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OBJECTIVE: The frequency of atherectomy in lower extremity arterial disease has increased substantially over the past several years, specifically in the office-based laboratory (OBL) setting, yet the efficacy compared with other interventions and the consequences of distal embolization remain unknown. Embolic protection devices (EPDs) have been used at varying rates depending on physician and practice setting. Previous studies have described lesion characteristics to consider when weighing the benefits and drawbacks associated with device use. Our study focuses on the use of atherectomy and EPDs in femoropopliteal arterial disease to better characterize resource use trends and postoperative outcomes in the inpatient and OBL interventional settings. METHODS: We conducted a retrospective analysis on endovascular interventions performed for femoral-popliteal occlusive disease that were entered into the Vascular Quality Initiative data registry between 2017 and 2021. A one:one greedy match, adjusted analysis based on inpatient or OBL location of procedure was used to compare the groups. Hierarchical logistical regression with selective use of principal component analysis was used to further explore the differences in EPD use and immediate postoperative outcomes. A proportional hazard model was used to demonstrate differences in reintervention rates up to 2 years postoperatively between patients who underwent atherectomy in the inpatient vs OBL treatment setting. RESULTS: 2849 matched pairs were inlcuded in the final analysis. In our cohort, there was 22% EPD use overall, 40% in the hospital setting and 4.4% in the OBL setting (P < .001). Among the patients with available follow-up information, OBL intervention setting increased probability of reintervention by 18% at 2 years postoperatively compared with the inpatient setting; however, there was no difference associated with EPD placement and rate of reintervention. CONCLUSIONS: Use of EPDs in the OBL setting compared with the hospital setting is dramatically decreased; however, no increased incidence of postoperative complications was seen compared to procedures performed in the hospital setting when controlling for patient and lesion characteristics. Patients with available follow-up data were more likely to undergo ipsilateral reintervention between 6 months and 2 years postoperatively if atherectomy was done in the OBL setting. Dedicated studies are encouraged to ensure patient safety, effective resource allocation, and long-term efficacy of OBL atherectomy as an ever-growing number of peripheral arterial procedures are transitioned to the OBL setting.

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BACKGROUND: Recent research shows that placement of an intraluminal shunt during a carotid endarterectomy (CEA) can be associated with postoperative complications. Therefore, we compared CEA operations with or without shunting to further analyze their clinical outcomes. METHODS: From the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,736 cases between 2016 and 2019 were analyzed to compare adult symptomatic and asymptomatic carotid stenosis patients who underwent a CEA operation, with or without shunt placement. RESULTS: Rates of stroke with a neurological deficit (p = 0.012), myocardial infarction (p = 0.021), and urinary tract infection (p = 0.030) were higher among symptomatic patients with shunting. Multivariate logistic regression revealed that risk of CNI was higher among both symptomatic (93.63%, p < 0.001) and asymptomatic (69.58%, p = 0.001) patients with shunting, irrespective of confounding variables. CONCLUSION: Shunting was found to be associated with higher rates of postoperative complications in both symptomatic and asymptomatic patient populations.

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OBJECTIVE: Underinsured patients can experience worse preoperative medical optimization. We aimed to determine whether insurance status was associated with carotid endarterectomy (CEA) urgency and postoperative outcomes. METHODS: We analyzed the Society for Vascular Surgery Vascular Quality Initiative Carotid Endarterectomy dataset from January 2012 to January 2021. Univariable and multivariable methods were used to analyze the differences across the insurance types for the primary outcome variable: CEA urgency. The analyses were limited to patients aged <65 years to minimize age confounding across insurers. We also examined differences in preoperative medical optimization and symptomatic disease and postoperative outcomes. A secondary analysis was performed to examine the effect of CEA urgency on the postoperative outcomes. RESULTS: A total of 27,331 patients had undergone first-time CEA. Of these patients, 4600 (17%) had Medicare, 3440 (13%) had Medicaid, 17,917 (65%) had commercial insurance, and 1374 (5%) were uninsured. The Medicaid and uninsured patients had higher rates of urgent operation compared with Medicare (20.0% and 34.7% vs 14.4%; P < .001), with no differences in the commercial group vs the Medicare group. Additionally, Medicaid and uninsured patients had lower rates of aspirin, statin, and/or antiplatelet use (93.6% and 93.5% vs 95.8%; P < .001) and higher rates of symptomatic disease (42.1% and 57.6% vs 36.2%; P < .001) compared with Medicare patients. The rate of perioperative stroke/death was higher for the Medicaid and uninsured patients than for the Medicare patients (1.63% and 1.89% vs 1.02%; P = .017 and P = .01, respectively), with no differences in the commercial group. Multivariable analysis demonstrated that compared with Medicare, Medicaid and uninsured status were associated with increased odds of an urgent operation (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5; and OR, 2.3; 95% CI, 2.0-2.7, respectively), symptomatic disease (OR, 1.2; 95% CI, 1.1-1.4; and OR, 2.2; 95% CI, 1.9-2.5, respectively), and perioperative stroke/death (OR, 1.6; 95% CI, 1.1-2.4; and OR, 1.8; 95% CI, 1.1-3.0, respectively) and a decreased odds of aspirin, statin, and/or antiplatelet use (OR, 0.71; 95% CI, 0.6-0.9; and OR, 0.76; 95% CI, 0.6-0.99, respectively). Additionally, the rates of perioperative stroke/death were higher for patients who had required urgent surgery compared with elective surgery (2.8% vs 1.0%; P < .001). Multivariable analysis demonstrated increased odds of perioperative stroke/death for patients who had required urgent surgery (OR, 2.4; 95% CI, 1.9-3.1). CONCLUSIONS: Medicaid and uninsured patients were more likely to require urgent CEA, in part because of poor preoperative medical optimization. Additionally, urgent operation was independently associated with worse postoperative outcomes. These results highlight the need for improved preoperative follow-up for underinsured populations.

