Abstract Objective The neutrophil-to-lymphocyte ratio (NLR) has been used as a surrogate marker of systemic inflammation. We sought to investigate the association between NLR and wound healing in ...diabetic wounds. Methods The outcomes of 120 diabetic foot ulcers in 101 patients referred from August 2011 to December 2014 were examined retrospectively. Demographic, patient-specific, and wound-specific variables as well as NLR at baseline visit were assessed. Outcomes were classified as ulcer healing, minor amputation, major amputation, and chronic ulcer. Results The subjects' mean age was 59.4 ± 13.0 years, and 67 (66%) were male. Final outcome was complete healing in 24 ulcers (20%), minor amputation in 58 (48%) and major amputation in 16 (13%), and 22 chronic ulcers (18%) at the last follow-up (median follow-up time, 6.8 months). In multivariate analysis, higher NLR (odds ratio, 13.61; P = .01) was associated with higher odds of nonhealing. Conclusions NLR can predict odds of complete healing in diabetic foot ulcers independent of wound infection and other factors.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective It has been reported that a failed endovascular intervention adversely affects results of lower extremity bypass (LEB). We reviewed rates of prior endovascular intervention (PEI) in ...patients undergoing LEB with autologous vein for critical limb ischemia (CLI) to determine effects on graft patency, limb salvage, and amputation-free survival. Methods Retrospective review was conducted of consecutive autologous vein LEBs performed for CLI between 2005 and 2012 at a tertiary care academic medical center. Results Overall, 314 autologous vein LEBs were performed for CLI, 71% for tissue loss. TransAtlantic Inter-Society Consensus II type D or type C lesions were present in 62% and 25%, respectively. The great saphenous vein was used as a conduit in 83%, and the distal target was infrapopliteal in 60%. The 30-day mortality rate was 3.5%. Primary patency rates at 1 year and 5 years were 61% and 45%. Secondary patency rates at 1 year and 5 years were 88% and 64%, with 23% requiring an intervention to maintain patency. The 5-year limb salvage rate was 89%, and the 5-year amputation-free survival was 49%. There were 61 patients (19%) who had undergone a PEI and 253 (81%) who underwent bypass with no prior endovascular intervention (NPEI). There were 19 iliac stents, 29 femoral interventions, 13 popliteal interventions, 9 crural interventions, 9 infrainguinal thrombectomies, and 13 infrainguinal thrombolyses. PEI and NPEI patients had similar demographics and prevalence of atherosclerotic risk factors. The 1-year primary patency rate was 62% for NPEI patients vs 59% for PEI patients ( P = .759). The 1-year and 2-year secondary patency rates were 87% and 79% for NPEI patients vs 89% and 78% for PEI patients ( P = .947). The 3-year limb salvage rate was 89% for NPEI patients vs 92% for PEI patients ( P = .445). The 3-year amputation-free survival was 59% for NPEI patients vs 52% for PEI patients ( P = .399). Median follow-up time was 323 days for NPEI patients (interquartile range, 83-918) vs 463 days for PEI patients (interquartile range, 145-946; P = .275). Conclusions Overall operative mortality, patency rates, and limb salvage for autologous vein LEB in CLI patients continue to be excellent in the endovascular era and are not necessarily affected by a prior ipsilateral endovascular procedure. Long-term survival remains poor in CLI patients requiring LEB.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Previous studies have combined anastomotic, catheter-induced, and atherosclerotic isolated femoral artery aneurysms (FAAs) to achieve adequate numbers for analysis and have recommended ...repair of asymptomatic FAAs with diameters ≥2.5 cm and all symptomatic FAAs. This study evaluated the contemporary management of isolated FAAs. Methods Patients with FAAs were evaluated using a standardized, prospectively maintained database by a research consortium. Results From 2002 to 2012, 236 FAAs were identified in 182 patients (mean age, 72 years; male-to-female ratio, 16:1) at eight institutions. The mean nonoperative mean diameter was 2.8 ± 0.7 cm, and the operative diameter was 3.3 ± 1.5 cm. FAA location was the common femoral artery in 191, superficial femoral artery (SFA) in 34, and profunda femoris artery in 11. Synchronous aneurysms (mean, 1.7 per patient) occurred in the aorta (n = 