Pre-existing Peripheral Vascular Disease Research Articles

Perioperative Risk Factors Predicting Hardware Exposure after Mandibulectomy and Reconstruction

Background and Hypothesis:Mandibulectomy is often required in the management of tumors, infection, or trauma of the head and neck. Reconstruction of the defect is accomplished via osteocutaneous free flaps and the use of titanium plates for fixation of the bone segments. Postoperative exposure of the mandibular hardware is an unfortunate outcome which results in significant quality of life detriment and often requires substantial revision surgery and reconstruction. We hypothesize that individuals with vasculopathic conditions and other circumstances that contribute to poor wound healing are more likely to experience hardware plate exposure following mandibular reconstruction.
 Methods:A single-institution, retrospective cohort study was performed on all adults undergoing mandibulectomy and osteocutaneous free flap reconstruction from 2010-2020. Demographics, patient history, surgical parameters, and follow-up data were collected. Comparisons and logistic regression were used to determine factors associated with postoperative hardware exposure.
 Results:The cohort consisted of 134 predominantly white (92.5%) male (65.7%) patients with mean age 58.4±13.0 years, 32 (23.9%) of whom had postoperative plate exposure. Between patients with and without exposure, there were no differences observed in demographics, substance use, surgical indications, or reconstructive techniques, neoadjuvant or adjuvant chemoradiation, nor 30-day major surgical site infection. The comorbidities of peripheral vascular disease, hypothyroidism, and immunosuppression were significantly more common in the plate exposure group. In multivariate logistic regression, peripheral vascular disease (OR [95%CI] = 18.8 [1.8-196.3]), hypothyroidism (OR [95%CI] – 3.5 [1.1-10.6]), and immunosuppression (OR [95%CI] =11.3 [2.4-54.1]) remained significant predictors of post-mandibulectomy hardware exposure.
 Conclusion and Potential Impact:Patients with pre-existing peripheral vascular disease, hypothyroidism, and/or immunosuppression have an increased risk of post-mandibulectomy hardware exposure. Understanding these risk factors can improve shared patient-surgeon decision making and counseling, as well as guide practitioners to focus on mitigating these comorbidities prior to surgery.

E-46 | Bedside Removal of Impella Devices in Cardiogenic Shock Patients Is Feasible and Safe

Patients with cardiogenic shock (CS) requiring mechanical circulatory support (MCS) are complex. The Impella CP (Abiomed, Danvers, MA) is a percutaneously placed left ventricular assist device and there is no established best-practice for device removal. Vascular complications from MCS devices are common and many patients undergo operative removal of these devices. To our knowledge there is no published data concerning the safety of bedside removal of femorally-placed Impella devices in the cardiovascular intensive care unit (CICU) for patients with CS. We conducted a retrospective chart review of all CS patients requiring MCS at our institution in 2020, approved by our institutional review board. In 2020 we cared for 84 patients requiring MCS in our CICU, excluding patients with intra-aortic balloon pumps. Of these, 55 patients had a femorally-placed Impella CP, either alone or with veno-arterial extracorporeal membrane oxygenation. 18 patients died with devices in place and three were transferred to another facility on MCS. 14 patients had their Impella removed in the operating room and five in the cardiac catheterization lab. 15 total patients (27%) underwent Impella removal at bedside in the CICU. Of the patients with bedside removal, a vascular closure device was used in the vast majority (87%). Only one patient had post-removal leg ischemia requiring surgical or endovascular intervention; this patient had preexisting peripheral vascular disease and the Impella was removed via manual pressure for clinical ischemia. Bedside removal of femorally-placed Impella CP devices is feasible and safe in select CS patients. More research is needed to establish best-practices for MCS device removal.

ACT Transition from Hospital to Home Orthopaedic Survey: a cross-sectional survey of unplanned 30-day readmissions for patients having total hip arthroplasty

ObjectivesThe aim of this study was to identify patient, hospital and transitional factors associated with unplanned 30-day readmissions in patients who had a total hip arthroplasty (THA).DesignA cross-sectional survey was...

Transtibial Osseointegration for Patients with Peripheral Vascular Disease: A Case Series of 6 Patients with Minimum 3-Year Follow-up.

