Recognizing the impact of the decision making by the dialysis access surgeon on the successful placement of autogenous arteriovenous hemodialysis access, the Society for Vascular Surgery assembled a ...multispecialty panel to develop practice guidelines in arteriovenous access placement and maintenance with the aim of maximizing the percentage and functionality of autogenous arteriovenous accesses that are placed. The Society commissioned the Knowledge and Encounter Research Unit of the Mayo Clinic College of Medicine, Rochester, Minnesota, to systematically review the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance. The panel then formulated practice guidelines in seven areas: timing of referral to the access surgeon, operative strategies to maximize the placement of autogenous arteriovenous accesses, first choice for the autogenous access, choice of arteriovenous access when a patient is not a suitable candidate for a forearm autogenous access, the role of monitoring and surveillance in arteriovenous access management, conversion of a prosthetic arteriovenous access to a secondary autogenous arteriovenous access, and management of the nonfunctional or failed arteriovenous access. For each of the guidelines, the panel stated the recommendation or suggestion, discussed the evidence or opinion upon which the recommendation or suggestion was made, detailed the values and preferences that influenced the group's decision in formulating the relevant guideline, and discussed technical remarks related to the particular guideline. In addition, detailed information is provided on various configurations of autogenous and prosthetic accesses and technical tips related to their placement.
Objective The purpose of this study was to compare the knowledge base and surgical skills of 0/5 integrated resident (IR) and 5/2 independent fellow (IF) vascular surgery trainees using milestones. ...Methods An anonymous survey, endorsed by the Association of Program Directors in Vascular Surgery, was sent to all program directors (PDs) of IR and IF training programs. The survey asked PDs to assess their trainees' milestones in postgraduate year (PGY) 4 to 7 pertinent to knowledge base and surgical skills using a 5-point Likert scale. The PDs were then asked to choose their trainees' three strongest and weakest milestones and to select from a list which factors were contributing most to the trainees' strengths and weaknesses. Results were grouped by training paradigm and year, with comparisons made between IR PGY4 and PGY 6 trainees and IF PGY5 and PGY7 trainees. Milestone means and strengths, weaknesses, and contributing factor response rates were compared using a Mann-Whitney U test. Results Of 166 surveys sent, 56 (34%) PDs replied and evaluated a total of 87 trainees, 12 IR PGY4, 12 IR PGY5, 35 IF PGY6, and 28 IF PGY7. IR PGY4s were found to be lower than IF PGY6s in knowledge of procedural anatomy, and there was a trend that all IR PGY4 milestones were lower than IF PGY6 milestones. There was no difference in ranking of strongest milestones. Open surgical skills were ranked as a weakness of IR PGY4s more than of IF PGY6s. Time spent on vascular surgery call contributed more to the IR PGY4's strengths, whereas time spent on general surgery contributed more to the IF PGY6's strengths. Not enough time spent in outpatient clinics contributed more to the IR PGY4's weaknesses, whereas no factors contributed more to the IF PGY6's weaknesses. IR PGY5s were found to be lower than IF PGY7s in open surgical skills, and there was a trend that all IR PGY5 milestones were lower than IF PGY7 milestones. Open surgical skills were ranked as a strength of IF PGY7s more than of IR PGY5s. Open surgical skills were ranked as a weakness of IR PGY5s more than of IF PGY7s. No factors contributed more to the IR PGY5's strengths, whereas time spent on general surgery contributed more to the IF PGY7's strengths. Not enough time spent in the vascular laboratory and performing open surgical procedures contributed more to the IR PGY5's weaknesses, whereas no factors contributed more to IF PGY7's weaknesses. Conclusions PDs of IR trainees should consider increasing time on general surgery and performing open surgical procedures.