113), in the iliac (n = 109), popliteal (n = 86), and hypogastric (n = 56) arteries, and in the contralateral common femoral artery (n = 34), SFA (n = 9), and profunda femoris artery (n = 2). Of the aneurysms repaired, 66% were asymptomatic; other indications for repair were claudication (18%), local pain (8%), nerve compression (3%), rupture (2%), acute thrombosis (1%), and rest pain (0.5%). Acute aneurysm-related complications (rupture, thrombosis, embolus) were associated ( P < .05) with FAA diameter >4 cm and intraluminal thrombus, but not location. Mean diameter of asymptomatic aneurysms that developed acute complications was 5.7 ± 1.3 cm for rupture, 4 ± 1.1 cm for thrombosis, and 3.5 cm for embolus. Repair was by interposition or bypass graft in 177 FAAs and by endovascular repair in three SFA aneurysms. Two perioperative deaths, of myocardial infarction and multisystem organ failure, occurred at 30 days. Operative complications included wound infection (6%), seroma (3%), and bleeding (2%). No amputations occurred through 5 years in the operative or nonoperative groups. Survival in operated-on patients was 99% (n = 138) at 3 months, 92% at 1 year, and 81% (n = 20) at 5 years. Conclusions This largest study of isolated FAAs demonstrates that (1) acute complications did not occur in FAAs ≤3.5 cm, repair criteria of asymptomatic FAAs should be changed to >3.5 cm, and chronic intraluminal thrombus should reduce the threshold for repair, and that (2) current indications for symptomatic FAA repair result in low morbidity and should remain unchanged.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective This study determined wound complication rates, intervention rates, failure mechanisms, patency, limb salvage, and overall survival after lower extremity revascularization using open vein ...harvest (OVH) vs endoscopic vein harvest (EVH) for critical limb ischemia. Methods A single-institution review was conducted of consecutive patients who underwent infrainguinal bypass with a single-segment reversed great saphenous vein between 2005 and 2012. Results A total of 251 patients with critical limb ischemia underwent revascularization, comprising 153 with OVH and 98 with EVH. The OVH group had a lower mean body mass index (26.7 vs 29.9 kg/m2 ; P = .001). There were no other differences in demographics, comorbidities, medications, smoking, or in the proximal or distal anastomotic site. Median operative times were 249 minutes (OVH) vs 316 minutes (EVH; P < .001). Median postoperative hospital length of stay was 7 days (OVH) vs 5 days (EVH; P < .001). Median follow-up was 295 days (OVH) vs 313 days (EVH; P = .416). During follow-up, 21 OVH grafts (14%) and 27 EVH grafts (28%) underwent an intervention ( P = .048). There were a similar number of surgical interventions: 50% (OVH) vs 61% (EVH; P = .449). Failed grafts had a mean of 1.2 stenoses per graft, regardless of harvest method. Median stenosis length was 2.1 cm (OVH) vs 2.5 cm (EVH; P = .402). At 1 and 3 years, the primary patency was 71% and 52% (OVH) vs 58% and 41% (EVH; P = .010), and secondary patency was 88% and 71% (OVH) vs 88% and 64% (EVH; P = .266). A secondary patency Cox proportional hazard model showed EVH had a hazard ratio of 2.93 (95% confidence interval, 1.03-8.33; P = .044). Overall and harvest-related wound complications were 44% and 29% (OVH) vs 37% and 12% (EVH; P = .226 and P = .002). At 5 years, amputation-free survival was 48% (OVH) vs 54% (EVH; P = .305), and limb salvage was 89% (OVH) and 91% (EVH; P = .615). Conclusions OVH and EVH have similar failure mechanisms, limb salvage, amputation-free survival, and overall survival. EVH is associated with impaired patency, increased need for intervention, longer operative times, shorter hospital stays, and decreased vein harvest site wound complications. OVH of the great saphenous vein may provide optimal patency but was not necessarily associated with better patient-centered outcomes. Similar limb salvage rates and amputation-free survival may justify the use of EVH, despite inferior patency, to capture shorter hospital stays and decreased wound complications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective Both runoff scores and direct (DR) vs indirect revascularization (IR) according to pedal angiosomes have unclear impact on outcome for patients with critical limb ischemia (CLI). We ...compared DR vs IR and runoff scores in CLI patients undergoing infrapopliteal bypass