Lower Extremity Vascular Surgery Research Articles

Managing incisional wounds with Prevena VAC therapy in lower-extremity vascular surgery: A comparative study.

Vascular surgical site infections have been reported with an overall incidence of 5-10% for patients undergoing arterial interventions and as high as 10-20% for lower-limb bypass grafting procedures. Given that vascular surgery patients are known to be at a higher risk of postoperative wound infections and other complications, our objective was to evaluate a potential method to reduce such complications. This study compares the rate of wound healing complications between incisional negative pressure wound therapy (NPWT) and conventional dressings in vascular surgery patients with infra-inguinal incisions. The primary endpoint is complete closure of the wound at the 2-week follow-up appointment. Secondary endpoints include frequency infections requiring antibiotics, need for wound revision, and wound dehiscence. A prospective cohort study with retrospective control group was performed following infra-inguinal vascular surgeries for peripheral arterial disease at the Mount Carmel Health System. The patients included in this study were those who underwent a lower-extremity vascular procedure with primary closure of an incision distal to the groin between January 2014 and July 2018. Patients that had received an infra-inguinal incision with primary closure were included. Patients in the experimental group who had a Prevena Wound VAC were compared with a retrospectively obtained control arm treated with conventional dressings. Data regarding wound healing and complications, specifically infections and wound dehiscence, were obtained. A total of 201 patients were recruited in our study: 64 in the Prevena group and 137 in the control group. There was a significant reduction in the number of open wounds in the Prevena group compared to the control group at the 2-week follow-up (10.9% Prevena vs 33.6% control; p = .0005). When evaluated in aggregate, there was a statistically significant reduction in the number of patients who succumbed to any complication in the Prevena arm compared with traditional dressings (13 (20.3%) Prevena vs 72 (52.6%) control; p < .0001). The results of our study suggest there should be a significant consideration for the use of NPWT as a prophylactic measure to reduce the risk of wound complications of primarily closed infra-inguinal incisions in vascular surgery patients following common vascular procedures. Its use is particularly effective for patients at enhanced risk of infection, especially those with poor vascularization from BMI, smoking, and diabetes. This leads to decreased trends in antibiotic use, ED visits, readmissions, and surgical revisions, which translates to decreased utilization of hospital resources and economic burden.

Perioperative Glycemic Surveillance and Control—Current Practices, Efficacy and Impact on Postoperative Outcomes following Infrainguinal Vascular Intervention

Perioperative glycemic control plays a pivotal role in improving postsurgical outcomes. Hyperglycemia occurs frequently in surgical patients and has been associated with higher rates of mortality and postoperative complications. However, no current guidelines exist regarding intraoperative glycemic monitoring of patients undergoing peripheral vascular procedures and postoperative surveillance is often restricted to diabetic patients. We sought to characterize the current practices around glycemic monitoring and efficacy of perioperative glycemic control at our institution. We also examined the impact of hyperglycemia in our surgical population. This was a retrospective cohort study performed at the McGill University Health Centre and Jewish General Hospital in Montreal, Canada. Patients undergoing elective open lower extremity revascularization or major amputation between 2019 and 2022 were included. Data collected from the electronic medical record included standard demographics, clinical, and surgical characteristics. Glycemic measurements and perioperative insulin use were recorded. Outcomes included 30-day mortality and postoperative complications. A total of 303 patients were included in the study. Overall, 38.9% of patients experienced perioperative hyperglycemia defined as glucose ≥180mg/dL (10mmol/L) during their hospital admission. Only 12 (3.9%) patients within the cohort underwent any intraoperative glycemic surveillance, while 141 patients (46.5%) had an insulin sliding scale prescribed postoperatively. Despite these efforts, 51 (16.8%) patients remained hyperglycemic for at least 40% of their measurements during their hospitalization. Hyperglycemia in our cohort was significantly associated with an increased risk of 30-day acute kidney injury (11.9% vs. 5.4%, P=0.042), major adverse cardiac events (16.1% vs. 8.6%, P=0.048), major adverse limb events (13.6% vs. 6.5%, P=0.038), any infection (30.5% vs. 20.5%, P=0.049), intensive care unit admission (11% vs. 3.2%, P=0.006) and reintervention (22.9% vs. 12.4%, P=0.017) on univariate analysis. Furthermore, multivariable logistic regression including the covariates of age, sex, hypertension, smoking status, diabetic status, presence of chronic kidney disease, dialysis, Rutherford stage, coronary artery disease and perioperative hyperglycemia demonstrated a significant relationship between perioperative hyperglycemia and 30-day mortality (odds ratio [OR]: 25.00, 95% confidence interval [CI]: 2.469-250.00, P=0.006), major adverse cardiac events (OR: 2.08, 95% CI: 1.008-4.292, P=0.048), major adverse limb events (OR: 2.24, 95% CI: 1.020-4.950, P=0.045), acute kidney injury (OR: 7.58, 95% CI: 3.021-19.231, P<0.001), reintervention (OR: 2.06, 95% CI: 1.117-3.802, P=0.021), and intensive care unit admission (OR: 3.38, 95% CI: 1.225-9.345, P=0.019). Perioperative hyperglycemia was associated with 30-day mortality and complications in our study. Despite this, intraoperative glycemic surveillance occurred rarely in our cohort and current postoperative glycemic control protocols and management failed to achieve optimal control in a significant percentage of patients. Standardized glycemic monitoring and stricter control in the intraoperative and postoperative period therefore represent an area of opportunity for reducing patient mortality and complications following lower extremity vascular surgery.

