Jeffrey A. Kalish

Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: A review of the National Trauma Data Bank

INTRODUCTION AND OBJECTIVES Lower extremity (LE) arterial trauma and its treatment may lead to extremity compartment syndrome (ECS). In that setting, the decision to perform fasciotomies is multifactoral and is not well delineated. We evaluated the outcomes of patients with surgically treated LE arterial injury who underwent early or delayed fasciotomies. METHODS The National Trauma Data Bank (NTDB) was retrospectively reviewed for patients who had LE arterial trauma and underwent both open vascular repair and fasciotomies. Exclusion criteria were additional non-LE vascular trauma, head or spinal cord injuries, crush injuries, burn injuries, and declaration of death on arrival. Patients were divided into those who had fasciotomies performed within 8h (early group) or >8h after open vascular repair (late group). Comparative analyses of demographics, injury characteristics, complications, and outcomes were performed. RESULTS Of the 1469 patient admissions with lower extremity arterial trauma that met inclusion criteria there were 612 patients (41.7%) who underwent fasciotomies. There were 543 and 69 patients in the early and late fasciotomy groups, respectively. There was no significant difference in age, injury severity, mechanism of injury, associated injuries, and type of vascular repair between the groups. A higher rate of iliac artery injury was observed in the late fasciotomy group (23.2% vs. 5.9%, P<.001). Patients in the early fasciotomy group had lower amputation rate (8.5% vs. 24.6%, P<.001), lower infection rate (6.6% vs. 14.5%, P = .028) and shorter total hospital stay (18.5 ± 20.7 days vs. 24.2 ± 14.7 days, P = .007) than those in the late fasciotomy group. On multivariable analysis, early fasciotomy was associated with a 4-fold lower risk of amputation (Odds Ratio 0.26, 95% CI 0.14-0.50, P<.0001) and 23% shorter hospital LOS (Means Ratio 0.77, 95% CI 0.64-0.94, P = .01). CONCLUSION Early fasciotomy is associated with improved outcomes in patients with lower extremity vascular trauma treated with surgical intervention. Our findings suggest that appropriate implementation of early fasciotomy may reduce amputation rates in extremity arterial injury.

Outcomes and practice patterns in patients undergoing lower extremity bypass

BACKGROUND The appropriate application of endovascular intervention vs bypass for both critical limb ischemia (CLI) and intermittent claudication (IC) remains controversial, and outcomes from large, contemporary series are critical to help inform treatment decisions. Therefore, we sought to define the early and 1-year outcomes of lower extremity bypass (LEB) in a large, multicenter regional cohort, and analyze trends in the use of LEB with or without prior endovascular interventions. METHODS The Vascular Study Group of New England database was used to identify all infrainguinal LEB procedures performed between 2003 and 2009. The primary study endpoint was 1-year amputation-free survival (AFS). Secondary endpoints included in-hospital mortality and morbidity, including major adverse cardiac events. Trend analyses were conducted to identify annual trends in the proportion of LEBs performed for an indication of IC, in-hospital outcomes, including mortality and morbidity, and 1-year outcomes, including AFS. Analyses were performed on the entire cohort and then stratified by indication. RESULTS Between 2003 and 2009, 2907 patients were identified who underwent LEBs (72% for CLI; 28% for IC). The proportion that underwent LEB for IC increased significantly over the study period (from 19% to 31%; P < .0001). There was a significant increase over time in the proportion of LEBs performed after a previous endovascular intervention among both CLIs (from 11% to 24%; P < .0001) and ICs (from 13% to 23%; P = .02). Neither in-hospital mortality nor cardiac event rates changed significantly among either group. There was no significant change in 1-year AFS in patients with IC (97% in 2003 and 98% in 2008; P for trend .63) or in patients with CLI (73% in 2003 and 81% in 2008; P = .10). CONCLUSIONS Over the last 7 years, significant changes in patient selection for LEBs have occurred in New England. The proportion of LEBs performed for ICs as opposed to CLIs has increased. Patients are much more likely to have undergone prior endovascular interventions before undergoing a bypass. In-hospital and 1-year outcomes after LEB for both IC and CLI have remained excellent with no significant changes in AFS.

