Thomas W. Cheng

Retrograde popliteal access to treat femoropopliteal artery occlusive disease

Objective: Retrograde popliteal artery (RPA) access to treat superficial femoral artery and popliteal artery disease is an option when treatment through common femoral artery (CFA) access is not possible. Our goal was to compare the safety and efficacy of RPA access with CFA access for treatment of femoral and popliteal artery lesions. Methods: The Vascular Quality Initiative was queried for all patients undergoing RPA access from 2010 to 2016 for symptomatic peripheral arterial disease. These were compared with standard CFA access. Patients with acute limb ischemia were excluded. Preoperative, operative, and postoperative data were analyzed. Perioperative and 6‐month outcomes were analyzed. Multivariable analysis was used to assess the effect of RPA access on amputation or death, major adverse limb event (MALE) or death, patency, and death. Results: There were 30,074 patients with isolated superficial femoral and popliteal artery disease treated, 148 of whom had RPA access. Indications overall included claudication (56.3%), rest pain (13.9%), and tissue loss (29.8%). RPA access had a significantly lower rate of technical success compared with CFA access (80.4% vs 93.8%; P < .001). RPA access and CFA access were similar for rates of arterial dissection (8.3% vs 6.3%; P = .333), distal embolization (0% vs 1.2%; P = .183), access site hematoma (3.4% vs 3.1%; P = .849), and 30‐day mortality (1.4% vs 1.1%; P = .789). There were no differences between RPA access and CFA access for unadjusted 6‐month amputation‐free survival (94.8% vs 96%; P = .747) or survival (934.3% vs 95.6%; P = .845). MALE‐free survival (74.5% vs 83.5%; P = .016) and patency (70.3% vs 83.1%; P < .001) were significantly lower in the RPA access group. Multivariable analysis showed no differences between patients who were successfully treated by RPA access and CFA access for amputation‐free survival (hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.46‐3.32; P = .669), MALE‐free survival (HR, 1.57; 95% CI, 0.99‐2.5; P = .057), and survival (HR, 0.86; 95% CI, 0.43‐1.73; P = .675). RPA access was independently associated with loss of primary patency (HR, 1.91; 95% CI, 1.24‐2.94; P = .003). Conclusions: RPA access had lower technical success and primary patency compared with antegrade access at 6 months. There were no differences demonstrated between the two access techniques in perioperative morbidity and mortality or 6‐month amputation, MALE, and survival. This technique should be considered when CFA access cannot be accomplished.

VESS17. Factors Affecting Academic Advancement in Vascular Surgery

represented 2.1% of this cohort, mid-volume practitioners represented 9.6%, and low-volume vascular practitioners represented 88.3%. The percentage of midand high-volume vascular practitioners increased significantly (5.8% to 9.1% and 0.8% to 2.3%, respectively; P < .0001), as did the number of patients they treated (25,849 to 31,602 and 1561 to 6207, respectively; P < .0001). Low-volume interventionalists saw a significant decrease in both the number of patients treated and the percentage of their overall cohort size (51,796 to 33,771 and 93.4% to 87.8%, respectively; P < .001). Table I displays the outcome variables by vascular volume and associated significance values. Table II shows the multivariate regression analysis for the outcome variables. High-volume vascular surgeons had a 27% decreased odds of in-hospital mortality and 11% decreased odds of complication compared with low-volume practitioners when performing vascular procedures (P < .001). The average length of stay and total hospital charges for patients treated by high-volume vascular surgeons were 1.5 days and

VESS22. Access Site Complications for Antegrade and Retrograde Access of the Common Femoral Artery Are Similar

23,016 less than that of low-volume practitioners (P < .001). Conclusions: The majority of vascular practitioners have diverse practices. High-volume vascular interventionalists have improved outcomes with regard to mortality, length of stay, cost, and complications. In training the next generation of vascular surgeons, the focus should be on vascularspecific skills, and practicing vascular surgeons should look to concentrate their operative breadth with the goal of improving patient outcomes.

PC098. Short-Term Outcomes After Lower Extremity Arteriovenous Hemodialysis Access Are Poor

reintervention, 18%; major amputation, 15%; serial wound débridement, 11%; staged vascular reconstruction, 3%). Overall MALE rate was 57% (n 1⁄4 90). Additional operative details and intergroup comparison of conduit choices are highlighted in the Table. Conclusions: VS-GWIs can be safely managed with interposition reconstruction in a majority of patients with acceptable mortality and excellent wound healing rates. However, a significant proportion of patients experience MALEs, with most being bypass related reintervention, highlighting the need for close follow-up and graft surveillance. An autogenous conduit choice was associated with significantly lower rates of reoperation, with femoral vein representing an ideal option in managing complex VS-GWIs.