Background The relationship of hyperglycemia to general surgery outcomes is not well-understood. We studied the association of operative day and postoperative day 1 (POD1) blood glucose (BG) with ...outcomes after open colectomy for cancer. Study Design We retrospectively analyzed the 2000-2005 Veterans Affairs Surgical Quality Improvement Program database, linked with Veterans Affairs Decision Support System BG values. Median BG was categorized as hypoglycemic (<80 mg/dL); normoglycemic (BG 80−120 mg/dL); or mildly (BG 121−160 mg/dL), moderately (BG 161−200 mg/dL), or severely (BG >200 mg/dL) hyperglycemic. The relationship of BG to postoperative outcomes was assessed with multivariable logistic regression. Results We identified 9,638 colectomies. We excluded 511 procedures for emergency status or preoperative coma, mechanical ventilation, or sepsis. After excluding patients without recorded BG, we analyzed operative day and POD1 BG in 7,576 and 5,773 procedures, respectively. On multivariable analysis, operative day moderate hyperglycemia was associated with surgical site infection (odds ratio = 1.44; 95% CI, 1.10−1.87). POD1 severe hyperglycemia was associated with cardiac arrest (odds ratio = 2.31; 95% CI, 1.08−4.98) and death (odds ratio = 1.97; 95% CI, 1.23−3.15). POD1 mild (odds ratio = 2.20; 95% CI, 1.05−4.60), moderate (odds ratio = 3.44; 95% CI, 1.51−7.84), and severe (odds ratio = 3.94; 95% CI, 1.64−9.58) hyperglycemia and hypoglycemia (odds ratio = 6.74; 95% CI, 1.75−25.97) were associated with myocardial infarction. Associations were similar in diabetic and nondiabetic patients. Conclusions Even mild hyperglycemia was associated with adverse outcomes after colectomy, suggesting that a perioperative BG target of 80 to 120 mg/dL, although avoiding hypoglycemia, might be appropriate. Randomized clinical trials are needed to confirm these findings.
AbstractObjectiveIschemic colitis is a rare but devastating complication of endovascular repair of infrarenal abdominal aortic aneurysms. Although it is rare (0.9%) in standard endovascular aneurysm ...repair (EVAR), the incidence increases to 2% to 3% in EVAR with hypogastric artery embolization (HAE). This study investigated whether preservation of pelvic perfusion with iliac branch devices (IBDs) decreases the incidence of ischemic colitis. MethodsWe used the targeted EVAR module in the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing EVAR of infrarenal abdominal aortic aneurysm from 2012 to 2017. The cohort was further stratified into average-risk and high-risk groups. Average-risk patients were those who underwent elective repair for sizes of the aneurysms, whereas high-risk patients were repaired emergently for indications other than asymptomatic aneurysms. Within these groups, we examined the 30-day outcomes of standard EVARs, EVAR with HAE, and EVAR with IBDs. The primary outcome was the incidence of ischemic colitis. Secondary outcomes included mortality, major organ dysfunction, thromboembolism, length of stay, and return to the operating room. The χ2 test, Fisher exact test, Kruskal-Wallis test, and multivariate regression models were used for data analysis. ResultsThere were 11,137 patients who had infrarenal EVAR identified. We designated this the all-risk cohort, which included 9263 EVAR, 531 EVAR-HAE, and 1343 EVAR-IBD procedures. These were further stratified into 9016 cases with average-risk patients and 2121 cases with high-risk patients. In the average-risk group, 7482 had EVAR, 411 had EVAR-HAE, and 1123 had EVAR-IBD. In the high-risk group, 1781 had EVAR, 120 had EVAR-HAE, and 220 had EVAR-IBD. There was no significant difference in 30-day outcomes (including ischemic colitis) between EVAR, EVAR-HAE, and EVAR-IBD in the all-risk and high-risk groups. In the average-risk cohort, EVAR-HAE was associated with a higher mortality rate than EVAR (2.2% vs 1.0%; adjusted odds ratio, 2.58; P = .01). Although EVAR-IBD was not superior to EVAR-HAE in 30-day mortality, major organ dysfunction, or ischemic colitis in this average-risk cohort, EVAR-IBD exhibited a trend toward lower mortality compared with EVAR-HAE in this cohort, but it was not statistically significant (1.0% vs 2.2%; adjusted odds ratio, 0.42; P = .07). ConclusionsIschemic colitis is a rare complication of EVAR. HAE does not appear to increase the risk of ischemic colitis, and preservation of pelvic perfusion with IBDs does not decrease its incidence. Although HAE is associated with significantly higher mortality than standard EVAR in average-risk patients, the preservation of pelvic perfusion with IBDs does not appear to improve mortality over HAE.
