Mitchell R. Weaver

Basilic Vein Transposition: What is the Optimal Technique?

OBJECTIVES To compare the outcome of the one-stage basilic vein transposition (BVT) fistula with a modified, two-stage technique. DESIGN Retrospective case-controlled study, performed in an academic centre. MATERIAL A total of 173 candidates for BVT fistula (87 males, mean age 61 years). METHODS In one-stage BVT, the basilic vein is mobilised through a single incision, placed inside an anterolateral arm tunnel and anastomosed with the brachial artery. In two-stage procedures, the fistula-arterial anastomosis is created first, followed by the second stage, after fistula maturation several weeks later, when the basilic vein is mobilised through two skip incisions, transected near the anastomosis, placed inside an anterolateral arm tunnel and reanastomosed. Morbidity and fistula maturation rate were the main outcome measures. RESULTS In one-stage BVT (n=76), the incidence of venous hypertension, wound haematomas and all complications (17%, 13% and 43%, respectively) was significantly higher than in two-stage procedures (n=98) (4%, p=0.004, 3%, p=0.012 and 11%, p<0.001, respectively). Time (68 days) to fistula use was significantly decreased in one-stage BVT than in two-stage procedures (132 days, p<0.001) but failure to mature rate was equivalent (15% vs. 18%, p=0.49). CONCLUSIONS Our results indicate that the two-stage BVT fistula through two skip-arm incisions is superior to the established one-stage procedure in terms of less morbidity but at the cost of a second operation and longer time to access use. Further research comparing these two techniques is necessary. Until this issue is resolved, an individualised approach is suggested.

Vein Mapping Prior to Endovenous Catheter Ablation of the Great Saphenous Vein Predicts Risk of Endovenous Heat-Induced Thrombosis

Objective: We investigate the value of vein mapping for predicting the risk of endovenous heat-induced thrombosis (EHIT) after endovenous laser treatment (EVLT) and radiofrequency ablation (RFA) of the great saphenous vein (GSV). Methods: In all, 355 consecutive vein mappings were retrospectively analyzed. A generalized estimating equations approach to linear logistic regression was used to evaluate the variables. Results: Among the 312 vein ablation of the GSV, 10 (3.2%) developed EHIT. When comparing the group of patients who developed EHIT versus no EHIT, the mean GSV diameter was 13.05 ± 5.59 mm versus 8.39 ± 3.38 mm (odds ratio [OR]: 1.25, P = .001), the presence of valvular incompetence at the saphenofemoral junction (SFJ) was 10.71% versus 0.44% (OR: 27.75, P =.001), and 3.09% in RFA versus 3.33% in EVLT (OR: 1.09, P = .89). Conclusions: Patients with valvular insufficiency of the SFJ and a large proximal GSV diameter had a significantly higher risk of developing heat-induced thrombosis after endovenous catheter ablation.

Contemporary presentation and evolution of management of neck paragangliomas

BACKGROUND The aim of the present study was to review the contemporary presentation and evolution of management of neck paragangliomas. METHODS Forty-one neck paragangliomas operated on in 36 patients over a 44 year period were included in the current report. The study period was divided into two parts, the first three decades (1964-1989), during which the current management techniques were evolved, and the last two decades (1990-2008). RESULTS Patients presented with a palpable neck mass (n = 17), cranial nerve (CN) palsy (n = 3) or both (n = 6), or the lesion was an incidental finding (n = 14). The use of cross-section imaging modalities (n = 24) increased from 35% during the first part of the study to 95% during the second part of the study (P < .001). Preoperative embolization (introduced in 1979) was performed in 60% (median size 4.3 cm for embolized vs 3 cm [P = .02], for non-embolized tumors). During the first study period, the frequency of Shamblin group II/III tumors was 95% compared with a frequency of 42% during the second study period (P < .001, odds ratio 25), median blood loss was 600 ml and 150 ml, respectively (P = .001) and the transfusion rate was 44% and 5%, respectively (P = .008). The incidence of temporary and permanent new CN deficits postoperatively was 22.5% and 10%, respectively, and was similar during the two study periods. Three tumors were malignant, based on lymph node involvement (n = 1) or development of late metastases (n = 2). CONCLUSIONS In the modern era, neck paragangliomas can be managed with a low incidence of long-term sequelae. Smaller, asymptomatic, and incidentally detected tumors are currently the most common presentation pattern.

