Linda M. Harris

Management of early (<30 day) vascular groin infections using vacuum-assisted closure alone without muscle flap coverage in a consecutive patient series

OBJECTIVE Vacuum-assisted closure (VAC) therapy without muscle flap coverage is our primary approach for graft preservation in early, deep groin infections with and without exposed grafts; however, concerns exist regarding its safety. We report our experience in a consecutive series of patients with early groin infections managed without muscle flap closure. METHODS All patients with early (<30 day), deep vascular groin infections without (Szilagyi II) or with (Szilagyi III) exposed vascular graft or suture line between January 2004 and December 2008 were reviewed. Graft preservation followed by local wound care with VAC was attempted in all with intact anastomoses, patent grafts, and absence of systemic sepsis. Szilagyi classification, microorganism cultured, duration of VAC use, time to healing, additional interventions, and follow-up data (limb salvage, survival) were analyzed. RESULTS Twenty-two patients (26 groins, mean age 69.1 +/- 9.5 years [range, 44-86 years]) presented with deep groin infections 16 +/- 5 days (range, 7-28 days) after the index procedure (bypass-polytetrafluoroethylene [n = 11], autologous vein [n = 3], endarterectomy/patch [n = 6], extra-anatomic bypass [n = 5], percutaneous closure device [n = 1]). Grafts were exposed in 12 groins (Szilagyi III, nine with suture lines). VAC was started one to six days (median, three) after operative debridement. All had positive wound cultures and received culture-directed antibiotic therapy for 47 +/- 45 days (range, 14-180 days). Length of stay was significantly more in Szilagyi III, whereas mean VAC use and time-to-healing were similar. Mean follow-up was 33.4 +/- 19.5 months (range, 2-72 months). All wounds healed (mean, 49 +/- 21 days). Two treatment failures occurred in the Szilagyi III group (17%). One patient had bleeding from the anastomotic heel eight days after debridement, had graft removal/in situ replacement and one presented with reinfection on day 117 and had partial graft removal/extra-anatomic bypass. There was no perioperative mortality or limb loss, but six late unrelated mortalities and one amputation at 46 months unrelated to the groin infection. CONCLUSIONS Management of early, deep groin wound infections with debridement, antibiotics, and VAC treatment is safe and enables graft preservation in the majority of patients with minimal morbidity, no perioperative limb loss, or mortality.

Vascular reactivity in patients with peripheral vascular disease

Noninvasive techniques have been used to demonstrate a specific pattern of impaired vasoactive response in the normal brachial artery of patients with clinical atherosclerosis. This is a physiologic reflection of the systemic nature of atherosclerosis and may be useful as a marker for identifying patients with preclinical atherosclerotic disease.

Screening for asymptomatic deep vein thrombosis in surgical intensive care patients

PURPOSE To identify the presence of occult deep vein thrombosis (DVT) in surgical intensive care unit (SICU) patients and to avoid unnecessary screening, we reviewed our experience with routine duplex screening for DVT in SICU patients. METHODS Over a 24-month period, all patients who were admitted to an SICU with an anticipated length of stay greater than 36 hours were studied to determine the prevalence of risk factors for asymptomatic proximal DVT. Risk factors, demographics, and operative data were collected and analyzed with multilinear regression, t tests and chi 2 analysis. RESULTS There was a 7.5% prevalence of major DVT in the 294 patients studied. APACHE II scores (14.5 +/- 6.24 vs 10.3 +/- 3.15; p < 0.0001) and emergent procedures (45.5% vs 23.2%; p > 0.0344) were associated with DVT by multifactorial analysis. Age was significant by univariate analysis. An algorithm based on the presence of any one of the three risk factors identified (APACHE II score 12 or more; emergent procedures; or age 65 or greater) could be used to limit screening by 30% while achieving a 95.5% sensitivity for identification of proximal DVT. CONCLUSION Absence of all three risk factors indicates a very low risk for DVT (1.1%). Screening of SICU patients is indicated because of a high prevalence of asymptomatic disease. Patients who have proximal DVT require active therapy and not prophylaxis. Costs and resources may be contained by using the above risk factors as a filter for duplex screening.