Readmissions after thoracic endovascular aortic repair

and need for a revision pelvic fixation (P < .05). Additionally, by Cox regression, initial fixation was a significant predictor of revision (HR, 3.94). A body mass index of >35 kg/m or prior abdominal surgeries were not found to be significant predictors in this case. Conclusions: Peritoneal dialysis catheter placement via a laparoscopic approach can be successfully performed in a diverse patient mix with positive results. However, given its association with complications in this study, careful consideration of buried catheter configuration and prophylactic pelvic fixation should be used.

IP153. Snuffbox Arteriovenous Fistulas Have Similar Outcomes and Patency to Wrist Arteriovenous Fistulas

Objective: The care of patients undergoing thoracic endovascular aortic repair (TEVAR) can be resource intensive, which can be driven by readmissions. Our objective was to characterize index readmissions at 30, 90, and 180 days after TEVAR. Methods: A retrospective analysis of the Nationwide Readmissions Database was performed for patients who underwent TEVAR in 2013. Multivariable analysis identified independent predictors for index readmission at 30, 90, and 180 days. Results: There were 4045 TEVARs performed for descending thoracic aortic dissection (37.7%), nonruptured aneurysm (56%), and ruptured aneurysm (6.3%). There were 419 (11.1%) index readmissions at 30 days, 895 (23.6%) at 90 days, and 1131 (29.8%) at 180 days. The most frequent reason for index readmission was heart related at 30 days (15.5%) and aorta related at 90 days (18%) and 180 days (19.6%). Reinterventions were performed at 6.4%, 9.5%, and 9.7% of 30‐, 90‐, and 180‐day readmissions, respectively. The majority of these included additional endovascular stent graft placement (51.9% of reinterventions at 30 days, 67.7% at 90 days, and 65.9% at 180 days). In multivariable analysis, 30‐day index readmission was associated with initial ruptured presentation (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.1‐3.5; P = .023) and diagnosis‐related group (DRG) severity grades of moderate (OR, 1.42; 95% CI, 0.74‐2.73), major (OR, 2.47; 95% CI, 1.28‐4.74), and extreme (OR, 1.60; 95% CI, 0.76‐3.36; P = .009). Index readmission at 90 days was independently associated with initial ruptured presentation (OR, 1.88; 95% CI, 1.18‐3.01; P = .008), urgent/emergent TEVAR (OR, 1.41; 95% CI, 1.08‐1.85; P = .014), and DRG severity grades of moderate (OR, 1.53; 95% CI, 0.95‐2.47), major (OR, 2.27; 95% CI, 1.39‐3.7), and extreme (OR, 2.45; 95% CI, 1.43‐4.18; P = .002). Finally, at 180 days, initial ruptured presentation (OR, 1.66; 95% CI, 1.05‐2.62; P = .029), urgent/emergent TEVAR (OR, 1.37; 95% CI, 1.08‐1.79; P = .013), and DRG severity grades of moderate (OR, 1.55; 95% CI, 1.01‐2.38), major (OR, 2.15; 95% CI, 1.38‐3.33), and extreme (OR, 2.39; 95% CI, 1.47‐3.89; P = .002) were, again, independently associated with index readmission. Conclusions: A large portion of patients treated with TEVAR were readmitted most commonly for heart‐related reasons at 30 days and aorta‐related reasons at 90 and 180 days. TEVAR performed to treat initial aortic rupture and greater DRG severity grade were independently associated with an index readmission at 30, 90, and 180 days. Urgent/emergent TEVAR was independently associated with an index readmission at 90 and 180 days. These factors are important to consider in using readmissions as a quality measure.

Intraoperative Heparin Use during Upper Extremity Arteriovenous Access Creation Does Not Affect Outcomes