Frequency, risk factors, and management of perigraft seroma after open abdominal aortic aneurysm repair

OBJECTIVE Perigraft seroma (PGS) causing enlargement of the native aneurysm sac after open abdominal aortoiliac aneurysm (AAA) repair is a rarely recognized complication with unknown clinical consequences. This study was undertaken to determine the frequency of PGS, identify associated risk factors, and review resulting complications and their management strategies. METHODS Charts of all patients who underwent open AAA repair at our institution from 1995 to 2009 and had at least one postoperative abdominal cross-sectional imaging study (the study subjects) were retrospectively reviewed. PGS was defined as a perigraft fluid collection present > 3 months postoperatively, ≥ 3-cm in diameter and having a radiodensity ≤ 25 Hounsfield units on computed tomography (CT). Patient records were reviewed for demographics, comorbidities, operative and postoperative variables, and long-term outcome. RESULTS Of the 111 study subjects identified, 13 had aortic reconstruction with Dacron grafts and 98 with polytetrafluoroethylene (PTFE) grafts. Twenty patients (18%) had PGS, all of whom had PTFE grafts (20 of 98; 20.4%). Mean age was 68.5 years and mean aneurysm diameter preoperatively was 6.4 cm (range, 4.0-10.9 cm). The average time from AAA repair to PGS detection was 51 months (range, 4-156 months). PGS averaged 6.0-cm in diameter (range, 3.0-11.0 cm). Multivariate analysis revealed that the following factors were associated with PGS development: diabetes (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1-21.2; P = .013), smoking (OR, 5.6; 95% CI, 0.73-33.74; P = .01), anticoagulation (OR, 7.2; 95% CI, 2.6-63.3; P = .003), bifurcated graft reconstruction (OR, 8.0; 95% CI, 2.6-94.1; P = .017), and left flank retroperitoneal approach for repair (OR, 7.1; 95% CI, 1.9-26.5; P = .003). Four patients (4 of 20; 20%) required intervention for PGS-related complications: 3 patients for symptomatic PGS expansion (1 patient with rupture) and 1 patient for acute limb ischemia secondary to graft limb compression and thrombosis. Two patients had open exploration, sac evacuation/reduction, and graft replacement with a Dacron graft: 1 patient for a ruptured aneurysm sac and 1 patient for persistent pain associated with sac enlargement. A third patient underwent a failed CT-guided drainage for abdominal pain and was subsequently treated with partial graft excision. The patient with acute limb ischemia was treated with catheter-directed thrombolysis and graft limb stenting. CONCLUSION PGS after open AAA repair occurs more frequently than previously reported. Complications requiring intervention can occur in up to 20% of patients with PGS. A variety of treatment modalities can be used to deal with the complications. Earlier CT surveillance is advised after open AAA repair with a PTFE graft if symptoms are suggestive of PGS development.

Survival after repair of pararenal and paravisceral abdominal aortic aneurysms

OBJECTIVE The objective of this study was to review our 27-year clinical experience with open proximal abdominal aortic aneurysm repairs, with a focus on long-term survival. METHODS A retrospective cohort study was undertaken of all patients who underwent proximal abdominal aortic aneurysm repair between 1986 and 2013 at a tertiary care referral center. Demographics, operative variables, complications, and 30-day mortality were analyzed. Postoperative acute kidney injury was analyzed by the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease)/Acute Kidney Injury Network criteria. Long-term survival was assessed through review of electronic medical records and the Social Security Death Index. Associations between demographics and complications were investigated to determine predictors of long-term survival. RESULTS The study identified 245 patients. Mean age was 71 years (range, 38-92 years); 69% were men, and 88% were white. Aneurysm type was juxtarenal in 127 patients (52%), suprarenal in 68 patients (28%), and type IV thoracoabdominal in 50 patients (20%). In-hospital mortality was 3.3% (eight patients), and 30-day mortality was 2.9% (seven patients). At least one major complication occurred in 64% of the patients, which included the following: acute kidney injury, 60% (persistent acute kidney injury at discharge, however, was 28%, and hemodialysis at discharge was 1.6%); major pulmonary complications, 22%; myocardial infarction, 4%; visceral ischemia, 2%; and paraplegia, 0.5%. Median follow-up was 54 months. Kaplan-Meier survival estimates were 70% at 5 years and 43% at 10 years. Variables associated with poorer survival included congestive heart failure (hazard ratio [HR], 3.5; P < .001), chronic obstructive pulmonary disease (HR, 1.8; P < .002), and increased aneurysm size at presentation (HR, 1.1; P < .013). Persistent stage 3 acute kidney injury was associated with poor long-term survival. CONCLUSIONS Open surgical repair of proximal abdominal aortic aneurysms can be performed with low mortality. Acute kidney injury is the most frequent complication, but the need for hemodialysis at discharge is low. Long-term survival is favorable. These data should assist in establishing benchmarks for endovascular repair of complex proximal abdominal aortic aneurysms.