Background:The management of peripheral vascular disease (PVD) can require amputation. Osseointegration surgery is an emerging rehabilitation strategy for amputees. In this study, we report on 6 patients who had PVD requiring transtibial amputation (PVD-TTA) and either simultaneous or subsequent osseointegration (PVD-TTOI).Methods:Six patients (aged 36 to 84 years) with transtibial amputation and preexisting PVD underwent osseointegration between 2014 and 2016 and were followed for 3 to 5 years. Pre- and postoperative clinical and functional outcomes (pain, prosthesis wear time, mobility, walking ability, and quality of life) and adverse events (infection, fracture, implant failure, revision surgery, additional amputation, and death) were prospectively recorded.Results:All patients’ mobility improved following osseointegration. Three patients initially had required the use of a wheelchair, precluding baseline walking tests; the other 3 were classified as K level 1 or 2, with mean baseline Timed Up and Go (TUG) test = 14.0 ± 2.2 s and 6-Minute Walk Test (6MWT) = 262 ± 75 m. At the time of the latest follow-up, all patients were K level 2 or 3; mean TUG = 12.7 ± 7.2 s and 6MWT = 353 ± 148 m. Four patients wore their prosthesis ≥16 hours daily. Three patients had superficial soft-tissue infections. One other patient experienced recurrent infections 2.8 years after osseointegration requiring debridements and transfemoral amputation; the patient died 2 days following surgery from myocardial infarction caused by coronary atherosclerosis.Conclusions:All 6 patients who underwent PVD-TTOI in this case series survived through 2 years. Patients who initially had used a wheelchair achieved and maintained independent, unaided ambulation until PVD-related impairments in the contralateral leg occurred in 1 patient. Patients previously using a traditional socket prosthesis reported improvement in mobility and quality of life. One patient’s death underscores the importance of careful patient selection. However, marked improvement in the other 5 patients suggests cautious optimism that PVD-TTA is not an absolute osseointegration contraindication. Conscientious further investigation seems appropriate.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abstract 197: Predictors of Early Left Ventricular Ejection Fraction Recovery in Patients Following Transcatheter Aortic Valve Replacement

Background: Transcatheter aortic valve replacement (TAVR) is recommended by guidelines in severe aortic stenosis (AS) in patients with high or intermediate surgical risk. However, AS and reduced left ventricular ejection fraction (LVEF) is associated with worse clinical outcomes. Many of these patients will have LVEF recovery after TAVR. The purpose of this study was to evaluate the predictors of early LVEF recovery. Methods: All patients with a baseline LVEF < 50% who underwent TAVR and had an echocardiogram within one-month post-TAVR (n=39) at a single center were included to determine the factors that predict an improvement in early LVEF. A 10% increase in LVEF within one month was used as a definition of early improvement in LVEF. Chi-square and T-test were used to examine differences in baseline characteristics between subjects with and without improvement in early LVEF. Results: The patient cohort was 77 ± 9 years, 76.9% male, STS 6.2 ± 3.7. Among the 56% who had an improvement in early LVEF, they were more likely to have a lower left ventricular end diastolic diameter (LVEDD) (5.0±0.8 cm vs. 5.7±0.6 cm; p-value = 0.01) and left ventricular end systole diameter (LVESD) (3.7±0.8 cm vs. 4.5±1.1 cm; p-value = 0.02). These patients were more likely to have a higher interventricular septum diastolic thickness (IVSd) (1.2±0.2 cm vs. 1.0±0.2 cm; p-value = 0.01) and less likely to have a pre-existing peripheral vascular disease (PVD; 13% vs. 50%; p-value=0.01). Conclusion: Our study suggests that LVEDD, LVESD, IVSd, and PVD may be used to predict early improvement in LVEF. These factors need to be further prospectively validated to determine patients who are more likely to benefit from TAVR.