Statin therapy after infrainguinal bypass surgery for critical limb ischemia is associated with improved 5-year survival

OBJECTIVE Although statin therapy has been linked to fewer short-term complications after infrainguinal bypass, its effect on long-term survival remains unclear. We therefore examined associations between statin use and long-term mortality, graft occlusion, and amputation after infrainguinal bypass. METHODS We used the Vascular Study Group of New England registry to study 2067 patients (71% male; mean age, 67 ± 11 years; 67% with critical limb ischemia [CLI]) who underwent infrainguinal bypass from 2003 to 2011. Of these, 1537 (74%) were on statins perioperatively and at 1-year follow-up, and 530 received no statin. We examined crude, adjusted, and propensity-matched rates of 5-year surviva1, 1-year amputation, graft occlusion, and perioperative myocardial infarction. RESULTS Patients taking statins at the time of surgery and at the 1-year follow-up were more likely to have coronary disease (38% vs 22%; P < .001), diabetes (51% vs 36%; P < .001), hypertension (89% vs 77%; P < .001), and prior revascularization procedures (50% vs 38%; P < .001). Despite higher comorbidity burdens, long-term survival was better for patients taking statins in crude (risk ratio [RR], 0.7; P < .001), adjusted (hazard ratio, 0.7; P = .001), and propensity-matched analyses (hazard ratio, 0.7; P = .03). In subgroup analysis, a survival advantage was evident in patients on statins with CLI (5-year survival rate, 63% vs 54%; log-rank, P = .01) but not claudication (5-year survival rate, 84% vs 80%; log-rank, P = .59). Statin therapy was not associated with 1-year rates of major amputation (12% vs 11%; P = .84) or graft occlusion (20% vs 18%; P = .58) in CLI patients. Perioperative myocardial infarction occurred more frequently in patients on a statin in crude analysis (RR, 2.2; P = .01) but not in the matched cohort (RR, 1.9; P = .17). CONCLUSIONS Statin therapy is associated with a 5-year survival benefit after infrainguinal bypass in patients with CLI. However, 1-year limb-related outcomes were not influenced by statin use in our large observational cohort of patients undergoing revascularization in New England.

Blood Transfusion for Lower Extremity Bypass Is Associated with Increased Wound Infection and Graft Thrombosis

BACKGROUND Packed RBC transfusion has been postulated to increase morbidity and mortality after cardiac/general surgical operations, but its effects after lower extremity bypass (LEB) have not been studied extensively. STUDY DESIGN Using the Vascular Study Group of New Englands database (2003-2010), we examined 1,880 consecutive infrainguinal LEB performed for critical limb ischemia. Perioperative transfusion was categorized as 0 U, 1 to 2 U, and ≥3 U. Cohort frequency group matching was used to compare groups of patients receiving 1 to 2 U and 0 U with patients receiving ≥3 U using age, coronary artery disease, diabetes, urgency, and indication of revascularization. Primary end points were perioperative mortality, wound infection, and loss of primary graft patency at discharge, as well as 1-year mortality and loss of primary graft patency. RESULTS In the study cohort, 1,532 LEBs (81.5%) received 0 U, 248 LEBs (13.2%) received 1 to 2 U, and 100 LEBs (5.3%) received ≥3 U transfusion. In the study cohort and group frequency matched cohort, transfusion was associated with significantly higher perioperative wound infection (0 U:4.8% vs 1 to 2 U: 6.5% vs ≥3 U: 14.0%; p = 0.0004) and graft thrombosis at discharge (4.5% vs 7.7% vs 15.3%; p < 0.0001). At 1 year, there were no differences in infection or graft patency. In multivariate analysis, transfusion was independently associated with increased perioperative wound infection in the study cohort and group frequency matched cohort (1 to 2 U vs 0 U: adjusted odds ratio [OR] = 1.4; 95% CI, 0.8-2.5; p = 0.263; ≥3 U vs 0 U: OR = 3.5; 95% CI, 1.8-6.7; p = 0.0002; overall p = 0.002) and increased graft thrombosis at discharge (1 to 2 U vs 0 U: OR = 2.1; 95% CI, 1.2-3.6; p = 0.01; ≥3 U vs 0 U: OR = 4.8; 95% CI, 2.5-9.2; p < 0.0001, overall p < 0.0001). CONCLUSIONS Perioperative transfusion in patients undergoing LEB is associated with increased perioperative wound infection and graft thrombosis. From this observational study, it appears transfusion does not have major consequences during mid-term follow-up, but the presumed benefits of blood replacement should be weighed carefully because of the increased risk of perioperative complications with transfusion.

Routine use of ultrasound guidance in femoral arterial access for peripheral vascular intervention decreases groin hematoma rates