>10 g/dL; men, >12 g/dL), moderate (hemoglobin: women, 7-9.9 g/dL; men, 9-11.9 g/dL), and severe (hemoglobin: women, <7 g/dL; men, <9 g/ dL) anemia. Multivariate logistic and Cox regression analyses were implemented to evaluate 30-day mortality and primary patency (PP) at 1 year, respectively. Results: A total of 28,013 patients undergoing HD access surgery were identified (normal-mild, 22%; moderate, 69%; and severe, 9% anemia). Compared with normal-mild and moderate anemia, patients with severe anemia were slightly younger and were more likely to undergo AVF (Table). History of smoking, congestive heart failure, functional dependency, and peripheral arterial disease were also higher in severe anemia, whereas history of chronic obstructive pulmonary disease , dialysis, prior AVF or arteriovenous graft, and tunnel catheter use were higher among patients with normal-mild anemia (Table; all P < .05). Postoperative bleeding (2.2% vs 1.9% vs 2.2%) and 30-day outcomes including swelling (0.7% vs 0.4% vs 0.5%) and wound infection (0.1% vs 0.3% vs.0.3%) were similar in mild-normal, moderate, and severe anemia groups, respectively (all P > .05). However, 30-day mortality was significantly higher in patients with severe anemia compared with normal-mild and moderate anemia (2.1% vs 1.0% and 1.1%, respectively; P < .001). After adjustment for potential confounders, compared with normal-mild, severe anemia was associated with 68% higher risk of 30-day mortality (odds ratio, 1.68; 95% confidence interval [CI], 1.03-2.76; P 1⁄4 .04; Fig). No difference was seen between normal-mild and moderate anemia (odds ratio, 0.81; 95% CI, 0.561.17; P 1⁄4 .26). PP at 1 year was similar between the three groups (51% vs 50% vs 50%; P 1⁄4 .45). However, compared with normal-mild anemia, multivariate Cox regression demonstrated 16% increased risk of loss of PP with severe anemia (adjusted hazard ratio, 1.16; 95% CI, 0.99-1.25; P 1⁄4 .03) but similar PP in moderate anemia (adjusted hazard ratio, 1.05; 95% CI, 0.98-1.14; P 1⁄4 .18). Conclusions: In this large study of HD patients undergoing HD access placement, compared with normal-mild anemia, severe anemia was associated with 16% increased risk of loss of PP and 68% increased risk of 30-day mortality. No difference was seen in mortality or PP between normal-mild and moderate anemia. We strongly recommend correction of severe anemia to moderate level before access placement.

Perioperative outcomes after reoperative carotid endarterectomy are worse than expected

BACKGROUNDnThere are conflicting data about the effect of heparin use on perioperative outcomes during upper extremity arteriovenous (AV) access creation. Our goal was to assess the effect of the use and degree of intraoperative heparin on perioperative outcomes after AV access creation.nnnMETHODSnAll upper extremity AV access cases performed at a tertiary academic medical center between 2014 and 2017 were reviewed. Patient and procedural details including intraoperative heparin use and dosing as well as protamine use were analyzed. Full heparin dose was defined as 80-100 U/kg and partial heparin dose as less than 80 U/kg. Perioperative arterial thrombosis or distal embolism, hematoma, and early loss of primary patency within 30xa0days were evaluated. Multivariate analysis was performed to assess the effect of heparin use.nnnRESULTSnThere were 550 AV access cases identified: brachiocephalic (37.5%), brachiobasilic (29.3%), and radiocephalic fistulas (12.9%), and AV grafts (16.9%). Average patient age was 62.6xa0years and 58.9% were male. Full heparinization was used in 21.3%, partial heparinization in 58.7%, and no heparin was used in 20% of cases. Protamine was used in 94.9% of full heparin cases and 51.4% of partial heparin cases. No perioperative arterial thrombosis or distal embolism was observed. Perioperative wound hematoma rate was 3.4%, 3.1%, and 0.9% in full heparin, partial heparin, and no heparin cohorts, respectively (Pxa0=xa00.42). Early loss of primary patency was 11.1%, 7.7%, and 6.4% for full heparin, partial heparin, and no heparin cases, respectively (Pxa0=xa00.39). There were no differences in return to the operating room or perioperative survival. On multivariable analysis, full heparin use (odds ratio [OR] 3.82, 95% confidence interval [CI] 0.41-35.9, Pxa0=xa00.24) and partial heparin (OR 4.03, 95% CI 0.5-32.6, Pxa0=xa00.19) use were not significantly different from no heparin cases with respect to 30-day perioperative hematoma rate. Full heparin (OR 1.76, 95% CI 0.65-4.78, Pxa0=xa00.26) and partial heparin (OR 1.13, 95% CI 0.46-2.75, Pxa0=xa00.79) were not significantly different from no heparin cases with respect to early loss of primary patency.nnnCONCLUSIONSnIntraoperative heparin use, at full or partial doses, did not affect perioperative outcomes after AV access creation. Overall complication event rate was low for all groups. AV access can be safely performed without intraoperative heparin use.