Retrograde Dorsalis Pedis Angiosomal Flow Compromised by Small Puncture Wound Leading to Transmetatarsal Amputation

Pedal puncture wounds can precipitate a variety of complications, often resulting from a delay in treatment. Although the risk of infection predominates, direct vascular insult and subsequent ischemia is a lesser reported complication of these injuries. Consequently, this may have morbid results, especially on a background of pre-existing peripheral vascular disease. We present a case involving a small, plantar forefoot puncture wound, ultimately resulting in transmetatarsal amputation due to ischemic gangrene in an uncontrolled, but sensate, diabetic with profound vasculopathy. This presentation highlights the importance of considering the potential for macrovascular damage via pedal puncture, and the potentially magnified complications in patients with dependent retrograde angiosomal flow and compromised collateral circulation. Based on a thorough analysis of the literature and the findings in this clinical example, we advocate a detailed investigation of angiosomal blood supply through direct and indirect vessel flow in patients with peripheral arterial disease incurring puncture wounds. In these patients, lack of compensatory avenues of the pedal circulation may portend significant tissue loss in an otherwise inoffensive situation. Knowledge of this complication, although rare, may prompt the clinician to assess for its potential, and emphasize a preference for direct revascularization in those with critical limb ischemia.

PC180 Endovascular Stent Repair of Traumatic Superficial Femoral and Popliteal Artery Injuries: An Analysis of the National Trauma Data Bank

Despite increasing use of endovascular stent repair of traumatic arterial injuries, such repair of superficial femoral artery (SFA) and popliteal artery (PA) injuries remains uncommon and poorly studied. We describe characteristics and outcomes of trauma patients with SFA and PA injuries repaired using endovascular stenting. This was a retrospective National Trauma Data Bank analysis of trauma patients with a vascular injury isolated to the SFA and PA who underwent endovascular stent repair from 2007 to 2014. The prevalence of SFA and PA injuries was 0.2%, with an increasing trend in the annual use of endovascular stent repair ranging from 1.3% to 3.1% across the study period (P = .004) despite stable injury burdens (Fig 1). Included were 137 patients (81.5% males) with a median age of 31 years (interquartile range [IQR], 22-45 years). The most common comorbidity was smoking (23.4%), and none had pre-existing peripheral vascular disease. Mechanism of injury (MOI) was 57.4% penetrating. On presentation, 5.1% were hypotensive (systolic blood pressure <90 mm Hg), 9.5% were tachycardic (heart rate >120 beats/min), and 4.5% had Glasgow Coma Scale of <9. Median Injury Severity Score was 10 (IQR, 9-17). SFA injury was more common (65.0%) and associated with penetrating MOI (P < .001). PA injury was associated with blunt MOI (P < .001) and with fasciotomy both alone (P = .015) and with concomitant SFA injury (P = .035). Femur fracture and associated vein injury occurred in 35.8% and 7.3% patients, respectively. Median time to stent repair was 5 hours (IQR, 3-11 hours). Fasciotomy was performed in 21.2% patients after a median of 4 hours (IQR, 3-8 hours). The most common in-hospital complication was deep vein thrombosis (11.1%). Overall mortality was 5.8%. Age ≥65 years (P = .025) and Glasgow Coma Scale <9 (P = .045) were associated with mortality on univariate analysis, but only age ≥65 years was independently predictive (odds ratio, 7.5; 95% confidence interval, 1.5-36.4; P = .013). Amputation was performed in 5.1% patients, equally distributed between SFA and PA injury, after a median of 10 days (IQR, 4-32 days). Fasciotomy was significant on both univariate (P = .005) and multivariate analysis (odds ratio, 14.2; 95% confidence interval, 2.3-88.5; P = .005) of amputation, yet time to initial fasciotomy was not associated with amputation (4 vs 3.5 hours; P = .869, Fig 2). Endovascular stent repair of SFA and PA injuries is performed in stable trauma patients with low injury burdens. Death and amputation are infrequent, but age ≥65 years and fasciotomy are significant risk factors, respectively. Despite increasing annual trends, prospective studies are necessary to elucidate the proper algorithm for patient selection in the endovascular management of this patient population.Fig 2Risk factors for (A) overall mortality and (B) amputation. CI, Confidence interval; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; OR, odds ratio.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy Development of the PE-CH Score.