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OBJECTIVE: Carotid revascularization within 14 days of a neurologic event has been recommended by society guidelines. Transcarotid artery revascularization (TCAR) carries the lowest overall stroke rate for any carotid artery stenting technique. However, the outcomes of TCAR within 14 days of a neurologic event have not been directly compared with those after carotid endarterectomy (CEA). METHODS: We compared the 30-day outcomes of symptomatic patients who had undergone TCAR and CEA within 14 days of a stroke or transient ischemic attack (TIA) from January 2016 to February 2020 using the Society for Vascular Surgery Vascular Quality Initiative carotid artery stenting and CEA databases. Propensity score matching was used to adjust for patient risk factors. The primary outcome was a composite of postoperative ipsilateral stroke, death, and myocardial infarction (MI). RESULTS: A total of 1281 symptomatic patients had undergone TCAR and 13,429 patients had undergone CEA within 14 days of a neurologic event. After 1:1 propensity matching, 728 matched pairs were included for analysis. The primary composite outcome of stroke, death, or MI was more frequent in the TCAR group (4.7% vs 2.6%; P = .04). This was driven by a higher rate of postoperative ipsilateral stroke in the TCAR group (3.8% vs 1.8%; P = .005). No differences were found between TCAR and CEA in terms of death (0.7% vs 0.8%; P = .8) or MI (0.8% vs 1%; P = .7). Although TCAR procedures were shorter (median, 69 minutes [interquartile range, 53-85 minutes]; vs median, 120 minutes [interquartile range, 93-150 minutes]; P < .001) and the postoperative length of stay was similar (2 days; P = .3) compared with CEA, the TCAR patients were more likely to be discharged to a facility other than home (26% vs 19%; P < .01). Performing TCAR within 48 hours of a stroke was an independent predictor of postoperative stoke or TIA (odds ratio, 5.4; 95% confidence interval, 1.8-16). This increased risk of postoperative stroke or TIA was not found when performing TCAR within 48 hours of a TIA. CONCLUSIONS: TCAR within 14 days of a neurologic event resulted in higher ipsilateral postoperative stroke rates compared with CEA, especially when performed within 48 hours after a stroke.

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BACKGROUND: Preoperative functional status is appreciated as a key determinant of decision-making when evaluating patients for complex elective surgeries. We used the Vascular Quality Initiative to analyze the effect of being able to independently ambulate on outcomes after open abdominal aortic aneurysm (AAA) repairs. METHODS: We identified all patients who underwent elective or urgent open AAA repairs from January 2013 to August 2019 in the Vascular Quality Initiative registry. We recorded demographic variables, comorbidities, and operative factors such as approach, operative ischemia time, proximal clamp site, and presence of iliac aneurysms. Short-term and long-term outcomes included 30-day mortality, any perioperative complications, failure to rescue (defined as death after a complication), and 1-year all-cause mortality. We dichotomized patients based on their ability to independently ambulate (Ambulatory) or inability to ambulate independently (Non-Ambulatory) and used both multivariable logistic regressions and cox-proportional hazards models to evaluate outcomes. RESULTS: Of 5,371 patients, 328 (6.1%) could not ambulate independently and were more likely to be older (median age 69 vs. 72), female (25% vs. 38%), and have greater comorbidities. Overall outcomes were: 4.3% for 30-day mortality, 38.7% for complications, 10.2% for failure-to-rescue, and 6.9% for 1-year mortality. Univariate analysis showed higher rates of all adverse outcomes in non-ambulatory patients. On adjusted analysis, non-ambulatory patients had increased odds of complications by 46% (OR 1.46 [95%-CI 1.11-1.91]) and 1-year mortality by 46% (HR 1.46 [95%-CI 1.06-1.99]), but not failure to rescue (OR 1.05 [95%-CI 0.67-1.62]) or 30-day mortality (OR 1.22 [95%-CI 0.82-1.81]). Increased hospital volume, age, and increased operative renal ischemia time were independently associated with adverse outcomes. CONCLUSIONS: Non-ambulatory status was observed in a small percentage of patients undergoing open AAA repair but was associated with higher rates of post-operative complications and 1-year mortality. Ambulatory capacity is one of the key determinants of outcomes following open AAA repair. In patients with poor ambulatory function, a conservative approach is highly recommended over invasive open surgical intervention.