Background This study examined impact of obesity on outcomes after abdominal aortic aneurysm repair. Study Design Data were obtained from the Veterans Affairs National Surgical Quality Improvement ...Program. Body mass index (BMI) was categorized according to National Institutes of Health guidelines. Multivariate regression adjusted for 40 other risk factors to analyze trends in complications and death within 30 days. Results We identified 2,201 patients undergoing 1,185 open and 1,016 endovascular aneurysm repairs (EVAR) for abdominal aortic aneurysms from January 2004 through December 2005. BMI distribution was identical in both groups and reflected national population statistics: approximately 30% were normal (BMI 18.5 to 24.9), 40% were overweight (25.0 to 29.9), and 30% were obese class I (30.0 to 34.9), II (35.0 to 39.9), or III (≥40.0). After open repair, obesity of any class was independently predictive of wound complications (adjusted odds ratio = 2.4; 95% CI, 1.5 to 5.3; p = 0.002). Class III obesity was also an independent predictor or renal complications (adjusted odds rato = 6.3; 95% CI, 2.2 to 18.0; p < 0.0001) and cardiac complications (adjusted odds ratio = 4.5; 95% CI, 1.1 to 22.9; p = 0.045. After EVAR, obesity (any class) was predictive of wound complications (adjusted odds ratio = 3.1; 95% CI, 1.1 to 8.1; p = 0.026), but not predictive of other complications or death. Between the two types of operation, there were fewer complications and deaths after EVAR compared with open repair across all BMI categories, but outcomes were most disparate among the obese. Conclusions Obesity is an independent risk factor that surgeons should consider during patient selection and operative planning for abdominal aortic aneurysm repair. Obese patients appear to particularly benefit from successful EVAR over open repair, but if open repair is required, special attention should be paid to cardiac risk, perioperative renal protection, and aggresive wound infection prevention measures.
Background The role of obesity as a risk factor after carotid endarterectomy is not well-described. We undertook a study of the association of obesity with 30-day outcomes after carotid ...endarterectomy. Study Design After obtaining Institutional Review Board approval, we retrospectively analyzed prospectively collected data from carotid endarterectomies in the 2005−2006 Veterans Affairs Surgical Quality Improvement Program database. The association of body mass index (BMI; calculated as kg/m2 ) on 30-day outcomes was assessed using multivariable logistic regression. Results From 3,706 carotid endarterectomies, we excluded 22 for missing BMI and 39 for emergency status; 3,645 carotid endarterectomies were analyzed. BMI was underweight (<18.5) in 1.6%, normal (18.5 to 24.9) in 31.0%, overweight (25.0 to 29.9) in 40.8%, class I obese (30.0 to 34.9) in 19.3%, class II obese (35.0 to 39.9) in 5.8%, and class III obese (≥40) in 1.6%. On multivariable analysis, class II to III (odds ratio = 6.95; 95% CI, 1.89−25.58; p = 0.004) obesity was associated with death, and class II to III obesity was associated with cardiac complications (odds ratio = 3.68; 95% CI, 1.27−10.66; p = 0.02) compared with normal weight. Conclusions Obesity is an independent risk factor for death and cardiac complications after carotid endarterectomy. Surgeons should consider this when evaluating the risks and benefits of carotid endarterectomy in obese patients. Carotid artery stenting was not assessed, and future studies are needed to examine its role in management of obese patients.