Pulmonary embolism (PE) is a major cause of morbidity and mortality world-wide, and the use of thrombolytic therapy has been associated with favourable clinical outcomes in certain patient subsets. These potential benefits are counterbalanced by the risk of bleeding complications, the most devastating of which is intracranial haemorrhage (ICH). We retrospectively evaluated 9703 patients from the 2003-2012 nationwide in-patient sample database (NIS) who received thrombolytics for PE. All patients with ICH during the PE hospitalisation were identified and a clinical risk score model was developed utilizing demographics and comorbidities. The dataset was divided 1:1 into derivation and validation cohorts. During 2003-2012, 176/9705 (1.8 %) patients with PE experienced ICH after thrombolytic use. Four independent prognostic factors were identified in a backward logistic regression model, and each was assigned a number of points proportional to its regression coefficient: pre-existing Peripheral vascular disease (1 point), age greater than 65 years (Elderly) (1 point), prior Cerebrovascular accident with residual deficit (5 points), and prior myocardial infarction (Heart attack) (1 point). In the derivation cohort, scores of 0, 1, 2 and ≥ 5 points were associated with ICH risks of 1.2 %, 1.9 %, 2.4 % and 17.8 %, respectively. Rates of ICH were similar in the validation cohort. The C-statistic for the risk score was 0.65 (0.61-0.70) in the derivation cohort and 0.66 (0.60-0.72) in the validation cohort. A novel risk score, derived from simple clinical historical elements was developed to predict ICH in PE patients treated with thrombolytics.

Peripheral Vascular Complications Are Associated with Increased Mortality in Patients on Femoral Venous Arterial ECMO

147 patients from January 2008 to August 2015 underwent VA ECMO therapy at a single institution. The mean age of the patients was 49 ± 14 years (16 to 85 years) and 64% (n = 94) were male. The primary indications for VA-ECMO were primary graft failure post heart transplant (29%), cardiac arrest (22%) and post cardiotomy shock (19%). Despite 93% of patients having a backflow cannula, 25% still developed distal limb ischaemia leading to compartment syndrome in 10% and amputation in 4%. Age, diabetes and dialysis were strong predictors of distal limb ischaemia. Patients with pre-existing peripheral vascular disease were significantly at risk of compartment syndrome (p = 0.014) and amputation (p = 0.007). 30-day mortality was 50% in patients with compartment syndrome. Peripheral cannulation for VA ECMO can lead to ischaemic complications in significant numbers of patients in cardiogenic shock. Once these complications develop, patient outcomes are grim. Patients requiring femoral ECMO must be carefully assessed for vascular complications post insertion. Early intervention is vital with consideration given for alternate sites of cannulation.

Long term end-stage renal disease and death following acute renal replacement therapy in the ICU.

In ICU the need for acute renal replacement therapy (RRT) associates with high mortality and risk of end-stage renal disease (ESRD), but there are limited long-term data. We investigated these outcomes and their risk factors. Retrospective analysis of all adult patients admitted to a general, university hospital ICU 2005-2012, excluding chronic dialysis patients. ESRD was defined as need of RRT > 90 days or kidney transplant. Of 5766 patients included, 1004 (16%) received acute RRT; their 30-day mortality was 42% vs. 16% for those not requiring acute RRT (adjusted hazard ratio (HR) 1.13 (0.96-1.32)). The 90-day mortality was 55% for patients receiving acute RRT vs. 22% for those who did not (adjusted HR 1.32 (1.15-1.51)) and 1-year mortality was 63% vs. 30%, respectively, (adjusted HR 1.31 (1.16-1.48)). The 7-year risk of ESRD for ICU patients surviving 90 days was 10% for patients who received acute RRT vs. 0.5% among those who did not (adjusted HR 5.9 (2.9-12.4)). Independent risk factors for ESRD included pre-existing kidney disease, pre-existing peripheral vascular disease and use of acute RRT in ICU. The need of acute RRT was associated with markedly increased long term risk of death and ESRD; in contrast its use was not associated with 30-day mortality. In addition to acute RRT, decreased kidney function and peripheral vascular disease before ICU admission were risk factors for ESRD. It seems warranted offering medical follow-up to patients after acute RRT in ICU.