Carotid Endarterectomy Performed before the Weekend is Associated with Increased Length of Stay

OBJECTIVEnReoperative carotid endarterectomy (CEA) can be technically challenging because of significant scarring as a consequence of the initial CEA procedure. There are limited data that describe outcomes after reoperative CEA, and as such, our goal was to determine the effect of reoperative CEA on perioperative outcomes.nnnMETHODSnThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients undergoing index and reoperative CEA between 2005 and 2014. Multivariate analysis was performed to assess the effect of reoperative CEA on outcomes including stroke, major adverse cardiovascular event, and procedure time.nnnRESULTSnThere were 75,943 index and 140 reoperative CEAs identified. No differences were found in baseline demographics or comorbidities except that the reoperative group had a higher incidence of patients with end-stage renal disease (3.6% vs 1.1%; Pxa0= .004). Prior stroke with deficit (20.8% vs 15.4%; Pxa0= .137) and without deficit (11.5% vs 9.1%; Pxa0= .43) were similar between reoperative and index CEA groups. Both the reoperative and index initial CEA cohorts had comparable rates of surgical site infection (0.7% vs 0.3%; Pxa0= .462), return to the operating room (3.6% vs 4%; Pxa0= .816), readmission with 30xa0days (2.1% vs 6.9%; Pxa0= .810), myocardial infarction (2.1% vs 0.9%; Pxa0= .125), and perioperative death (0.7% vs 0.9%; Pxa0= .853). The reoperative cohort had a significantly higher rate of perioperative stroke (5.0% vs 1.6%; Pxa0=xa0.002) and a longer operative duration (137xa0± 54 vs 116xa0± 49xa0minutes; Pxa0< .001). Multivariate analysis revealed that reoperative CEA was an independent factor for postoperative stroke (odds ratio, 3.71; 95% confidence interval [CI], 1.61-8.57; Pxa0= .002), major adverse cardiovascular event (odds ratio, 2.76; 95% CI, 1.32-5.78; Pxa0= .007), and longer procedure time (means ratio, 1.21; 95% CI, 1.12-1.30; Pxa0< .001).nnnCONCLUSIONSnReoperative carotid surgery is associated with a longer operative time and higher risk for perioperative stroke compared with index CEA. This information informs the risk-benefit analysis for reoperation.

VESS24. The Femoral Vein Transposition Arteriovenous Fistula Is a Durable Hemodialysis Access in Patients Who Have Exhausted Upper Extremity Options

OBJECTIVEnLength of stay (LOS) is commonly used to gauge hospital resource utilization and can affect hospital profit margin. Other fields of surgery have showed that operations performed close to the weekend have longer LOS and higher patient morbidity. Our goal was to investigate whether asymptomatic patients undergoing elective carotid endarterectomy (CEA) earlier in the week had a shorter LOS and improved clinical outcomes compared to those treated before the weekend.nnnMETHODSnThe Vascular Quality Initiative database was queried for elective weekday CEAs performed for asymptomatic carotid stenosis from 2005 to 2017. Univariate and multivariate analyses were completed to compare outcomes based on the day of the week.nnnRESULTSnThere were 26,882 asymptomatic CEAs performed on Monday (20.3%), Tuesday (23.0%), Wednesday (21.3%), Thursday (18.8%), and Friday (16.6%). The mean patient age was 70.5xa0years, and 59.2% were male. Thirty-day mortality (0.4%) and perioperative complications including stroke (1.4%), myocardial infarction (0.7%), and return to the operating room (1.5%) were not significantly different across weekdays. Patients were discharged on statins in 84.2% of cases and aspirin in 91.5% of cases. The mean LOS ranged from 1.6xa0±xa02.2xa0days to 1.8xa0±xa03.2xa0days. CEAs performed on Fridays had a longer LOS (1.8xa0±xa02.4; Pxa0<xa00.001). Multivariate analysis demonstrated that CEAs performed on Friday had longer LOS compared to those performed on Monday through Thursday (means ratio: 1.05, 95% confidence interval [CI]: 1.03-1.07; Pxa0<xa00.001). However, there were no differences in perioperative complications to attribute this to. Friday CEA did not have an effect on discharge medication compliance with aspirin (odds ratio: 0.94, 95% CI: 0.82-1.07; Pxa0=xa00.339) or statin medications (odds ratio: 0.90, 95% CI: 0.79-1.03; Pxa0=xa00.126).nnnCONCLUSIONnAsymptomatic CEA performed before the weekend was associated with longer LOS although there were no differences in perioperative mortality, morbidity, and discharge medication compliance. Such LOS increase, albeit small, may affect the hospital profit margin for the procedure and performing an elective CEA on asymptomatic patients earlier in the week may benefit in a shorter LOS. Improved team staffing and resources on weekends are potential areas for improvement for earlier discharge; however, further investigation is needed.