BACKGROUND Use of fluoroscopy and bone landmarks to guide percutaneous common femoral artery (CFA) access has decreased access site complications compared with palpation alone. However, only limited case series have examined the benefits of ultrasound to guide CFA access during peripheral vascular intervention (PVI). We evaluated the effect of routine vs selective use of ultrasound guidance (UG) on groin hematoma rates after PVI. METHODS The Vascular Study Group of New England database (2010-2014) was queried to identify the complication of postprocedural groin hematoma after 7359 PVIs performed through CFA access. Hematoma (including pseudoaneurysms) was defined as minor (requiring compression or observation), moderate (requiring transfusion or thrombin injection), and major (requiring operation). Both procedure-level and interventionalist-level analyses were performed. Multivariable Poisson regression models were used to compare hematoma rates of interventionalists based on routine (≥80% of PVIs) and selective (<80%) utilization of UG in the adjusted overall sample and in multiple subgroups. RESULTS The overall postprocedural groin hematoma rate after PVI was 4.5%, and the rate of combined moderate and major hematoma was 0.8%. Among 114 interventionalists with ≥10 PVI procedures, routine and selective UG was used by 31 (27%) and 83 (73%) interventionalists, respectively. Routine UG was protective against hematoma (rate ratio [RR], 0.62; 95% confidence interval [CI], 0.46-0.84; P < .01). Subgroup analysis revealed that routine UG was also protective against hematoma under the following circumstances: age >80 years (RR, 0.47; 95% CI, 0.27-0.85; P = .01), body mass index ≥30 (RR, 0.51; 95% CI, 0.29-0.90; P = .02), and sheath size >6F (RR, 0.43; 95% CI, 0.23-0.79; P < .01). CONCLUSIONS Routine UG may potentially protect against the complication of hematoma for both modifiable and nonmodifiable patient and procedural characteristics. Encouraging routine UG is a feasible quality improvement opportunity to decrease patient morbidity after PVI.

The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality

OBJECTIVE The objective of this study was to evaluate the outcomes of patients after carotid endarterectomy (CEA) who developed postoperative hypertension or hypotension requiring the administration of intravenous vasoactive medication (IVMED). METHODS We examined consecutive, primary elective CEA performed by 128 surgeons within the Vascular Study Group of New England (VSGNE) database (2003-2010) and compared outcomes of patients who required postoperative IVMED to treat hyper- or hypotension with those who did not. Outcomes included perioperative death, stroke, myocardial infarction (MI), congestive heart failure (CHF), hospital length of stay, and 1-year stroke or death. Propensity score matching was performed to facilitate risk-adjusted comparisons. Multivariable regression models were used to compare the association between IVMED and outcomes in unmatched and matched samples. Factors associated with use of IVMED in postoperative hypertension and hypotension were evaluated, and predictive performance of multivariable models was examined using receiver operating characteristic (ROC) curves. RESULTS Of 7677 elective CEAs identified, 23% received IVMED for treatment of either postoperative hypertension (11%) or hypotension (12%). Preoperative neurological symptomatic status (20%) was similar across cohorts. In the crude sample, the use of IVMED to treat postoperative hypertension was associated with increased 30-day mortality (0.7% vs 0.1%; P < .001), stroke (1.9% vs 1%; P = .018), MI (2.4% vs 0.5%; P < .001), and CHF (1.9% vs 0.5%; P < .001). The use of IVMED to treat postoperative hypotension was also associated with increased perioperative mortality (0.8% vs 0.1%; P < .001), stroke (3.2% vs 1.0%; P < .001), MI (2.7% vs 0.5%; P < .001), and CHF (1.7% vs 0.5%; P < .001), as well as 1-year death (5.1% vs 2.9%; P < .001) or stroke (4.2% vs 2.1%; P < .001). Hospital length of stay was significantly longer among patients who needed IVMED for postoperative hypertension (2.8 ± 4.7 days vs 1.7 ± 5.5 days; P < .001) and hypotension (2.8 ± 5.9 days vs 1.7 ± 5.5 days; P < .001). In multivariable analysis, IVMED for postoperative hypertension was associated with increased MI, stroke, or death (odds ratio, 2.6; 95% confidence interval [CI], 1.6-4.1; P < .001). Similarly, IVMED for postoperative hypotension was associated with increased MI, stroke, or death (odds ratio, 3.2; 95% CI, 2.1-5.0; P < .001), as well as increased 1-year stroke or death (hazard ratio, 1.6; 95% CI, 1.2-2.2; P = .003). Smoking, coronary artery disease, and clopidogrel (ROC, 0.59) were associated with postoperative hypertension requiring IVMED, whereas conventional endarterectomy and general anesthesia were associated with postoperative hypotension requiring IVMED (ROC, 0.58). The unitization of IVMED varied between 11% and 38% across VSGNE, and center effect did not affect outcomes. CONCLUSIONS Postoperative hypertension requiring IVMED after CEA is associated with increased perioperative mortality, stroke, and cardiac complications, whereas significant postoperative hypotension is associated with increased perioperative mortality, cardiac, or stroke complications, as well as increased 1-year death or stroke following CEA. The utilization of IVMED varied across centers and, as such, further investigation into this practice needs to occur in order to improve outcomes of these at-risk patients.