Improving mortality trends for hospitalization of aortic dissection in the National Inpatient Sample

Population-based assessment of aortic dissection (AD) hospitalizations in the general United States population is limited. We assessed the current trends in AD admissions and in-hospital mortality for surgical and medical AD treatment. Patients admitted for primary diagnosis of AD were identified from the National Inpatient Sample database (2003-2012). Patients were identified by International Classification of Diseases-Ninth Revision diagnosis codes and categorized by treatment type: type A open surgical repair (TASR), type B open surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). Our primary outcomes were to evaluate admission trends and in-hospital mortality of AD. Secondary outcomes included postoperative complications. We used weighted national estimates of admissions to assess trends over time using linear regression. We also identified factors associated with mortality via a hierarchical multivariable logistic regression model. We identified 15,641 patients (60.7% male; mean age, 63.5years) admitted with a primary diagnosis of AD between 2003 and 2012. Intervention types included TASR in 3253 (20.8%), TBSR in 3007 (19.2%), TEVAR in 1417 (9.1%), and MM in 7964 (50.9%). Overall weighted admissions for AD increased significantly, from 6980 in 2003 to 8875 in 2012 (P< .01, test of trend), with increases in admission for TASR, from 1143 in 2003 to 2130 in 2012 (P< .01, test of trend), and TEVAR from 96 in 2005 to 1130 in 2012 (P< .01, test of trend). TBSR and MM admissions were stable, with TBSR admissions at 1519 in 2003 and 1540 in 2012 (P= .9, test of trend) and MM admissions at 4319 in 2003 and 4075 in 2012 (P= .8, test of trend). During the same interval, overall in-hospital mortality rates for AD decreased from 18.1% to 13.0% (P< .01, test of trend). When stratified by intervention type, mortality rates decreased for TASR, from 20.5% to 14.8% (P< .01, test of trend), for TBSR, from 18.0% to 14.3% (P= .03, test of trend), and for MM, from 17.5% to 13.9% (P< .01, test of trend). Mortality rates for TEVAR were stable, with an average mortality of 7.9% (P= .8, test of trend) during the study period. Factors associated with increased mortality included older age, Caucasian race, nonelective admission, pre-existing peripheral vascular disease, and acute postoperative complication of myocardial infarction, stroke, or kidney failure. Admissions at a center with high surgical volume were associated with a decreased mortality for TBSR admissions only (odds ratio, 0.55; 95% confidence interval, 0.4-0.7). Overall and surgical admission rates for AD appear to be increasing, and in-hospital mortality rates are decreasing. TEVAR mortality remains mostly unchanged, however, suggesting targets for further improvement in mortality for AD treatment. Decreased mortality for TBSR at centers with a high surgical volume may suggest a need for regionalization of AD care.

Neurovascular Injury in Hip Arthroplasty.

Neurological and vascular complications following hip arthroplasty are uncommon, and their impact ranges from transient and trivial to permanent and devastating. The proximity of neural and vascular structures makes any operation on the hip potentially hazardous. Direct or indirect injuries of these structures may occur during operative exposure and subsequent procedures. Thus, complete awareness of the anatomy of the pelvis and proximal femur is required. Peripheral nerve injuries can involve either distant sites or nerves in the immediate vicinity of the hip joint. Sciatic nerve injury is the most common nerve injury following total hip arthroplasty. Femoral nerve injury is much less common and is associated with an anterior approach. Its diagnosis is often delayed, but the prognosis is generally better than with sciatic nerve injury. The superior gluteal nerve is at risk during the direct lateral approach. Obturator nerve injury is the least common type of injury and has the least functional consequences. Vascular injuries are less common but more immediately life threatening. The mechanisms of vascular injury include occlusion associated with preexisting peripheral vascular disease and vascular injury during removal of cement during screw fixation of acetabular components, cages, or structural grafts. It is critical to avoid the anterior quadrants for acetabular screw fixation. All acetabular and femoral defects should be bone-grafted to avoid inadvertent cement migration. Following these guidelines, surgeons should be able to offer the most appropriate treatment and counseling to the patients.