Total percutaneous endovascular repair of abdominal aortic aneurysms using Perclose ProGlide closure devices.

Purpose: To describe a technique for access site closure in percutaneous abdominal aortic aneurysm (AAA) repair using double Perclose ProGlide devices to overcome the problems associated with the bulky delivery system and braided suture of the antecedent (Prostar) device. Technique: After obtaining guidewire access, 2 Perclose ProGlide sutures are deployed at 90° to each other. The appropriate sheaths are placed over the stiff guidewires. After the stent-graft procedure is completed, an assistant holds pressure while the knots are tightened with the stiff guidewire still in the artery. Once the second knot is tightened with the knot pusher and after confirming adequate hemostasis, the wire is removed, pressure is applied, and heparin reversed. This method has been used in 17 consecutive patients (age range 65–85 years) undergoing endovascular AAA repair. One patient needed patch angioplasty and 2 required small incisions for additional suture placements (81% primary success rate for total percutaneous repair, 90% success rate for all sites). Conclusion: We have found the double Perclose ProGlide technique to be easy to use, safe, and feasible for total percutaneous AAA repair. More experience with longer follow-up is needed to assess its potential to replace the Perclose Prostar closure device for total percutaneous AAA repairs.

Long-term limb salvage and survival after endovascular and open revascularization for critical limb ischemia after adoption of endovascular-first approach by vascular surgeons

OBJECTIVE The adoption of endovascular interventions has been reported to lower amputation rates, but patients who undergo endovascular and open revascularization are not directly comparable. We have adopted an endovascular-first approach but individualize the revascularization technique according to patient characteristics. This study compared characteristics of patients who had endovascular and open procedures and assessed the long-term outcomes. METHODS From December 2002 to September 2010, 433 patients underwent infrainguinal revascularization for critical limb ischemia (CLI; Rutherford IV-VI) of 514 limbs (endovascular: 295 patients, 363 limbs; open: 138 patients, 151 limbs). Patency rates, limb salvage (LS), and survival, as also their predictors, were calculated using Kaplan-Meier and multivariate analysis. RESULTS The endovascular group was older, with more diabetes, renal insufficiency, and tissue loss. More reconstructions were multilevel (72% vs 39%; P < .001) and the most distal level of intervention was infrapopliteal in the open group (64% vs 49%; P = .001). The 30-day mortality was 2.8% in the endovascular and 6.0% in the open group (P = .079). Mean follow-up was 28.4 ± 23.1 months (0-100). In the endovascular vs open groups, 7% needed open, and 24% needed inflow/runoff endovascular reinterventions with or without thrombolysis vs 6% and 17%. In the endovascular vs open group, 5-year LS was 78% ± 3% vs 78% ± 4% (P = .992), amputation-free survival was 30% ± 3% vs 39% ± 5% (P = .227), and survival was 36% ± 4% vs 46% ± 5% (P = .146). Five-year primary patency (PP), assisted-primary patency (APP), and secondary patency (SP) rates were 50 ± 5%, 70 ± 5% and 73 ± 6% in endovascular, and 48 ± 6%, 59 ± 6% and 64 ± 6% in the open group, respectively (P = .800 for PP, 0.037 for APP, 0.022 for SP). Multivariate analysis identified poor functional capacity (hazard ratio, 3.5 [95% confidence interval, 1.9-6.5]; P < .001), dialysis dependence (2.2 [1.3-3.8]; P = .003), gangrene (2.2 [1.4-3.4]; P < .001), need for infrapopliteal intervention (2.0 [1.2-3.1]; P = .004), and diabetes (1.8 [1.1-3.1]; P = .031) as predictors of limb loss. Poor functional capacity (3.3 [2.4-4.6]; P < .001), coronary artery disease (1.5 [1.1-2.1]; P = .006), and gangrene (1.4 [1.1-1.9]; P = .007) predicted poorer survival. Statin use predicted improved survival (0.6 [0.5-0.8]; P = .001). Need for infrapopliteal interventions predicted poorer PP (0.6 [0.5-0.9-2.2]; P = .007), whereas use of autologous vein predicted better PP (1.8 [1.1-2.9]; P = .017). CONCLUSIONS Patients who undergo endovascular revascularization for CLI are medically higher-risk patients. Those who have bypass have more complex disease and are more likely to require multilevel reconstruction and infrapopliteal intervention. Individualizing revascularization results in optimization of early and late outcomes with acceptable LS, although survival remains low in those with poor health status.

Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease

OBJECTIVE Hybrid reconstructions have been increasingly used for multilevel revascularization procedures as surgeons have embraced endovascular interventions. The goal of this study is to define the role of simple and complex hybrid techniques in patients who need multilevel revascularization. METHODS All patients undergoing arterial revascularization (endovascular [EV], open, hybrid) between June 2001 and May 2008 were included. Hybrid procedures were stratified as simple (sHYBRID group) when the endovascular-treated segment was TransAtlantic Society Consensus II (TASC) A/B, and complex (cHYBRID group), when TASC C/D. RESULTS Of the 654 patients, 770 limbs (67% critical limb ischemia), 226 (29%) had open, 436 (57%) had endovascular, and 108 (14%) had hybrid procedures (56 sHYBRID, 52 cHYBRID). The HYBRID group was more likely to have hypertension, chronic obstructive pulmonary disease, American Society of Anesthesia (ASA) 4, and aortoiliac reconstructions, with more ASA 4 in the cHYBRID than the sHYBRID group. Length of stay in the HYBRID group was significantly longer than the EV group, but less than open-treated groups. Endovascular intervention was performed for inflow in 85%, for runoff in 5%, and for both inflow and runoff in the remaining 10% of hybrid cases. Eleven (20%) sHYBRID cases were staged, while all cHYBRID cases were performed simultaneously. Femoral endarterectomy was more frequent in cHYBRID (75% vs 23% in sHYBRID), infrainguinal bypass (17% vs 55%) was more common in sHYBRID, the remainder being femoro-femoral bypasses (8% vs 21%). Endovascular procedures were primarily iliac interventions (91% in sHYBRID, 88% in cHYBRID). Thirty-day myocardial infarction/death rate was significantly higher in the HYBRID than the EV group, with no difference within the HYBRID group. The patency rates were similar in the sHYBRID and cHYBRID groups, and comparable to the endovascular and open treated patients with similar disease complexity. Limb salvage in patients who presented with critical limb ischemia was better in the cHYBRID group than other groups. Overall survival was similar in all groups. CONCLUSIONS Complex and simple hybrid procedures enable multilevel revascularizations in high-risk patients with comparable patency and limb salvage. Femoral endarterectomy plays a central role, especially in complex hybrid repairs. An increase in perioperative morbidity and mortality was observed in the hybrid group, likely due to attempting revascularization in higher risk patients.

Early results with cryopreserved saphenous vein allografts for infrainguinal bypass