Lower extremity revascularization in patient with infection at level of the scarpa's triangle by extra-anatomical bypass: experiences of Vietduc University Hospital

Background: Infected prosthetic arterial grafts at the Scarpa triangle is a serious complication in vascular surgery with high failure results. Extra-anatomic bypass is one of solution in literature, but there is no research in Vietnam yet. This report will share some experiences of Viet Duc hospital.[1] Subjects and methods: 03 patients with infected prosthetic arterial grafts at the Scarpa triangle after lower extremity vascular surgery were treated by femoral artery ligation, perineal femorofemoral bypass or obturator foramen bypass for lower extremity revascularization, on-site wound care. Result: Primary patency rate is 100% after surgery, inguinal incision can be well healed. Re-examination after 6 months without any signs of infection or limb ischemia, the inguinal incision was completely healed. Conclusion: Extra-anatomical bypass is an effective method for revascularization of the lower extremities in the case of infected prosthetic arterial grafts.

Targeting the most important complications in vascular surgery

ObjectiveThis study was conducted to identify the most clinically relevant and costly perioperative complications occurring in vascular surgery patients. MethodsThe analysis included patients in the 2012 to 2014 National Surgical Quality Improvement Program database undergoing one of four high-risk vascular procedures. The procedures—aortic reconstruction, lower extremity bypass, lower extremity amputation, and carotid endarterectomy (CEA)—were selected because they have been established as high risk in the literature, rendering them natural targets for quality improvement initiatives. Population-attributable fractions (PAFs) were used to estimate the impact of seven prespecified complications on 30-day outcomes in the study population. The PAF predicts the reduction in outcome anticipated if a particular complication were to be prevented across the study population. Unadjusted and adjusted PAFs were reported. CEA was analyzed separately from the other procedures. ResultsThe analysis included 72,805 National Surgical Quality Improvement Program patients. Pneumonia had the largest impact on the incidence of end-organ dysfunction in CEA patients (adjusted PAF, 24.4%; 95% confidence interval, 20.6-28.1), and cerebrovascular accident had the largest impact on mortality in these patients (adjusted PAF, 23.1%; 95% confidence interval, 18.5-27.3). In patients undergoing abdominal or lower extremity vascular surgery, bleeding and pneumonia had the largest impact on clinical outcomes and need for prolonged hospitalization, and surgical site infection had the largest impact on hospital readmission. In contrast, prevention of venous thromboembolism, urinary tract infection, and myocardial infarction do not demonstrate substantial impact on patient outcomes or resource utilization in either group of vascular surgery patients. ConclusionsQuality initiatives that can successfully reduce the occurrence of postoperative stroke, bleeding, and pneumonia will have the greatest clinical impact on the outcomes of vascular surgery patients. Initiatives that target complications such as venous thromboembolism, urinary tract infection, or myocardial infarction will have little impact on this patient population.