The effect of trainee involvement on perioperative outcomes of abdominal aortic aneurysm repair

OBJECTIVE Although the effect of trainee involvement has been evaluated across different specialties, their effects on perioperative outcomes after abdominal aortic aneurysm (AAA) repair have not been examined. Our goal was to examine the association between resident and fellow intraoperative participation with perioperative outcomes of endovascular AAA repair (EVAR), open infrarenal AAA repair (OIAR), and open juxtarenal AAA repair (OJAR). METHODS The American College of Surgeons National Surgical Quality Improvement Program data set (2005-2012) was queried to identify all patients who underwent EVAR, OIAR, or OJAR. Multivariate analysis was performed to assess the association of trainee involvement with perioperative morbidity and mortality. RESULTS We identified 16,977 patients: 12,003 with EVAR, 3655 with OIAR, and 1319 with OJAR. Propensity matching and multivariate analyses revealed that there was no significant difference in perioperative death, cardiac arrest/myocardial infarction, pulmonary, renal, venous thromboembolic, or wound complications, or return to the operating room. However, trainee involvement in AAA repair led to a significant increase in operative time for EVAR (163 ± 77 vs 140 ± 67 minutes; P < .001), OIAR (217 ± 91 vs 185 ± 76 minutes; P < .001), and OJAR (267 ± 115 vs 214 ± 106 minutes; P < .001) and an extended length of stay for EVAR (3.1 ± 5.3 vs 2.8 ± 4.5 days; P < .001) and OIAR (10.6 ± 11.8 vs 9.1 ± 8.9 days; P < .001). CONCLUSIONS Trainee participation in aneurysm repair was not associated with major adverse perioperative outcomes. However, it was associated with an increased operative time and length of stay and therefore may lead to increased resource utilization and cost.

Comparison of outcomes after endovascular and open repair of abdominal aortic aneurysms in low-risk patients

In randomized trials endovascular aortic aneurysm repair (EVAR) has been shown to have superior perioperative outcomes compared with open aneurysm repair (OAR). However, outcomes in patients at low risk of complications are unclear and many surgeons still prefer OAR in this cohort. The objective was to analyse perioperative and longer‐term outcomes of OAR and EVAR in this low‐risk group of patients.

Perioperative Outcomes in Patients Requiring Iliac Conduits or Direct Access for Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND Iliac conduit or direct iliac access (ICDA) can be used when anatomy is unfavorable for femoral access during abdominal endovascular aortic aneurysm repair (EVAR). The impact of this approach has not been adequately addressed. The objective of this study was to analyze perioperative outcomes of patients requiring use of ICDAs for EVAR. METHODS Patients undergoing EVAR with and without ICDA were identified in the 2005-2012 National Surgical Quality Improvement Program data sets. Perioperative morbidity and mortality were assessed by crude comparison of matched groups and multivariate analyses. RESULTS Of 15,082 patients undergoing infrarenal EVAR 147 (1%) required ICDA. The ICDA group had a higher proportion of females (25.9% vs. 17.8%, P = 0.017), peripheral vascular disease (12.9% vs. 5.5%, P = 0.001), and patients with a history of dyspnea (31.3% vs. 23.1%, P = 0.024). There was no difference in age (74.5 ± 8.4 conduit vs. 73.5 ± 8.5). On multivariate analysis, the ICDA cohort had a higher rate of mortality (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.4-5.4; P = 0.004) and an increase in other major complications including cardiac arrest and/or myocardial infarction (OR, 2.9; 95% CI, 1.3-6.3; P = 0.007), pulmonary complications (OR, 2.1; 95% CI, 1.2-3.9; P = 0.013), and postoperative length of stay (means ratio, 1.3; 95% CI, 1.1-1.4; P = 0.001). There was a trend toward increased bleeding complications with ICDA. Matched analyses of comorbidities revealed that patients requiring ICDA had higher perioperative mortality (6.8% vs. 2.3%, P = 0.008), cardiac (4.8% vs. 1%, P = 0.004), pulmonary (8.8% vs. 3.4%, P = 0.006), and bleeding complications (10.2% vs. 4.6%, P = 0.016). CONCLUSIONS Our results demonstrate that the use of ICDA during EVAR is associated with increased morbidity and mortality. In situations where anatomy mandates the use of iliac conduits or access for EVAR, surgeons should consider this increased risk. Open repair or the use of lower profile devices, if possible, should be considered as options for these patients.

Selective Use of Endovascular Techniques in the Management of Vascular Trauma

Endovascular techniques have become crucial to the success of many elective and emergent vascular surgical cases. Although diagnostic angiography has always played a central role in the evaluation and management of vascular trauma, interventions such as stent grafting and coil embolization are increasingly being used as treatment modalities. Research exists to support the selective use of endovascular techniques in the management of blunt and penetrating vascular trauma, and specific scenarios and indications will be reviewed here. To ensure the most favorable outcomes, vascular interventionalists must always be aware of the limitations of these techniques as well as the limitations facing them in their hospital practice environments.