PURPOSE Cryopreserved saphenous vein allografts (CSVA) are available for use in arterial reconstructions; however, patency rates in the infrainguinal position are not well described. METHODS We reviewed our experience with 38 patients who underwent 43 infrainguinal bypasses with CSVA as the conduit. The group includes 21 women and 17 men with a mean age of 69 +/- 11 years. Mean follow-up is 8.2 +/- 5.5 months. Logistic regression was used to analyze five variables in an attempt to identify predictors of success or failure: distal anastomosis to the popliteal artery versus a crural artery, one-vessel versus two- or three-vessel runoff, postoperative anticoagulation versus none, primary reconstructions versus reoperations, and one segment versus two segments of CSVA required. RESULTS The cumulative patency rate at 12 months by life-table analysis is 66%. Logistic regression revealed that primary reconstructions were more likely to succeed than reoperations (p = 0.03) and operations completed with one segment of CSVA were more likely to succeed than those requiring more than one segment of vein (p = 0.03). CONCLUSIONS We conclude that (1) the short-term patency of infrainguinal bypasses with CSVA suggests that they may be acceptable alternatives to prosthetic grafts in the below-knee position, and (2) primary reconstructions performed with one segment of CSVA are more likely to succeed.

Superior limb salvage with endovascular therapy in octogenarians with critical limb ischemia

OBJECTIVE The goal of this study is to compare our results following open and endovascular infrainguinal revascularizations in patients >or=80 and <80 years old presenting with critical limb ischemia (CLI) and to determine if limb salvage (LS) attempt is justified in patients >or=80 with CLI, especially following endovascular interventions. METHODS A retrospective analysis of 344 consecutive patients (399 limbs) who presented with CLI and underwent infrainguinal open or endovascular (EV) revascularizations between June 2001 and December 2007 was performed. Patients >or=80 (89 patients, 101 limbs) and <80 years old (255 patients, 298 limbs) were compared for demographics, characteristics, patency, limb salvage, sustained clinical success (preservation of limb, freedom from target extremity revascularization (TER), and resolution of symptoms), secondary clinical success (preservation of limb and resolution of symptoms), overall improvement (preservation of limb, improvement of symptoms), and survival. RESULTS Patients >or=80 were more likely to be nonambulatory and have coronary artery disease, whereas those <80 were more likely to have hypertension, hyperlipidemia, dialysis-dependence, active tobacco abuse, and taking beta-blockers. Primary amputation rates were similar between two groups (<80 vs >or=80, 6.7% vs 8.1%, P = .530). Perioperative mortality was significantly worse in >or=80 group in the open-treated group (16.2% vs 2.9%, P = .009), whereas it was similar in EV-treated patients (3.1% vs 0.6%, P = .197). The patency rates were similar between groups, however, LS was significantly better in >or=80 EV-treated patients than <80 group, whereas it was similar between groups in open-treated patients. Sustained clinical success, secondary clinical success, and overall improvement rates were similar between age groups. Endovascular-treated patients in >or=80 had significantly better overall improvement than those who were treated by open revascularization (24-month overall improvement 83% +/- 5% vs 61% +/- 9%, P = .043). Multivariate analysis showed diabetes, infrapopliteal intervention, presence of gangrene, nonambulatory status, dialysis-dependence, and runoff status being associated with limb loss whereas age being >/= or <80 was not. Age, coronary artery disease, chronic obstructive pulmonary disease, nonambulatory status, and dialysis-dependence were found to be independently associated with decreased survival. CONCLUSIONS Our results suggest that revascularization in patients >/=80 with CLI is justified, especially when an endovascular intervention can be accomplished. Although limb salvage following endovascular interventions were better in the >/=80 group, sustained clinical success, and secondary clinical success rates were similar following open and endovascular interventions in both age groups. Open procedures carry a high perioperative mortality in the >/=80 age group and should be avoided if possible.