The efficacy and safety of clopidogrel in vascular surgery patients with immediate postoperative asymptomatic troponin T release for the prevention of late cardiac events: Rationale and design of the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo-VII (DECREASE-VII) trial

Major vascular surgery patients are at high risk for developing asymptomatic perioperative myocardial ischemia reflected by a postoperative troponin release without the presence of chest pain or electrocardiographic abnormalities. Long-term prognosis is severely compromised and characterized by an increased risk of long-term mortality and cardiovascular events. Current guidelines on perioperative care recommend single antiplatelet therapy with aspirin as prophylaxis for cardiovascular events. However, as perioperative surgical stress results in a prolonged hypercoagulable state, the postoperative addition of clopidogrel to aspirin within 7 days after perioperative asymptomatic cardiac ischemia could provide improved effective prevention for cardiovascular events. DECREASE-VII is a phase III, randomized, double-blind, placebo-controlled, multicenter clinical trial designed to evaluate the efficacy and safety of early postoperative dual antiplatelet therapy (aspirin and clopidogrel) for the prevention of cardiovascular events after major vascular surgery. Eligible patients undergoing a major vascular surgery (abdominal aorta or lower extremity vascular surgery) who developed perioperative asymptomatic troponin release are randomized 1:1 to clopidogrel or placebo (300-mg loading dose, followed by 75 mg daily) in addition to standard medical treatment with aspirin. The primary efficacy end point is the composite of cardiovascular death, stroke, or severe ischemia of the coronary or peripheral arterial circulation leading to an intervention. The evaluation of long-term safety includes bleeding defined by TIMI criteria. Recruitment began early 2010. The trial will continue until 750 patients are included and followed for at least 12 months. DECREASE-VII is evaluating whether early postoperative dual antiplatelet therapy for patients developing asymptomatic cardiac ischemia after vascular surgery reduces cardiovascular events with a favorable safety profile.

Postoperative Modulation of Central Nervous System Prostaglandin E2by Cyclooxygenase Inhibitors after Vascular Surgery: Retracted

The clinical availability of injectable cyclooxygenase inhibitors allows examination of the importance of cyclooxygenase 1 and 2 after surgery. The authors hypothesize that spinal prostaglandin E2 increases with lower extremity vascular surgery and that spinal prostaglandin E2 decreases with intravenous postsurgical administration of either a mixed cyclooxygenase 1/2 inhibitor (ketorolac) or a cyclooxygenase 2 selective inhibitor (parecoxib). Thirty patients undergoing elective lower extremity revascularization under continuous spinal anesthesia had cerebrospinal fluid obtained at baseline and then up to 6 h after the start of surgery. Four hours after surgical incision, patients were randomized to receive intravenous parecoxib 40 mg, ketorolac 30 mg, or preservative-free normal saline. Patients were administered intravenous fentanyl in the postanesthesia care unit and acetaminophen/oxycodone on the surgical ward to control pain. Cerebrospinal fluid prostaglandin E2 concentrations were increased during and after surgery. After surgery, intravenous parecoxib 40 mg rapidly decreased cerebrospinal fluid prostaglandin E2, and intravenous ketorolac 30 mg also reduced cerebrospinal fluid prostaglandin E2 compared with placebo, but not as much as parecoxib. Postanesthesia care unit pain scores were reduced in the two drug groups compared with placebo, and surgical ward pain scores were also decreased for both drug groups, especially with parecoxib. No patient receiving parecoxib required postoperative intravenous fentanyl. Acetaminophen/oxycodone consumption was reduced in both drug groups compared with placebo, more so with parecoxib. Cerebrospinal fluid prostaglandin E2 is elevated in patients after lower extremity vascular surgery. Postsurgical intravenous administration of the cyclooxygenase 1/2 inhibitor ketorolac, and especially the cyclooxygenase 2 inhibitor parecoxib, reduces cerebrospinal fluid prostaglandin E2 concentration and postoperative pain.

