Purandath Lall

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.

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.

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.

Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease

OBJECTIVES TransAtlantic Society Consensus (TASC)-II recommends bypass for TASC D and low-risk patients with TASC C lesions but does not specify graft types. Percutaneous balloon angioplasty/stenting (PTA/S) and above knee femoropopliteal bypass (AK-FPB) using polytetrafluoroethylene (PTFE) for these lesions were compared to determine if graft type should be part of the TASC-II recommendations for the treatment of TASC C lesions. METHODS Consecutive patients who underwent AK-FPB with PTFE, or PTA/S for TASC-II C (PTA/S-C) or D (PTA/S-D) SFA lesions between June 2001 and April 2007 were retrospectively analyzed. The primary end points were primary, assisted-primary, and secondary patency rates. RESULTS In 127 patients (mean age, 68.7 +/- 10.0 years; median, 68; range, 49-97), 139 limbs were treated (46 AK-FPB, 49 PTA/S-C, 44 PTA/S-D). The mean occlusion and stented lengths were 9.9 +/- 3.8 and 24.3 +/- 6.6 cm (median, 10 and 20 cm) in PTA/S-C, and 26.6 +/- 5.5 and 30.0 +/- 5.2 cm (median, 26 and 29 cm) in PTA/S-D. Technical success was 84% in PTA/S-D and 100% in other groups. Mean follow-up was 26.4 +/- 18.0 months (median, 24). The 12- and 24-month primary patency was 83% +/- 6% and 80% +/- 7% for PTA/S-C; 54% +/- 8% and 28% +/- 12% for PTA/S-D; and 81% +/- 6% and 75% +/- 7% for AK-FPB (P < .001 PTA/S-D vs PTA/S-C and AK-FPB); assisted-primary patency was 95% +/- 3% and 95% +/- 3% for PTA/S-C, 62% +/- 8% and 49% +/- 10% for PTA/S-D, and 81% +/- 6% and 75% +/- 7% for AK-FPB (P < .001, PTA/S-C vs PTA/S-D; P = .003, PTA/S-C vs AK-FPB; and P = .03, PTA/S-D vs AK-FPB). Secondary patency was 98% +/- 3% and 98% +/- 3% for PTA/S-C; 72 % +/- 7% and 54% +/- 11% for PTA/S-D, and 81% +/- 6% and 78% +/- 7% for AK-FPB. Secondary patency was significantly better in PTA/S-C than AK-FPB (P = .003) and PTA/S-D groups (P < .001). The difference was marginally better in AK-FPB than in PTA/S-D (P = .064). CONCLUSIONS PTA/S for TASC-II C lesions has a superior midterm patency than AK-FPB using PTFE, and AK-FPB with PTFE has better primary and assisted-primary patency than PTA/S-D. The TASC-II recommendations should be modified to recommend treatment of SFA TASC-II C lesions by PTA/S rather than PTFE bypass for all patients. PTA/S of TASC-II D lesions should only be considered in high-risk patients who cannot tolerate a bypass procedure using PTFE.

Insulin use is associated with poor limb salvage and survival in diabetic patients with chronic limb ischemia

OBJECTIVE The goal was to compare the outcomes in patients with disabling claudication (DC) or critical limb ischemia (CLI) to determine if diabetics (DM) have poorer patency, limb salvage (LS), and survival rates than nondiabetic patients and if the diabetic regimen affects these outcomes. METHODS All patients who presented with DC or CLI between June 2001 and September 2008 were included. Non-DM patients were compared with those with DM who are currently managed by diet only or oral medications (D-OM), oral medications plus insulin (OM+INS), or insulin alone (INS). RESULTS Of the 746 patients (886 limbs), there were 406 patients (464 limbs) in non-DM, 96 patients (135 limbs) in D-OM, 98 patients (118 limbs) in OM+INS, and 146 patients (185 limbs) in INS groups. There were more patients with coronary artery disease, hypertension, and renal insufficiency in the DM group than non-DM, with the INS group having the highest incidence of renal insufficiency/dialysis (46%/20%). Gangrene and foot sepsis were significantly more frequent in patients in OM+INS (45%/3%) and INS (50%/6%) than non-DM (15%/0.2%) and D-OM groups (25%/1%; P < .001). More patients in the INS group (14%) and OM+INS (9%) had primary amputation than non-DM (4%) and D-OM (4%; P < .01). Mean follow-up was 26.3 +/- 20.7 months. Overall survival following revascularization was similar in D-OM and non-DM and OM+INS and INS, the latter being significantly worse (P < .001). The LS rate in D-OM and non-DM was also identical, whereas OM-INS and INS had significantly worse LS, with OM-INS marginally better than INS (P = .094). Primary patency (PP) was worse in endovascular-treated patients on insulin than non-DM and D-OM patients (P < .001), whereas PP was similar between groups in open-treated patients. Multivariate analysis showed that coronary artery disease, renal insufficiency, chronic obstructive pulmonary disease, indication for intervention, insulin use, nonambulatory status, and statin drug non-use were independently associated with decreased survival, whereas insulin use, presence of gangrene, need for infrapopliteal interventions, and nonambulatory status were independently associated with limb loss. TransAtlantic Inter-Society Consensus (TASC) classification of the treated lesions being C or D, infrapopliteal interventions, and indication of intervention (DC vs CLI) were independently associated with primary patency, whereas insulin use was not. CONCLUSIONS Diabetic patients who present with limb ischemia can be subdivided into three distinct subgroups based on their diabetic regimen. The survival and LS rates of those controlled with diet or OM are nearly identical to nondiabetics, both of which are significantly better than OM+INS or INS. The PP rate in endovascular-treated patients is worse in patients who are on insulin. Being on insulin is independently associated with decreased survival and limb loss but not PP.