Predictors of limb loss despite a patent endovascular-treated arterial segment

OBJECTIVE The goal of this study was to assess the frequency and predictors of major amputation with patent endovascular-treated arterial segments (PETAS) in patients with critical limb ischemia. METHODS The study included 358 consecutive patients (412 limbs) who underwent endovascular (236 limbs) or open (176 limbs) revascularizations for critical limb ischemia from June 2001 through May 2007. Patients with limb loss despite PETAS were compared with the rest of the endovascular-treated group (EV-other, n = 212) and with those who underwent amputations with patent bypasses (APB). RESULTS The EV group underwent 30 amputations (24 in PETAS, 6 in EV-other), and 37 occurred in the open group (14 in APB, 23 in open-other). Amputations occurring despite a patent revascularized segment constituted 38% of limb loss in open and 80% in EV-treated patients (P = .001). Limb loss occurred earlier in the PETAS group (58% vs 30% <or=3 months). Primary indications for limb loss in the PETAS group were extensive tissue loss or limb dysfunction after radical debridement of infection or gangrene (37%), recurrent infection (42%), and failure to reverse ischemia (21%). There were more patients with diabetes in PETAS group (96%) than in the APB group (64%, P = .018). Diabetes, dialysis-dependence, lower albumin level, gangrene, and infrapopliteal interventions were more likely in the PETAS group than in the EV-other group. Multivariate analysis showed diabetes (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.22-8.13, P = .018), gangrene (OR, 3.33; 95% CI, 1.43-7.75; P = .005), and infrapopliteal interventions (OR, 3.09; 95% CI, 1.38-6.94; P = .006), predicted limb loss with patent open or EV-treated segments, whereas dialysis-dependence, peroneal artery-only runoff, albumin level <3 g/dL, location at the heel, and treatment type did not. CONCLUSIONS Amputation despite PETAS is the most common means of limb loss in patients undergoing endovascular revascularization for limb salvage. It is likely the result of aggressive attempts at limb salvage and usually occurs <or=3 months after the intervention. Patients with diabetes and gangrene undergoing infrapopliteal interventions are at a significantly high risk. Adjuncts to reduce tissue loss, preserve limb function, and prevent recurrent infection are needed to prevent limb loss despite PETAS, especially in diabetic patients.

Peroneal artery-only runoff following endovascular revascularizations is effective for limb salvage in patients with tissue loss

OBJECTIVE Peroneal artery bypass is effective for limb salvage (LS), however, the efficacy of peroneal artery-only runoff (PAOR) following endovascular (EV) interventions is unknown. The goal of our article was to compare the efficacy of EV interventions with PAOR to those with other runoff vessels for LS in patients presenting with tissue loss. METHODS A retrospective review of 111 consecutive patients who underwent infrainguinal EV revascularizations for nonhealing ulcers/gangrene between June 2001 and December 2006 was performed. Patients with PAOR (n = 33) were compared with those with other vessel runoff (OTHER, n = 78). Fisher exact test and chi2 test were used for comparing variables, Kaplan-Meier analyses for patency, LS, and Cox regression multivariate analysis was used for identifying factors associated with limb loss. RESULTS The patients in PAOR were older, but other morbidities were similar between groups. The most distal level of intervention was infrapopliteal (tibioperoneal or peroneal artery) in 42% in PAOR group whereas this was 24% in OTHER group (P = .071). Preoperative ankle-brachial index (ABI) was similar (0.49 +/- 0.23 vs 0.50 +/- 0.23), however, postprocedure ABI was significantly less for patients with PAOR (0.76 +/- 0.21 vs 0.92 +/- 0.13, P = .001). The primary patency, assisted primary patency, secondary patency and LS were not significantly different between groups. There was also no difference in time-to healing between groups (PAOR vs OTHER, 2.9 +/- 2.1 mo vs 3.7 +/- 3.6 mo, P = .319). We found the presence of gangrene (odds ratio [OR]: 3.5, 95% confidence interval [CI], 1.1-10.8, P = .028) and dialysis-dependence (OR: 2.9, 95% CI, 1.0-8.2, P = .046) to be associated with limb loss, when adjusted for diabetes, hypertension, hyperlipidemia, smoking, location of wound, and PAOR. CONCLUSION Endovascular revascularization with PAOR results in acceptable patency and limb salvage rates in patients presenting with tissue loss, and is equivalent to other vessel runoff for patency, limb salvage and wound healing rates.