Background This study aimed to analyze outcomes of surgical management for popliteal artery aneurysms (PAA). Methods This is a retrospective analysis of prospectively collected data regarding ...operations for PAA obtained from 123 United States Veterans Affairs Medical Centers as part of the National Surgical Quality Improvement Program. Univariate analyses and multivariate logistic regression were used to characterize 33 risk factors and their associations with 30-day morbidity and mortality. Survival and amputation rates, observed at one and two years after surgery, were subject to life-table and Cox regression analyses. Results There were 583 operations for PAA in 537 patients during 1994-2005. Almost all were in men (99.8%) and median age was 69 years (range, 34 to 92 years). Most had multiple co-morbidities, 88% were ASA (American Society of Anesthesiologists) class 3 or 4, and 81% were current or past smokers (median pack-years = 50). Only 16% were diabetic. Serious complications occurred in 69 (11.8%) cases, of which 37 (6.3%) required arterial-specific reinterventions. Eight patients died within 30 days, a mortality of 1.4%. Risk factors associated with increased complications included: African-American race (odds ratio OR 2.8 95% confidence interval 1.5-5.2, P = .002), emergency surgery (OR 3.8 2.0-7.0, P < .0001), ASA 4 (OR 1.9 1.1-3.5, P = .04), dependent functional status (OR 2.5 1.4-4.7, P = .004), steroid use (OR 3.2 1.2-8.7, P = .03), and need for intraoperative red blood cell transfusion of any quantity (OR 6.3 3.5-11.2, P < .0001). Independent predictors for complications in the multivariate model were dependent functional status (adjusted OR 2.1 1.1-4.3, P = .049) and intraoperative transfusion (adjusted OR 4.5 2.3-8.9, P = .0002). Postoperative bleeding complications within 72 hours independently predicted early amputation (adjusted OR 25.5 1.7-393, P = .02). Unadjusted patient survival was 92.6% at one year and 86.1% at two years. Limb salvage in surviving patients was 99.0% at 30 days, 97.6% at one year, and 96.2% at two years. Dependent preoperative functional status was the only factor predictive of worse two-year limb salvage (adjusted OR 4.6 1.9-10.9, P = .001), but remained high at 88.2% versus 97.1% in independent patients. Conclusions Surgical intervention for PAA is associated with low operative mortality and offers excellent two-year limb salvage, even in high-risk patients. Patients' preoperative functional status and perioperative blood transfusion requirements were the most predictive indicators of negative outcomes.
Objective Dialysis access failure is a major cause of morbidity, mortality, and cost in end-stage renal disease. We undertook a study to determine the influence of medication use on dialysis access ...failure. Methods After institutional review board approval, we performed a retrospective analysis of all upper extremity hemodialysis accesses placed from 2005 to 2009 at the Washington DC Veterans Affairs Medical Center. For each access, the date of failure was recorded. For patients who died or were lost to follow-up, the date of the last documented functional patency (censoring) was recorded. The primary exposures were 12 medication classes. Patient demographics, behaviors, comorbidities, and access characteristics were used as covariates. Patency rates were calculated using Kaplan-Meier methods. Cox proportional hazard models controlling for patient characteristics and all medication classes, with procedures clustered within patients, were used to determine the influence of medication class on primary patency. Results Two hundred sixty autogenous and 126 prosthetic newly placed accesses were identified. Of these, three lower extremity accesses and six accesses with unknown thrombosis date were excluded. Forty-five (18%) of the remaining 257 autogenous accesses were excluded for primary nonfunctionality (patent, but with inadequate venous dilatation for initial hemodialysis), because the primary outcome was long-term functional patency. The remaining 212 autogenous and 120 prosthetic accesses were analyzed. Primary patency rates at 1 and 2 years were 55.2% and 49.1% for autogenous accesses, and 50.2% and 29.7% for prosthetic accesses, respectively. On multivariable analysis, angiotensin receptor blockers (ARBs) were associated with reduced hazard of both autogenous (hazard ratio HR, 0.35; 95% confidence interval CI, 0.16-0.76; P = .008) and prosthetic (HR, 0.41; 95% CI, 0.18-0.95; P = .039) access failure. On subgroup analysis, ARBs prolonged autogenous access primary patency among patients receiving antiplatelet medication (aspirin, clopidogrel; HR, 0.16; 95% CI, 0.05-0.52; P = .002) but had no demonstrable benefit among patients not receiving antiplatelets (HR, 1.35; 95% CI, 0.34-5.31; P = .670). There were no significant drug–drug interactions in the analysis of prosthetic accesses. Weighted regression models demonstrated low multicollinearity among the model variables. Conclusion Our data suggest that therapy with an ARB plus antiplatelet agent is associated with prolonged autogenous access primary patency, and therapy with an ARB with or without antiplatelet agents is associated with prolonged prosthetic access primary patency. Randomized studies are needed to confirm the causal role of ARBs and to determine the optimal therapeutic regimen (dose, timing, and duration) to promote access patency.