Predictors of prolonged vasopressin infusion for the treatment of septic shock

PurposeProlonged catecholamine use has been linked with poor clinical outcomes, including higher mortality. The objective was to identify characteristics that may be predictive of prolonged arginine vasopressin (AVP) use for 7 days or more in patients with septic shock. Materials and MethodsThis was a retrospective nested cohort analysis of adult patients receiving AVP as initial hemodynamic support for septic shock, either alone or in combination with norepinephrine, between 2008 and 2010. ResultsUnivariate factors predictive of patients requiring extended AVP support were peripheral vascular disease (PVD) (48% vs 18%, P = .001), congestive heart failure (30% vs 12%, P = .024), and acute kidney injury (AKI) (83% vs 49%, P = .003). Patients requiring extended AVP support more frequently experienced a new intensive care unit (ICU) arrhythmia, typically atrial fibrillation (39% vs 7%, P < .001), and had higher 28-day mortality (74% vs 20%, P < .001). Multivariate analysis revealed that the strongest independent predictors of prolonged AVP dependence were new ICU arrhythmia (odds ratio [OR], 5.3; 95% confidence interval [CI], 1.6-17.8), PVD (OR, 4.3; 95% CI, 1.4-13.1), and AKI (OR, 3.9; 95% CI, 1.1-14.5). ConclusionsPatients with preexisting PVD and AKI and those experiencing a new ICU arrhythmia on AVP may be more likely to remain on AVP for 7 or more days.

Temporary axillobifemoral bypass as an adjunct to endovascular aneurysm repair using fenestrated stent grafts

Prolonged endovascular procedures requiring a large diameter sheath in each groin can be associated with significant intraoperative lower limb ischemia, particularly in those with pre-existing peripheral vascular disease. We report the case of a patient who suffered severe ischemia-reperfusion injury following endovascular repair of a pararenal aortic aneurysm using a fenestrated stent graft and describe the use of temporary axillobifemoral bypass in a patient with similar comorbidities undergoing the same procedure. We propose this adjunctive technique as a means of maintaining antegrade limb perfusion and avoiding the peripheral and central metabolic consequences of ischemia-reperfusion injury.

Open Repair for Ruptured Abdominal Aortic Aneurysm: Is It Possible to Predict Survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

Incidence des accidents cardiovasculaires au cours de la maladie de Horton : résultats préliminaires de l'étude prospective en double cohorte GRACG

Giant cell arteritis is the most frequent vasculitis. Cardiovascular events such as cerebrovascular accident or ischemic heart disease may occur in patients with giant cell arteritis. However, their real incidence, as well as their relative risk compared to the general population, remains unknown. Purpose. – To assess in a prospective, double cohort study, the incidence of cardiovascular events in giant cell arteritis patients compared to controls, after controlling for cardiovascular risk factors. Patients and methods. – We included on predefined criteria 432 newly diagnosed patients with giant cell arteritis, each assigned to sex- and age-matched controls randomly selected from the general population. Cardiovascular risk factors (high-blood pressure, diabetes, smoking, hypercholesterolemia and preexisting peripheral vascular disease) were collected at inclusion. During the 24-month follow-up, all cardiovascular events were collected. After stratification for cardiovascular risk factors, a log-rank test was performed to compare cases and controls. A parametric survival model was used for multivariate analysis. Results. – Cardiovascular events all combined were significantly increased in patients with giant cell arteritis (RR = 2.15 [1.21–3.81], P = 0.009), and were mainly associated with age ( P = 0.0001), past history of cardiovascular disease ( P = 0.023) but also with giant cell arteritis ( P = 0.009). However, each subset of cerebrovascular accident (RR = 2.42 [0.84–7]) or ischemic heart disease (RR = 1.67 [0.72–3.89]) increased but did not significantly. Conclusion. – Cardiovascular events incidence is increased in patients with giant cell arteritis, and prescription of preventive antiagregant treatment may be discussed.