for foot wounds. Methods Patients who had tibial/pedal bypass for a foot/ankle wound from 2005-2011 were identified and operations classified as DR or IR based on wound location and bypass target. A blinded observer reviewed angiograms for an intact pedal arch and calculated standard Society for Vascular Surgery (single tibial) and modified (composite tibial) runoff scores. Comorbidities, wound characteristics, wound healing, major amputation, and overall survival were determined. Results A total of 106 limbs were revascularized in 97 patients; 54 limbs had DR and 52 had IR, although only 36% of wounds corresponded to a single, distinct angiosome. Wound characteristics and comorbidities were similar between groups. Mean standard (7.9 vs 7.2; P = .001) and modified (22.2 vs 20.0; P = .02) runoff scores were worse (higher number indicates worse runoff) in the IR vs DR groups; 33% had a complete pedal arch. Complete wound healing (78% vs 46%; P = .001) and time to complete healing (99 vs 195 days; P = .002) were superior with DR vs IR but were not influenced by runoff score, modified runoff score or presence of complete plantar arch. In multivariate models controlling for runoff score, DR remained a significant predictor for wound healing (odds ratio, 2.9; 95% confidence interval, 1.1-7.4; P = .028) and reduced healing time (hazard ratio, 2.1; 95% confidence interval, 1.2-3.7; P = .012). Mean amputation-free survival (75 vs 71 months for DR vs IR; P = .82) and median survival (36 vs 33 months DR vs IR; P = .22) were not different for DR vs IR. Conclusions DR according to pedal angiosomes provides more efficient wound healing, but is possible in only one-half of the patients and does not affect amputation-free or overall survival. DR is associated with improved runoff scores, but current runoff scores have little clinical utility in predicting outcomes in CLI patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives Peripherally inserted central catheters (PICCs) may be complicated by upper extremity (UE) superficial (SVT) or deep venous thrombosis (DVT). The purpose of this study was to determine ...current PICC insertion patterns and if any PICC or patient characteristics were associated with venous thrombotic complications. Methods All UE venous duplex scans during a 12-month period were reviewed, selecting patients with isolated SVT or DVT and PICCs placed ≤30 days. All UE PICC procedures during the same period were identified from an electronic medical record query. PICC-associated DVTs, categorized by insertion site, were compared with all first-time UE PICCs to determine the rate of UE DVT and isolated UE SVT. Technical and clinical variables in patients with PICC-associated UE DVT also were compared with 172 patients who received a PICC without developing DVT (univariable and multivariable analysis). Results We identified 219 isolated UE SVTs and 154 UE DVTs, with 2056 first-time UE PICCs placed during the same period. A PICC was associated with 44 of 219 (20%) isolated UE SVTs and 54 of 154 UE DVTs (35%). The rates of PICC-associated symptomatic UE SVT were 1.9% for basilic, 7.2% for cephalic, and 0% for brachial vein PICCs. The rates of PICC-associated symptomatic UE DVT were 3.1% for basilic, 2.2% for brachial, and 0% for cephalic vein PICCs (χ 2 P < .001). Univariate analysis of technical and patient variables demonstrated that larger PICC diameter, noncephalic insertion, smoking, concurrent malignancy, diabetes, and older age were associated with UE DVT ( P < .05). Multivariable analysis showed larger catheter diameter and malignancy were the only variables associated with UE DVT ( P < .05). Conclusions The incidence of symptomatic PICC-associated UE DVT is low, but given the number of PICCs placed each year, they account for up to 35% of all diagnosed UE DVTs. Larger-diameter PICCs and malignancy increase the risk for DVT, and further studies are needed to evaluate the optimal vein of first choice for PICC insertion.