Patterns and Outcomes of Aortofemoral Bypass Grafting in the Era of Endovascular Interventions

OBJECTIVES The aim of the study is to study contemporary presentation patterns and clinical results in patients undergoing aortofemoral bypass (AFB) surgery. DESIGN This was a retrospective comparative study. MATERIAL AND METHODS During a 14-year period, 269 consecutive patients (mean age 65 years) underwent AFB. Indications included occlusive disease with severe intermittent claudication (IC) (n = 86), critical limb ischaemia (CLI, n = 97) and aneurysmo-occlusive disease (n = 86). RESULTS From 2000-07 on, AFB was performed more frequently for occlusive disease with CLI than for other indications (48% vs. 31% before 2000, P = 0.009) and also in women (51% vs. 32% before 2000, P = 0.003), compared to the period before 2000. Thirty-day mortality was reduced during 2000-2007 to 2.4%, compared with 4.3% during 1993-1999, although this difference was not statistically significant (P = 0.73). Morbidity did not change substantially over the study period. Predictors of 30-day mortality included indication (CLI = 4.1% vs. claudication = 1.2% (P = 0.37)) and chronic kidney disease (CKD, serum creatinine > 1.5 mg dl⁻¹) (11.1% vs. 2.9% in normal renal function, P = 0.07), the latter being the single predictor on multivariate analysis (hazard risk 4.2, P = 0.047). Overall 5 and 10-year assisted primary and secondary patency was 95% and 88%, and 99% and 95%, respectively. Survival at 5 and 10 years was 69% and 48%, respectively. Patient age (hazard risk 1.05, P < 0.001), CKD (hazard risk 1.79, P = 0.018) and diabetes (hazard risk 1.56, P = 0.022) were independent predictors of worse long-term survival. Long-term outcome did not change over the course of the study. CONCLUSIONS In the contemporary era, AFB is more likely to be performed for CLI and in women than in the past. Despite these changes, perioperative mortality and morbidity remain low and long-term outcome excellent.

Late endovascular aneurysm repair infection presenting with juxatrenal aortic rupture treated with in situ aortic replacement

Infection of an endovascular abdominal aneurysm repair (EVAR) is rare but has become more prevalent with the standardization of EVAR for treating infrarenal abdominal aortic aneurysms. The understanding of this complex aortic condition has improved but still remains to evolve. We present a patient with an EVAR infection manifesting with juxtarenal aortic rupture as a result of a urinary tract infection. This report describes an unusual presentation of an EVAR infection treated with in situ aortic reconstruction and provides >1 year of follow-up.

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms

Objective It is not clear whether endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) results in an increase in renal insufficiency during the long term compared with open repair (OR). We reviewed our experience with AAA repair to determine whether there was a significant difference in postoperative and long‐term renal outcomes between OR and EVAR. Methods A retrospective cohort study was conducted of all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow‐up laboratory values were excluded. Preoperative, postoperative, 6‐month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated on the basis of the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Change in GFR was defined as preoperative GFR minus the GFR at each follow‐up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categorical data and linear regression for continuous variables. Results During the study period, 763 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (317 ORs and 358 EVARs). Mean age was 73.9 years. Seventy‐nine percent were male, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as GFR below 60 mL/min. Using a multivariate logistic model to control for all variables, OR was found to have a 1.6 times greater chance for development of immediate postoperative AKI compared with EVAR (P = .038). Hypertension and aneurysm size were independent risk factors for development of AKI (P = .012 and .022, respectively). Using a linear regression model to look at GFR decline during several years, there was a greater decline in GFR in the EVAR group. This became significant starting at postoperative year 4. AKI and preoperative renal dysfunction were independent risk factors for long‐term decline in renal function. Conclusions Although AKI is less likely to occur after EVAR, patients undergoing EVAR experience a significant but delayed decline in GFR over time compared with OR. This became apparent after postoperative year 4. Studies comparing EVAR and OR may need longer follow‐up to detect clinically significant differences in renal function.

