharge and projected cost savings, without increasing readmission rates.

Endovascular repair of abdominal aortic aneurysms

Endovascular repair of abdominal aortic aneurysms is an important technique in the vascular surgeons armamentarium, which has created a seismic shift in the management of aortic pathology over the past two decades. In comparison to traditional open repair, the endovascular approach is associated with significantly improved perioperative morbidity and mortality. The early survival benefit of endovascular abdominal aortic aneurysm repair is sustained up to 3 years postoperatively, but longer-term life expectancy remains poor regardless of operative modality. Nonetheless, most abdominal aortic aneurysms are now repaired using endovascular stent grafts. The technology is not perfect as several postoperative complications, namely endoleak, stent-graft migration, and graft limb thrombosis, can develop and therefore lifelong imaging surveillance is required. In addition, a postoperative inflammatory response has been documented after endovascular repair of aortic aneurysms; the clinical significance of this finding has yet to be determined. Subsequently, the safety and applicability of endovascular stent grafts are likely to improve and expand with the introduction of newer-generation devices and with the simplification of fenestrated systems.

Minimally Invasive Arterial Interventions for Wounds

Critical limb ischemia (CLI) refers to rest pain or ulceration/gangrene that develops in the extremities from extensive peripheral atherosclerosis. Open bypass surgery has long been the gold standard technique to offer revascularization and limb salvage to these often ill and complex patients. However, over the last several decades, a minimally invasive technique based on the intra-arterial use of wires and catheters has been developed which has revolutionized the way CLI is treated. Currently, numerous endoluminal treatment strategies exist, including balloon angioplasty, stenting, and atherectomy, which can generate reasonable limb salvage rates. More research is necessary, however, to identify which device is optimal with regard to durability and costs as well as which patients should undergo endovascular surgery as opposed to a bypass.

Implications of Secondary Aortic Intervention After Thoracic Endovascular Aortic Repair for Acute and Chronic Type B Dissection

interval, 1.8-17.8; P 1⁄4 .002) were independent predictors for the development of neurologic impairment. An interaction term between cLEIT and CIA lumen of 8 mm or less was significant statistically (P 1⁄4 .042), indicating that the presence of small CIA lumen modifies the effect of cLEIT. As shown in the Fig, in patients with CIA lumen of 8 mm or less, the risk of neurologic impairment increases rapidly after 2.5 hours of LE ischemia and becomes nearly certain after 4 hours of ischemia time. In contrast, patients with a larger CIA can tolerate a longer duration of ischemia and demonstrate a less steep rise in the risk for LE neurologic impairment. Conclusions: LE neurologic impairment after FEVAR is strongly associated with cLEIT and patent CIA lumen of 8 mm or less. Our data indicate that when cLEIT is expected to exceed 2.5 hours (in patients with small CIA) or 3 hours (in patients with CIA lumen >8 mm), measures to ensure perfusion of LEs should be undertaken.

Thirty-year trends in aortofemoral bypass for aortoiliac occlusive disease

Objective: Endovascular intervention has supplanted open bypass as the most frequently used approach in patients with aortoiliac segment atherosclerosis. We sought to determine whether this trend together with changing demographic and clinical characteristics of patients undergoing aortobifemoral bypass (ABFB) for aortoiliac occlusive disease (AOD) have an association with postoperative outcomes. Methods: Using a prospectively maintained institutional database, we identified patients who underwent ABFB for AOD from 1985 to 2015. Patients were divided into two cohorts: the historical cohort (HC) included patients who underwent ABFB for AOD from 1985 to 1999 and the contemporary cohort (CC) who underwent ABFB for AOD from 2000 to 2015. Medical and demographic data, procedural information, postoperative complications, and follow‐up data were extracted. Cox proportional hazards regression was used to evaluate associations with the end point of primary patency. A similar analysis was performed for major adverse limb events (MALEs; the composite of above‐ankle amputation, major reintervention, graft revision, or new bypass graft of the index limb) in the subset of patients with critical limb ischemia. Results: There were a total of 359 cases: 226 in the HC and 133 in the CC. The CC had more women (56.4% vs 43.8%; P = .02), smokers (87.2% vs 67.7%; P = .001), and patients who failed prior aortoiliac endovascular intervention (17.3% vs 4.8%; P = .0001), but fewer patients with coronary artery disease (32.3% vs 47.3%; P = .005). Thirty‐day mortality was less than 1% in both cohorts, but 10‐year survival was higher in the CC (67.7% vs 52.6%; P = .02). Five‐year primary, primary‐assisted, and secondary patency were higher in the HC (93.3% vs 82.2%; P = .005; 93.8% vs 85.7%; P = .02; 97.5% vs 90.4%; P = .02, respectively). CC membership, decreasing age, prior aortic surgery, and decreasing graft diameter were significant independent predictors of loss of primary patency after adjustment (hazard ratio [HR], 7.03; 95% confidence interval [CI], 2.80‐17.63; P < .0001; HR, 0.93; 95% CI, 0.90‐0.96; P < .0001; HR, 18.80; 95% CI, 5.94‐59.58; P < .0001; and HR, 0.73; 95% CI, 0.55‐0.95; P = .02, respectively). Similarly, CC membership, prior aortic surgery, and decreasing graft diameter were significant independent predictors of MALE in the critical limb ischemia cohort after adjustment (HR, 21.13; 95% CI, 4.20‐106.40; P = .0002; HR, 40.40; 95% CI, 3.23‐505.61; P = .004; and HR, 0.51; 95% CI, 0.30‐0.86; P = .01, respectively). Conclusions: Compared with the pre‐endovascular era, demographic and clinical characteristics of patients undergoing ABFB for AOD in the CC have changed. Although long‐term patency is slightly lower among patients in the CC during which a substantial subset of AOD patients are being treated primarily via the endovascular approach, durability remains excellent and limb salvage unchanged. After adjustment, the time period of index ABFB independently predicted primary patency and MALE, as did graft diameter and prior aortic surgery. These changing characteristics should be considered when counseling patients and benchmarking for reintervention rates and other outcomes.