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Background Statins are recommended for use in patients with peripheral arterial disease (PAD) to reduce cardiovascular events and mortality. However, much of the data regarding benefits of ...statins stem from the cardiovascular literature. Here, we review the literature regarding statin use specifically in patients with PAD regarding its effects on cardiovascular events and mortality, limb-related outcomes, statin use after endovascular interventions, statin dosing, and concerns about statins. Methods We performed a literature review using PubMed for literature after the year 2000. Search terms included “statins,” “peripheral arterial disease,” “peripheral vascular disease,” “lipid-lowering medication,” and “cardiovascular disease.” Results There is good evidence of statins lowering cardiovascular events and cardiovascular-related mortality in patients with PAD. Though revascularization rates were reduced with statins, amputation rates and amputation-free survival did not improve. Small randomized controlled trials show that patients taking statins can slightly improve pain-free walking distance or pain-free walking time, although the extent of the effect on quality of life is unclear. Statin use for patients undergoing endovascular interventions is recommended because of the reduction of postoperative cardiovascular events. Not enough data exist to support local effects of systemic statin therapy, such as prevention of restenosis. For statin dosing, there is little increased benefit to intense therapy compared with the adverse effects, whereas moderate-dose therapy has significant benefits with very few adverse effects. Adverse effects of moderate-dose statin therapy are rare and mild and are greatly outweighed by the cardiovascular benefits. Conclusions There is strong evidence to support use of statins in patients with PAD to reduce cardiovascular events and mortality. Use in patients undergoing open and endovascular interventions is also recommended. Statin use may reduce the need for revascularization, but reductions in amputation have not been shown. Moderate-dose statin therapy is safe, and the minor risks are greatly outweighed by benefits.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
A modern series of acute aortic occlusion Crawford, Jeffrey D., MD; Perrone, Kenneth H., BS; Wong, Victor W., MD ...
Journal of vascular surgery,
04/2014, Volume:
59, Issue:
4
Journal Article
Peer reviewed
Open access
Objective Acute aortic occlusion (AAO) is a rare condition associated with substantial morbidity and mortality. The most recent large series was published over 15 years ago and included patients from ...the 1980s. Previous studies reported up to 50% of AAOs are caused by embolization, with a mortality rate approaching 50%. We reviewed our recent experience with AAOs to identify current etiologies and outcomes in a contemporary series of patients with AAOs. Methods Current Procedural Terminology codes and data from a prospectively maintained vascular surgical database were used to identify patients with acute occlusion of the native aorta between 2005 and July 2013. AAOs secondary to trauma, dissection, or graft occlusion were excluded. Results We identified 29 patients with AAOs treated at our institution. Twenty-three patients were transferred from referring hospitals with a mean transfer time of 3.9 hours (range, 0.5-7.5 hours). Twenty-two presented with occlusion below the renal arteries and seven with occlusion extending above the renal arteries. Resting motor/sensory lower extremity deficits were noted in 17 patients. Eight patients presented with complete paraplegia. Etiology was felt to be aortoiliac thrombosis in 22 cases, embolic occlusion in 2, and indeterminate in 5. Surgical revascularization was performed in 26 cases (extra-anatomic bypass in 18, thromboembolectomy in 5, and aortobifemoral bypass in 3 patients. Three patients had no intervention. Acute renal failure developed in 15 patients and rhabomyolysis in 10 patients. Fasciotomy was performed in 19 extremities. Nine extremities were amputated in six patients. Overall mortality was 34% with a 30-day mortality of 24% and a postprocedure mortality of 15%. Conclusions AAO is an infrequent but devastating event. The dominant etiology of AAOs is now thrombotic occlusion. Despite advances in vascular surgery and critical care over the past 2 decades, associated morbidity and mortality remain substantial with high rates of limb loss, acute renal failure, rhabdomyolysis, and death. Mortality may be improved with expeditious extra-anatomic bypass.