Thrombolysis for native arterial occlusions of the lower extremities: Clinical outcome and cost

Introduction: Intra-arterial thrombolysis is commonly used as the initial treatment of acute or subacute lower extremity ischemia. Methods: To evaluate the efficacy and cost of thrombolysis, we retrospectively analyzed 100 consecutive cases (87 patients) in which intra-arterial lysis (urokinase) was used as the initial treatment for native arterial lower extremity occlusive disease. The mean age of patients was 67 years, 57% of the patients were male, and preexisting peripheral vascular disease was present in 74%. Presenting symptoms were limb-threatening ischemia (53%) and claudication (47%). Acute symptoms (< 2 weeks' duration) were present in 48%. Results: The 30-day morbidity rate was 31%, and four patients died. Complications were significant bleeding (23%), ischemic stroke (1%), and renal failure with (2%) and without (2%) dialysis. Concomitant angioplasty was performed in 63%. Complete or significant lysis as demonstrated with angiography was achieved in 75% of iliac, 58% of femoropopliteal, and 41% of crural vessels ( P < .001). Within 30 days of lysis, 9% of patients underwent major amputation and 20% surgical revascularization (in 3 patients the extent of revascularization was lessened by the lytic therapy). Amputation-free survival was 83% and 75% at 6 months and 2 years, respectively. Relief of ischemia (defined as relief of claudication or limb salvage without major surgical intervention) was achieved in only 70% and 43% of patients at 30 days and 2 years, respectively (Kaplan-Meier analysis; mean follow-up, 31 months). Patients with aortoiliac disease had significantly better outcomes than those with infrainguinal disease ( P = .03). Duration or type of presenting symptoms did not predict outcome. The cost of the initial hospitalization per patient for thrombolysis was $18,490. Conclusion: Thrombolysis can be as or more costly than surgery and is associated with a suboptimal outcome in a significant number of patients. These data lead us to caution against a uniform policy of initial thrombolysis for patients who present with lower extremity ischemia. (J Vasc Surg 2001;33:1148-57.)

Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease.

Renal transplant artery stenosis (RTAS) continues to be a problematic, but potentially correctable, cause of post-transplant hypertension and graft dysfunction. Older transplant recipients, prone to peripheral vascular disease (PVD), may have pseudoRTAS with PVD involving their iliac system. We retrospectively analyzed 819 patients who underwent kidney transplantation between 1993 and 1997 to determine the contribution of pseudoRTAS to renal transplant renovascular disease. Univariate analyses were performed for donor and recipient variables, including age, weight, gender, race, renal disease, cholesterol and creatinine values, human leukocyte antigen (HLA) matching, cytomegalovirus (CMV) infection, and immunosuppressive medications. Significant variables were then analyzed by a Cox proportional hazards model. Ninety-two patients (11.2%) underwent renal transplant arteriogram (Agram) or magnetic resonance angiography (MRA) for suspected RTAS. RTAS or pseudoRTAS, defined as one or more hemodynamically significant lesions in the transplant artery or iliac system, was evident in 44 patients (5.4%). Variables significantly associated with RTAS by univariate analysis were weight at the time of transplant (p = 0.0258), male gender (p = 0.034), discharge serum creatinine > 2 mg/dL (p = 0.0041), and donor age (p = 0.0062). Variables significantly associated with pseudoRTAS by univariate analysis were weight at the time of transplant (p = 0.0285), recipient age (p = 0.0049), insulin-dependent diabetes mellitus (IDDM; p = 0.0042), panel reactive antibody (PRA) at transplant (p = 0.018), and body mass index (p = 0.04). Weight at transplant and donor age remained significantly associated with an increased risk for RTAS in a multivariate stepwise Cox proportional hazards model. IDDM, transplant PRA, weight at transplant, and donor age were significantly associated with an increased risk for pseudoRTAS in a multivariate stepwise Cox proportional hazards model. Importantly, both RTAS and pseudoRTAS were associated with poorer graft survival (p < 0.007 for each). Renal transplant renovascular disease encompasses pre-existing PVD acting as pseudoRTAS, as well as classical RTAS. Efforts to identify and correct renal transplant renovascular disease of either nature are important, given its negative impact on graft survival.

An analysis of limb-threatening lower extremity wound complications after 1090 consecutive coronary artery bypass procedures.