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OBJECTIVE: Patients without adequate outpatient follow-up often present requiring emergency hemodialysis and then undergo permanent dialysis access placement at a later time. We sought to examine the relationship between type of insurance and whether a patient was already on dialysis at time of surgery. METHODS: The Vascular Quality Initiative Hemodialysis Access registry was queried for all adult patients undergoing first time permanent hemodialysis access between January 2015 and September 2019. Patient and procedural characteristics were examined in patients split by private insurance-Medicare more than 65 years of age, Medicare less than 65 years of age, and Medicaid. The primary outcome was whether patients were on dialysis at the time of surgery. RESULTS: There were 19,307 adult patients that underwent first time placement of an arteriovenous fistula or graft. Of these patients, 9729 (50%) had Medicare, 7179 (37%) had private insurance, and 2399 (12%) had Medicaid. The patients with Medicare were subgrouped by age with 2968 (31%) being less than 65 years of age and 6761 (69%) being more than 65 years of age. Patients with Medicare and less than 65 were the most likely to be on dialysis at the time of surgical access placement at 67%, whereas 59% of Medicaid patients were on dialysis, and 53% each group of patients with Medicare and more than 65 years of age and private insurance were on dialysis. After adjustment for patient characteristics, patients with Medicare who were less than 65 and more than 65 years of age were both significantly more likely to be on dialysis at time of surgery compared with private insurance with odds ratio (OR) of 1.64 (95% confidence interval [CI], 1.49-1.80; P < .001) and an OR of 1.11 (95% CI, 1.03-1.20; P = .007), respectively. After adjustment, patients with Medicaid were no longer significantly more likely to be on dialysis. Secondary outcomes demonstrated, after adjustment, no difference in the association between a surgical fistula vs graft in any insurance groups; however, patients with Medicare and who were less than 65 years of age were more likely to have a nonradial artery used for anastomosis with an OR of 1.18 (95% CI, 1.04-1.34; P = .011). CONCLUSIONS: Certain types of insurance are correlated with being on dialysis at the time of access placement. Although associations were seen between insurance type and surgical access characteristics, these were associations predominantly insignificant when patient demographics and status of dialysis were controlled for. These potential gaps in care represent an area for improvement that deserves further exploration.

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Objectives: To understand the impact that video telehealth has on outpatient visit volume and reimbursement as a method of maintaining care. Background: As the coronavirus disease 2019 (COVID-19) spread across the United States starting in 2020, it caused numerous areas of medicine and healthcare to reexamine how we provide care to patients across all disciplines. One method clinicians used to rapidly adapt to these transformed settings was video telehealth, which was previously rarely used. Methods: This retrospective review examined outpatient volume and reimbursement data of a large, academic department of surgery. The study reviewed data during 2 time periods: pre-COVID-19 (February 1, 2020, to March 15, 2020) and COVID-19 (March 16, 2020, to April 30, 2020). Results: During the period of February 1 to April 30, 13,193 outpatient visits were analyzed. The pre-COVID-19 group contained 9041 (68.5%) visits, whereas the COVID-19 group contained 4152 (31.4%) visits. All divisions noted a drop in visit volume from pre-COVID-19 compared with COVID-19. There was rapid adoption of video telehealth during COVID-19, which made up most patient visits during that time (61.3%). We also found that video telehealth led to significant reimbursements while also allowing patients in numerous states to receive care. Conclusions: Previously, video telehealth was used by clinicians in a small portion of outpatient visits. However, safety concerns surrounding COVID-19 forced multiple changes to the way care is provided. Although outpatient volume at our center was less than that before the pandemic, video telehealth was rapidly adopted by providers and allowed for safe and effective outpatient care to patients in a high number of states while still being reimbursed at a high rate.

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A 65-year-old woman presented to our institution with 4 months of severe pain on the plantar aspect of her foot. She had chronic foot pain secondary to Morton's neuroma and had recently undergone neurectomy. She was found to have a large pseudoaneurysm on the plantar aspect of her foot. She was taken to the operating room for an open repair from a plantar approach. We obtained the patient's consent to publish this case.