Outcomes of antegrade and retrograde open mesenteric bypass for acute mesenteric ischemia

Background: Acute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Few contemporary reports focus specifically on patients undergoing open mesenteric bypass (OMB) or delineate outcome differences based on bypass configuration. This is notable, because there is a subset of patients who are poor candidates for endovascular intervention including those with flush mesenteric vessel occlusion, long segment occlusive disease, and a thrombosed mesenteric stent and/or bypass. This analysis reviewed our experience with OMB in the treatment of AMI and compared outcomes between patients undergoing either antegrade or retrograde bypass. Methods: A single‐center, retrospective review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. A preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in‐hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan‐Meier estimation and Cox proportional hazards regression were used to analyze all end points. Results: Eighty‐two patients (female 54%; age 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. A history of prior stent/bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass and the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were more likely to be male (53% vs 25%; P = .02), have coronary artery disease (48% vs 25%; P = .06), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Concurrent bowel resection was evenly distributed (antegrade, 45%; retrograde, 45%; P = .9) and 37% (n = 30) underwent subsequent resection during second look operations. The median duration of stay was 16 days (interquartile range, 9‐35 days) and 78% (n = 64) experienced at least one major complication with no difference in rates between antegrade/retrograde configurations. In‐hospital mortality was 37% (n = 30; multiple organ dysfunction, 22; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia, 1; stroke, 1; 30‐day mortality, 26%). The median follow‐up was 8 months (interquartile range, 1‐26 months). The 1‐ and 3‐year primary patency rates were both 82% ± 6% (95% confidence interval, 71%‐95%), with 10 patients requiring reintervention. Estimated survival at 1 and 5 years was 57% ± 6% and 50% ± 6%, respectively. Bypass configuration was not associated with complication rates (P > .10), in‐hospital mortality (log‐rank, P = .3), or overall survival (log‐rank, P = .9). However, a higher risk of reintervention was observed in patients undergoing retrograde bypass (hazard ratio, 3.0; 95% confidence interval, 0.9‐11.0; P = .08). Conclusions: OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with comparable outcomes as retrograde OMB. The bypass configuration choice should be predicated on patient presentation, anatomy, physiology, and surgeon preference; however, an antegrade configuration may provide a lower risk of reintervention.

VESS12. Trends in Aortofemoral Bypass for Aortoiliac Occlusive Disease: A Thirty-Year Experience

Objectives: In 2009, the Society for Vascular Surgery (SVS) developed objective performance goals (OPGs) to define the therapeutic benchmarks for catheter-based revascularization in critical limb ischemia (CLI) based upon outcomes from randomized trials of lower extremity bypass (SVS OPG cohort). Current real-world performance relative to these benchmarks remains unknown. The objective of this study was to determine whether lower extremity bypass (LEB) and infrainguinal endovascular intervention (IEI) performed for CLI in a contemporary national cohort met OPG safety benchmarks. Methods: SVS OPG criteria were applied to 11,043 revascularizations for CLI performed from 2011 to 2015 in the National Surgical Quality Improvement Project (NSQIP) vascular-targeted modules. Primary 30-day safety OPGs, including major adverse cardiac events (MACE), major adverse limb events (MALE), and amputation, were calculated for all OPG-eligible NSQIP LEB (bypass with single-segment saphenous vein, n 1⁄4 3,835; Table I) and IEI (defined as angioplasty, stenting, and/or atherectomy, n 1⁄4 3,526; Table I) cohorts and within anatomic high-risk (infrapopliteal disease) and clinical high-risk (age >80 and tissue loss) cohorts defined by SVS OPG criteria. These were compared with SVS OPGs using c comparisons. Results: Compared with the SVS OPG cohort, the NSQIP LEB and IEI cohorts had fewer anatomic high-risk patients (LEB: 51% vs SVS OPG 60%; P < .0001; IEI: 17% vs SVS OPG: 60%; P < .0001), and the LEB cohort had fewer clinical high-risk patients (LEB: 11% vs SVS OPG: 16%; P < .0001). In the OPG-eligible NSQIP cohorts, LEB and IEI were associated with lower 30-day MACE but higher 30-day MALE and amputation compared