The objective of this study was to examine and characterize limb-threatening lower extremity wound or soft tissue complications after coronary artery bypass (CABG) and determine risk factors for their cause. While minor wound problems of the leg after CABG are not uncommon, serious limb-threatening complications, though less frequent, do occur and are often de-emphasized in the surgical literature. A review of 1090 consecutive CABG procedures performed from January 1, 1995 through December 31, 1995 was instituted, which screened for limb-threatening lower extremity wound or soft tissue complications defined as wounds that: required additional surgery for treatment; prolonged the length of stay; or which required lengthy home health nursing for treatment. Minor lymph leaks, leg swelling, infections or wound problems treated as an outpatient were excluded. Of 1090 patients, 54 (5.0%) experienced a limb-threatening lower extremity complication. Complications were categorized as vein harvest incision non-healing (n = 36, 66.7%), decubitus ulceration (n = 11, 20.4%), forefoot ischemia/embolization (n = 10, 18.5%), groin hematoma/abscess (n = 6, 11.1%), severe cellulitis (n = 3, 5.6%), or a combination (n = 12, 22.2%). Statistically significant risk factors by univariate and bivariate analysis for a complication included older age (68 years vs 62 years, p = 0.007), female sex (57% vs 28%, p < 0.001), diabetes (57% vs 33%, p = 0.005) and longer pump time (129 min vs 114 min, p = 0.009). These complications necessitated five major lower extremity amputations and nine revascularization procedures. Chronic lower extremity ischemia from peripheral vascular disease (PVD) was a major contributing factor for the development of wounds in at least 23 (42.6%) of these patients, though suspected in only 10 (43.5%) preoperatively. A non-healing vein harvest incision below the knee of a patient retrospectively found to have inadequate distal circulation for healing occurred in 17 (31.5%) of the total 54 cases. It was concluded that non-healing vein incisions, decubitus ulcers and forefoot ischemic lesions frequently occurring in older diabetic females with undetected pre-existing PVD, comprise the majority of limb-threatening leg complications after CABG. Nearly one-third of the complications may have been avoided had the vein harvest incision not been made at the ankle of a patient with unappreciated PVD.

NATIVE PERIPHERAL VASCULAR DISEASE CONTRIBUTES TO RENAL TRANSPLANT RENOVASCULAR DISEASE

288 Renal transplant artery stenosis (RTAS) is a relatively rare complication of renal transplantation, especially with the current techniques for vascular anastomoses. However, older patients (pts) prone to peripheral vascular disease (PVD), are more frequently being considered as candidates for renal transplantation. PVD involving the iliac system in this context can mimic RTAS(pseudoRTAS) and detrimentally affect graft function. We retrospectively analyzed 819 pts who underwent primary and non-primary kidney transplantation alone between 1993 and 1997 to determine the extent of pseudoRTAS. The population consisted of 506 M and 313 F. 92 pts (11.2%), suspected of having RTAS with new onset lower extremity edema and an increase in serum creatinine(Cr) underwent angiography (Agram) or magnetic resonance angiography (MRA). 4 pts underwent Agram or MRA involving the transplant renal artery for other reasons. RTAS or pseudoRTAS was defined as one or more hemodynamically significant lesions in the renal transplant artery or iliac system diagnosed by Agram or MRA. PseudoRTAS or RTAS was evident in 44 pts (5.4%), including 5 pts with pseudoRTAS and RTAS, 15 with pseudoRTAS, and 24 with RTAS. The recipient factor most significantly associated with RTAS and pseudoRTAS was increased weight at time of transplant (p < 0.0009). Other recipient factors that were associated with RTAS or pseudoRTAS included:TableThere was no significant association between RTAS or pseudoRTAS and race, pre-transplant dialysis modality, use of cyclosporine, FK506 or MMF, CMV infection, PRA, or HLA matching. In evaluating donor variables, available for 491 cadaveric transplants in this group, only older donor age was significantly associated with RTAS or pseudoRTAS (p < 0.0005). These data suggest that ischemic renal disease in renal transplant recipients may be increasing in incidence, taking on a new guise encompassing RTAS and pre-existing PVD that acts as pseudoRTAS.