Abstract Background Functional status is a simple and rapidly assessable metric that may be used as a predictor for surgical outcomes. This study examined the association of functional status with ...short-term mortality after abdominal aortic aneurysm (AAA) repair in octogenarians to characterize the utility of functional status as a means of preoperative risk assessment. Methods All patients who underwent endovascular and open AAA repair from 2002 to 2010 within the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database were identified. Functional status, defined as an ordinal scale from 1 to 3 (1, independent; 2, partially dependent; 3, totally dependent), was examined using multivariate regression models with 30-day mortality as the primary outcome. For the purpose of analysis, this 3-point scale was converted into a binomial scale of function, with “normal” including 1 (completely independent) and “abnormal” including 2 or 3 (partially to totally dependent). Results We identified 9030 patients who underwent AAA repair (46.6% open and 53.4% endovascular). Mortality at 30 days was 2.8% for the entire cohort (4.2% open, 1.7% endovascular; P < .001). There were 1340 patients aged ≥80 years, of which 67.3% underwent endovascular AAA repair. Among all age groups, functional status was a significant predictor of 30-day mortality (<80 years, P < .001; ≥80 years, P < .001). The ≥80 cohort with abnormal function status also demonstrated increased operative mortality ( P = .002), length of stay ( P = .001), and incidence of pulmonary complications ( P = .025) compared with the cohort with normal functional status. Multivariate logistic regression demonstrated that within the ≥80-year-old cohort, only functional status remained a significant predictor of mortality ( P < .001). In addition, the strength of the association between functional status and mortality was greater in the older cohort than in the younger one (Cox regression hazard ratio: 3.13 vs 2.18). Conclusions Functional status is a simple and rapidly applicable predictor of mortality within AAA patients and may be a useful tool to help preoperatively risk-stratify elderly patients presenting with AAA in need of repair. Further studies are needed to understand how best to apply these data to the clinical setting to guide preoperative decision making.
AbstractObjectiveCarotid endarterectomy (CEA) is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. However, in the modern era, the benefit of CEA in ...asymptomatic octogenarian patients has come into question. This study investigates real-world outcomes of CEA in asymptomatic octogenarians. MethodsPatients who underwent CEA for asymptomatic carotid stenosis were identified in the American College of Surgeons National Surgical Quality Improvement Program CEA-targeted database from 2012 to 2017. They were stratified into two groups: octogenarians (≥80 years old) and younger patients (<80 years old). The 30-day outcomes evaluated included mortality and major morbidities such as stroke, cardiac events, pulmonary, and renal dysfunction. Multivariable logistic regression was used for data analysis. ResultsWe identified 13,846 patients with asymptomatic carotid stenosis who underwent an elective CEA including 2509 octogenarians and 11,337 younger patients. Octogenarians were more likely to be female and less likely to be diabetic or smokers compared with younger patients. There was no difference in preoperative use of statins or antiplatelet therapy. Examination of 30-day outcomes revealed that octogenarians had slightly higher mortality (1.2% vs 0.5%; odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P < .01), and a higher risk of return to the operating room (3.3% vs 2.3%; odds ratio, 1.4; 95% confidence interval, 1.1-1.9; P = .01). However, there was no difference between octogenarians and younger patients in adverse cardiac events or pulmonary, renal, or wound complications. Twenty-five octogenarian and 138 younger patients suffered from periprocedural stroke at a similar rate (1.0% vs 1.2%; P = .54). Stroke/death occurred for 51 of 2509 patients (2.0%) in the older group and 184 of 11,337 patients (1.6%) in the younger group, a difference that was not significant ( P = .15). ConclusionsThe 30-day outcomes of CEA in octogenarians are comparable with those in younger patients. Although the octogenarians had slightly higher mortality than younger patients, the absolute risk of mortality was still low at 1.2%. Therefore, CEA is safe in asymptomatic carotid stenosis in octogenarians. Overall life expectancy and preoperative functional status, rather than age, should be the major determinants in the decision to operate.
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