Effect of clonidine pre-medication on propofol requirements during lower extremity vascular surgery: a randomized controlled trial

Pre-medication with clonidine reduces the requirement for volatile agents during general anaesthesia. This may also be true for anaesthesia with propofol, but the amount of dose reduction has not been measured. Because clonidine also affects cardiac output and thus regional blood flow it could alter the pharmacokinetics of propofol. This randomized, double-blind placebo-controlled trial aimed to study the effect of clonidine pre-medication on dose requirement for propofol during lower extremity vascular surgery using the bispectral index (BIS) as a measure of anaesthetic depth. After oral pre-medication with either clonidine 3 microg kg(-1) or placebo, 39 subjects had lower limb vascular surgery using propofol infusion for anaesthesia. Anaesthetic depth was adjusted to a BIS of 45. Predicted plasma propofol concentrations were noted every 30 min from a target-controlled propofol infusion pump and arterial samples were taken at the same time for propofol measurements. Patients in both groups were anaesthetized to similar depths of anaesthesia as indicated by BIS readings (P=0.44). The groups had comparable mean (95% CI) arterial concentrations of propofol, 4.8 (3.5-6.1) microg ml(-1) in the patients given clonidine, and 4.6 (3.4-5.7) microg ml(-1) in the patients given placebo (P=0.81). However, the average plasma concentration predicted by the target-controlled infusion was less in the clonidine group [3.2 (2.9-3.5)] than in the group given placebo [3.6 (3.3-3.9)] microg ml(-1) (P<0.05). Pre-medication with clonidine reduces the requirement for propofol, which is a pharmacokinetic effect and not a pharmacodynamic central sedative effect.

Complications of Major Aortic and Lower Extremity Vascular Surgery

Atheromatous disease and invasive intervention of the aortoiliac and distal arteries are common. Morbidity and mortality have been reduced through understanding and management of patient risk factors. Complications of this form of treatment affect all organ systems; mortality is most frequently caused by a cardiovascular complication (eg, myocardial infarction). Infection, leading to aortoenteric fistula is a dreaded complication, and paraplegia, though rare, is a devastating outcome. Multiorgan failure and death may result from a systemic inflammatory response syndrome. Vascular surgery for infrainguinal disease also has a significant cardiovascular complication rate. Resulting complications may affect all organs; loss of an extremity may occur. The first part of this article reviews perioperative and postoperative complications of open aortic repair and lower-extremity revascularization and addresses the issue of regional anesthesia for major vascular surgery. The second part reviews endovascular aortic repair (EVAR). EVAR is a new intervention that combines surgery and radiology. Complications of EVAR are similar to open repair, but early results suggest they may be less frequent. New technology leads to new complications; endoleaks, migration of the endoprosthesis, and surgical conversion are unique to EVAR. The benefits of EVAR may be less blood loss, shorter hospitalization, and less cardiovascular stress; the risks may be aneurysm recurrence, prolonged surveillance and repeated secondary procedures. The development of EVAR, the complications, and the anesthesia-related concerns of EVAR, including its use in management of acute abdominal aortic aneurysm are reviewed.

Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks

Background Lymphatic leaks are a major source of morbidity after lower extremity vascular surgery. We determined the ability of isosulfan blue (Lymphazurin) use to identify and help ligate offending lymphatics, and compared postoperative complication rates and length of stay versus nonoperative therapy alone. Methods From January 1993 through March 2002, we identified 15 patients with lymphatic leaks. The first group consisted of 5 patients treated nonoperatively. The second group was 10 patients (11 explorations) treated operatively aided by isosulfan blue, after a trial of nonoperative therapy. Results Isosulfan blue identified the leak in 10 of 11 cases. Mean drainage time for the nonoperative group was 47.6 days versus 1.8 days for the operative group ( P = 0.036). Within the operative group, the mean drainage time during their initial conservative treatment phase was 15 days versus 1.8 days after surgery ( P < 0.01). Complications were significantly less in the operative group ( P < 0.05). Postoperative length of stay was a mean of 4.7 days versus 8.1 days for nonoperative patients ( P = not significant). Conclusions Intraoperative isosulfan blue use accurately identifies disrupted lymphatic channels and helps ensure definitive ligation. This simple procedure is associated with fewer complications, and a trend toward shorter hospital stay.