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As associated co-morbidities have transformed over time, the evaluation and management of peripheral arterial disease have evolved as well. New classification systems have been created to better understand the severity of a patient's condition and the risk of amputation. These classifications include the Wound, Ischemia, and Foot Infection (WIfI) and Global Anatomic Staging System (GLASS) classification systems. Through the utility of these systems, a patient's disease can be appropriately staged and managed with medical, endovascular, or surgical therapies or a combination of these. Endovascular therapies specifically have grown with the explosion of new technologies. There are numerous options for patients with disease amenable to endovascular therapy. In this review article, we discuss a number of these different endovascular therapies as well as the new classification systems.

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The perceived prevalence of renal artery aneurysms is increasing, probably because of the widespread use of cross-sectional imaging. The majority of these aneurysms are found incidentally and are asymptomatic. There are no clear guidelines for when to repair these aneurysms, although most practitioners recommend intervention around the 2- to 3-cm size cutoff. These can be managed endovascularly or with open surgery; however, aneurysms at the hilum may require a complex repair to avoid nephrectomy. We present a case of a hilar renal artery aneurysm managed with laparoscopic nephrectomy with ex vivo aneurysm resection and repair followed by autotransplantation.

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A 17-year-old girl presented to our institution with abdominal and pelvic pain found to be due to extrinsic compression of the left renal vein, causing a saccular aneurysm and renal vein dilation with varices consistent with nutcracker syndrome. She was managed with an open aneurysm resection and transposition of the left renal vein.

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We present a case of a 60-year-old woman with chronic lower abdominal pain and green urine. Further workup revealed a cholecystovesicular fistula (CVF), a newly coined term to indicate a fistula between the gallbladder and the urinary bladder. The CVF was treated surgically. The pathophysiology of CVF is thought to result from gallbladder perforation into the liver. Over time, a tract forms inferiorly until it meets another organ, in this case, the urinary bladder. This later complication of the gallbladder disease joins the broader spectrum of cholecystic fistulas. To our knowledge, a CVF has never been reported in the literature.

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An 81-year-old woman presented to our institution with a contained ruptured mycotic aortic aneurysm involving the takeoff of the celiac artery that required ligation of the celiac trunk, resulting in foregut ischemia and the need for revascularization. The technique of aortic reconstruction with delayed hepatic artery revascularization by a common iliac artery to hepatic artery bypass is described.

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Klippel-Trenaunay syndrome is a rare disorder consisting of the triad of vascular and/or lymphatic malformations, capillary malformations, and soft tissue or bony hypertrophy. Symptom control is the mainstay of treatment for these patients, with many of the symptoms never fully being relieved. In this case report, we present the case of a 46-year-old man with chronic lower extremity ulcerations unresponsive to wound care therapy. Owing to the chronic nature of his wounds and associated pain, reconstruction of his iliac vein was performed using polytetrafluoroethylene graft and an arteriovenous fistula.

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A novel family of synthetic biodegradable poly(ester-amide)s (Arg-PEAs) was evaluated for their biosafety and capability to transfect rat vascular smooth muscle cells, a major cell type participating in vascular diseases. Arg-PEAs showed high binding capacity toward plasmid DNA, and the binding activity was inversely correlated to the number of methylene groups in the diol segment of Arg-PEAs. All Arg-PEAs transfected smooth muscle cells with an efficiency that was comparable to the commercial transfection reagent Superfect. However, unlike Superfect, Arg-PEAs, over a wide range of dosages, had minimal adverse effects on cell morphology, viability or apoptosis. Using rhodamine-labeled plasmid DNA, we demonstrated that Arg-PEAs were able to deliver DNA into nearly 100% of cells under optimal polymer-to-DNA weight ratios, and that such a high level of delivery was achieved through an active endocytosis mechanism. A large portion of DNA delivered, however, was trapped in acidic endocytotic compartments, and subsequently was not expressed. These results suggest that with further modification to enhance their endosome escape, Arg-PEAs can be attractive candidates for non-viral gene carriers owning to their high cellular uptake nature and reliable cellular biocompatibility.

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Measurement of blood pressure (BP) poses some unique challenges in hemodialysis patients. Timing of BP measurement in relation to dialysis, changes in interdialytic weight gain, and inconsistent BP measurement technique in dialysis units contribute to the variability of BP readings in this population. This may contribute to the equivocal relationship between hypertension and cardiovascular outcomes documented in several epidemiologic studies in this population. Home BP readings are promising, but need to be validated as a measure of the burden of hypertension in this population. It is important to standardize BP measurement in all hemodialysis units according to published guidelines to improve the management of hypertension. Future research studies should carefully validate the technique used to measure BP.

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