PC206. Correlation of Age With Patient Reported Symptoms and Venous Clinical Severity Score for Patients With Varicose Veins

Objectives: Previously published data demonstrated that elderly patients older than age 65 benefit from vein ablation procedures. The objective of this study is to compare young, middle-aged, and older patients who underwent varicose vein ablation using our institutional Vascular Quality Initiative Varicose Vein Registry (VQI VVR). Methods: Retrospective analysis of a prospective registry of all vein procedures in the VQI VVR was performed from January 2015 to August 2017 at our tertiary care institution. We divided all patients into three groups depending on their age at presentation: young (group A, age <45), middle (group B, age 45-64), and old (group C, age >65). Comparison data included patient demographics, past medical history, clinical outcomes, patient reported outcomes, and postoperative complications. Clinical outcomes were assessed by the clinical, etiology, anatomy, and pathophysiology (CEAP) classification and venous clinical severity score (VCSS). Patient reported outcomes were assessed by heaviness, achiness, swelling, throbbing, itching (HASTI) symptoms and their impact on work and activity. Statistical testing included c test for categorical variables and student t-test for continuous variables using SPSS statistical software. Results: There were a total of 1035 procedures performed during the study period: 133 patients were age <45 (group A), 559 were age 45 to 64 (group B), and 342 were age >65 (group C). Majority of the vein procedures were for truncal vein reflux and more than two-third were females across all age groups. VCSS scores were significantly higher for the older age groups (Table). HASTI scores were significantly lower for the older age groups when compared with the younger group (Table). Younger patients (group A) had more commercial insurance (P < .001), less anticoagulation use (P < .001). There was no significant difference between the groups in terms of positive history for superficial phlebitis, DVT, or prior varicose vein procedure.

Benefit of Arterial Duplex Ultrasound Stent Imaging After Superficial Femoral Artery Stent Implantation: Impact of Surveillance Method on Postprocedural Outcome

Objective: In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex ultrasound stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation (SI), whether surveillance with ADSI yielded a better outcome than in those with only anklebrachial index (ABI) follow-up. Methods: We performed a retrospective analysis of all patients undergoing SFA SI for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI (ADSI group) and those with ABI follow-up only (ABI group). Life-table analysis comparing stent patency, major adverse limb event (MALE), limb salvage, and mortality between groups was performed. Results: There were 248 patients with SFA SI included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous regarding clinical indication (claudication/critical limb ischemia, ADSI 39%/61% vs ABI 38%/62%; P 1⁄4 .982) and TransAtlantic Inter-Society Consensus classification (A/B/C/D for ADSI 17%/45%/16%/22% and ABI 21%/43%/16%/20%; P 1⁄4 .874). Primary patency (PP) was similar between groups at 12, 36, and 56 months (ADSI, 65%/43%/32%; ABI, 69%/34%/34%; P 1⁄4 .770), whereas ADSI patients showed an improved assisted PP (84%/68%/54%) vs ABI (76%/38%/38%; P 1⁄4 .008) and secondary patency (Fig 1). There was a greater freedom from MALE in the ADSI group (91%/76%/64%) vs the ABI group (79%/46%/46%; P < .001) at 12, 36, and 56 months of followup. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA SI intervention (P 1⁄4 .001), whereas ABI patients were more likely to undergo an amputation (P < .001; Fig 2). Conclusions: In SFA SI, patients with ADSI follow-up demonstrate an advantage in assisted PP and secondary patency and are more likely to undergo an endovascular reintervention. These factors likely effected a