Measures of success and health-related quality of life in lower-extremity vascular surgery.

Lower-extremity vascular surgery is most often indicated for patients with critical leg ischemia but has increasingly been used for patients with disabling intermittent claudication. This article reviews indications, follow-up protocols, and procedure-related outcomes including perioperative and late mortality, complications, and long-term patency rates, which vary with patient risk factors, vascular disease severity, and hospital volume. Population-based studies have yet to establish whether rates of limb-preserving bypass surgery are related to overall amputation rates, partly because of the continued high rate of primary amputation. The functional benefits of vascular surgery have been traditionally assessed by treadmill protocols and batteries of physical tests. Claudication treatment is increasingly being measured by both generic and disease-specific functional and health-related quality-of-life questionnaires. Patient self-reported measures of physical functioning and walking ability are reviewed. Finally, conclusions are presented about trends in lower-extremity bypass surgery rates.

How acute pain management affects outcome

Many factors can contribute to patient outcome after surgery. The method of acute pain relief may be an important factor in postoperative outcome. This article discusses the pathophysiology of pain and highlights the effects of different modes of analgesia on patient outcome variables. Epidural anesthesia and analgesia can decrease the risk of vaso-occlusive complications after lower extremity vascular surgery. Currently, there is inconclusive evidence that mode of acute pain relief affects clinical outcome after thoracic surgery. After abdominal operations, both epidural analgesia and intravenous patient-controlled analgesia may reduce the incidence of pulmonary complications in selected patients, and epidural analgesia can hasten the return of gastrointestinal motility and potentially shorten the hospital stay. For patients undergoing hip or knee replacement, spinal and epidural techniques can improve clinical outcome by preventing the development of thromboembolic complications.

REGIONAL VERSUS GENERAL ANESTHESIA

Over the last decade medical care has been driven by two dominant forces: pressures to reduce use of medical resources and improvements in quality of patient care. Improvements in patient outcome and reduced use of resources have been suggested to result from using regional techniques as compared with general anesthesia alone for high-risk patients undergoing significant operative procedures. Other proposed advantages of regional anesthesia techniques include decrease in the neuroendocrine “stress” response, improved postoperative pulmonary function, reduced thrombotic complications, and reduced perioperative cardiac morbidity. Patients with cardiac disease undergoing noncardiac surgery represent a significant management challenge to the anesthesiologist. Unlike patients presenting for cardiac surgery, these patients frequently do not have extensive work-ups directed at the cardiovascular system, have not been as aggressively medically managed, and are not expected, based upon their surgical procedure, to need cardiac monitoring or intervention after surgery. Outcome research comparing regional with general anesthesia over the last decade has been focused primarily on the high-risk patient undergoing noncardiac vascular surgery. Vascular surgery patients have been shown to be at higher risk of perioperative cardiac morbidity than patients having other types of surgery, 9 and patients with peripheral vascular disease have a higher rate of mortality overall than those without it. 5 Patients who are at high risk for cardiovascular morbidity can be expected to have an increased rate of morbidity regardless of their anesthetic. Thus, trials performed upon a relatively small number of patients can have a large enough number of adverse outcomes to establish whether one type of anesthetic is more dangerous than another. Options for regional anesthesia for patients with cardiovascular disease include use of subarachnoid or epidural local anesthetics or narcotics, regional anesthesia for carotid artery endarterectomy, use of interscalene or axillary block for placement of fistulas in the arm for renal dialysis, and intercostal blockade as an adjunct for upper abdominal surgery. Several recent prospective clinical trials have examined the use of epidural or spinal anesthesia either as an adjunct or as the sole anesthetic for procedures, including thoracic surgery, aortic surgery, and lower extremity vascular surgery. Non-neuraxial regional anesthesia has not been studied with the same intensity. It does not involve as great a physiologic trespass because it does not cause sympathectomy, which may be accompanied by hypotension. It is also appropriate for less major surgery, such as eye surgery or arteriovenous fistula formation, for patients with renal failure. Even though patients having these procedures often have cardiac disease, these surgical procedures are not associated with high rates of perioperative cardiovascular complications. Therefore, this article focuses upon neuraxial anesthesia rather than upon other types of regional anesthesia.