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective The aim of this systematic review is to describe the literature and assessment tools evaluating vascular surgical operative performance that could potentially be used for the assessment of ...educational outcomes applicable to the Milestone Project and the Next Accreditation System. Methods A systematic review of PubMed/MEDLINE, EMBASE, PsycINFO, and key journals from 1985 to 2013 was performed to identify English-language articles describing assessment of vascular surgical skills and competence. Qualifying studies were abstracted for data concerning study aims, study and assessment setting, skills measured, and metrics used to determine competency. Strengths, weaknesses, and psychometric robustness of the assessment tools were determined. Results The literature search identified 617 citations. After title and abstract review, 65 articles were retrieved for full-text assessment and 48 articles were included in the final review. Twenty-nine articles assessed open vascular skills; 19, endovascular skills; six, nontechnical skills; and one, teamwork skills. The majority (84%) of studies were performed in a simulated environment, four (8%) were performed in the operating room, and the remaining three were performed in both a simulated environment and an operating room. Strengths and weaknesses of assessment tools were study and assessor dependent, with none applicable to all study scenarios or procedures. Conclusions The literature describing assessment tools pertinent to vascular surgery is diverse. Existing assessment tools may be relevant to individual technical skill acquisition assessment; however, an operative assessment tool relevant to vascular/endovascular surgery and generalizable to the wide spectrum of technical and nontechnical skills pertinent to vascular surgery needs to be developed, validated, and implemented to allow the practical assessment of resident readiness to operate in an unsupervised setting.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective Lifelong surveillance is recommended for both endovascular aneurysm repair and acute, uncomplicated type B thoracic aortic dissection, though compliance remains a significant challenge. We ...sought to determine factors associated with failure to obtain recommended surveillance. Methods Patients surviving to discharge who had endovascular repair of thoracic (thoracic endovascular aortic aneurysm repair TEVAR) or abdominal aortic aneurysms (endovascular aortic aneurysm repair EVAR) or medical management for type B dissections from 2004-2011 were reviewed. Primary end points were compliance with follow-up and need for reintervention. Comorbidities examined included coronary artery disease, congestive heart failure, hypertension, chronic obstructive pulmonary disease, diabetes, and chronic kidney disease. Socioeconomic factors examined were age, sex, distance from hospital, discharge destination (ie, home or skilled nursing facility), and insurance type. Endoleak and sac expansion were recorded, as were complications, including endograft migration, infection or thrombosis, and aneurysm degeneration. Results Two hundred four patients, median age 71.9 years, were identified; 171 had EVAR and 33 had type B dissection. EVAR patients included 45 thoracic, 100 abdominal, and 12 thoracoabdominal endografts, as well as 7 iliac artery aneurysm repairs and 7 proximal/distal graft extensions. Median follow-up was 28 ± 10.5 months. Overall, 56% were lost to follow-up, whereas 11% never returned for surveillance after initial hospitalization. Follow-up was compared for each of the comorbidities and socioeconomic factors; none were found to significantly affect follow-up. The known complication rate was 9.3% (n = 19), with reintervention performed in 14% of EVAR/TEVAR patients. Thirty-eight percent of medically managed patients with type B dissections eventually required surgical intervention. All-cause 5-year mortality was 27% as determined by the Social Security Death Index. Conclusions Despite a significant rate of reintervention following EVAR, TEVAR, and type B dissection, long-term compliance with surveillance is limited. In addition, predicting who is at risk of being lost to follow-up remains difficult. If current recommendations for lifelong surveillance are to be followed, coordinated protocols are required to capture EVAR, TEVAR, and type B dissection patients to ensure optimal follow-up for these patients. However, the lack of survival benefit in those with complete follow-up suggests that further study is needed with regard to ideal duration of long-term follow-up.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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