Ambulatory percutaneous endovascular abdominal aortic aneurysm repair.

OBJECTIVE Percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) has been associated with fewer groin wound complications and shorter operative times, but same-day discharge (SDD) has not been reported. The goal of our article is to assess the feasibility and safety of ambulatory PEVAR and identify patient characteristics that are eligible for this approach. METHODS Consecutive patients who underwent elective endovascular abdominal aortic aneurysm repair (EVAR) between March 2011 and December 2012 were reviewed. SDD was discussed during the preoperative visit with patients who were functionally independent, without significant comorbidities, and had favorable anatomy. These patients were given the option to be discharged in the evening of the PEVAR after 6 hours of bed rest if the procedure was uneventful. Causes for discharge delay and early outcomes were analyzed. RESULTS During the study period, 79 patients underwent abdominal aortic aneurysm (AAA) repair, 64 of whom (mean age, 70.2 ± 9.9; range, 59-97) had elective EVAR (3 ruptures, 5 acute presentations, 3 fenestrated EVARs, 4 elective open AAA repairs were excluded). Fifty-three patients (83%) had bilateral percutaneous access, seven had unilateral percutaneous (11%) access, and the remaining four (6%) had bilateral femoral endarterectomies. The percutaneous closure success rate was 96% in 113 attempts (three conversions for inadequate hemostasis, one for inability to deploy device). Mean length of stay was 1.3 ± 1.4 days (median, 1 day) with no 30-day mortality. Twenty-one patients (33%) were discharged the same day (SDD group), 24 (37%) on postoperative day (POD) 1, 16 (25%) on POD 2/3, and 3 (5%) stayed ≥ 4 days. One patient in the SDD group was readmitted on POD 3 after EVAR for severe postimplantation syndrome. Of the 23 patients who were discharged on POD 1, 10 were kept overnight due to severe chronic obstructive pulmonary disease, coronary artery disease, or advanced age, three transportation issues, two inability to void, two patient preference, two for renal protection, and four due to unplanned femoral cutdown. Patients in the SDD group were significantly younger (66.5 ± 5.4 years vs 72.0 ± 10.6 years; P = .029), had smaller AAAs (5.3 ± 0.5 cm vs 5.9 ± 1.0 cm; P = .013), less blood loss (115 ± 90 mL vs 232 ± 198 mL; P = .012), and shorter operating time (79 ± 24 minutes vs 121 ± 73 minutes; P = .013). There were fewer American Society of Anesthesiologists 4 patients in the SDD group (24% vs 48%; P = .056). The majority (81%) of patients in all groups had general anesthesia (86% vs 79% SDD vs others; P = .523). CONCLUSIONS Ambulatory PEVAR was found to be feasible and safe in one-third of patients undergoing elective EVAR who did not have excessive medical risk, had good functional capacity, and underwent an uneventful procedure. The impact of SDD on cost-effectiveness needs to be further assessed and may not be feasible in hospitals reimbursed based on admission status.

Complete spontaneous regression of an extrahepatic portal vein aneurysm.

Primary portal venous aneurysms are rare; however, they are the most common visceral venous aneurysms, and their pathogenesis is not fully understood. Complications include thrombosis, rupture, and mass effect on adjacent structures. The optimal management of these patients is not known. We describe a patient whose large (6-cm) portal vein aneurysm underwent complete spontaneous regression over several years of serial observation. To our knowledge, this observation has not been reported in the English literature.