Surgery For Peripheral Vascular Disease Research Articles

Surgical risk model for acute diffuse peritonitis based on a Japanese nationwide database: an initial report on the surgical and 30-day mortality

Acute diffuse peritonitis (ADP) is an important surgical complication associated with high morbidity and mortality; however, the risk factors associated with a poor outcome have remained controversial. This study aimed in collecting integrated data using a web-based national database system to build a risk model for mortality after surgery for ADP. We included cases registered in the National Clinical Database in Japan. After data cleanup, 8,482 surgical cases of ADP from 1,285 hospitals treated between January 1 and December 31, 2011 were analyzed. The raw 30-day and surgical mortality rates were 9.0 and 14.1 %, respectively. The odds ratios (>2.0) for 30-day mortality were as follows: American Society of Anesthesiologists (ASA) class 3, 2.69; ASA class 4, 4.28; ASA class 5, 8.65; previous percutaneous coronary intervention (PCI), 2.05; previous surgery for peripheral vascular disease (PVD), 2.45 and disseminated cancer, 2.16. The odds ratios (>2.0) for surgical mortality were as follows: ASA class 3, 2.27; ASA class 4, 4.67; ASA class 5, 6.54, and disseminated cancer, 2.09. The C-indices of 30-day and surgical mortality were 0.851 and 0.852, respectively. This is the first report of risk stratification after surgery for ADP using a nationwide surgical database. This system could be useful to predict the outcome of surgery for ADP and for evaluations and benchmark performance studies.

Benefits associated with achieving optimal risk factor levels for the primary prevention of cardiovascular disease in older men.

Most incident cardiovascular disease (CVD) occurs after patients reach the age of 65. The additive benefits of aggressive risk factor management with advancing age are not well established. To evaluate the relationship between control of four modifiable risk factors (smoking, non-high density lipoprotein cholesterol, blood pressure, and aspirin use) and risk of CVD in a primary prevention population of older men. U.S. male physicians from the Physicians' Health Study (n = 4182; an epidemiologic follow-up of a randomized trial of aspirin and beta-carotene) who in 1997 were ≥ 65 years, free of CVD and diabetes, and had a blood sample on file were studied. Cox proportional hazard models were adjusted for age and competing causes of death. The first of any CVD event, defined as cardiovascular death, nonfatal myocardial infarction, angina, coronary revascularization, nonfatal stroke, transient ischemic attack, carotid artery surgery, and other peripheral vascular disease surgery, was measured. Mean follow-up was 9.3 years, mean age was 73 years, and 96% were nonsmokers. Compared with when 4 of 4 risk factors were controlled (6.0% of participants), control of 0 of 4 risk factors almost quadrupled the risk of CVD (0.4% of participants; event rate 41.2%; hazard ratio [HR] 3.83, 95% confidence interval [95% CI] 1.72-8.55); control of 1 of 4 risk factors more than doubled the risk (14.2% of participants; HR 2.53, 95% CI 1.80-3.57); control of 2 of 4 risk factors almost doubled the risk (43.8% of participants; HR 1.94, 95% CI 1.41-2.69), and those with control of 3 of 4 risk factors also were at increased risk (35.6% of participants; HR 1.80, 95% CI 1.30-2.50). Control of each additional risk factor was associated with greater cardiovascular protection (P for trend P = .002). Depending on the number of risk factors controlled, the number-needed to control to prevent one CVD event ranged from 5 to 22. Control of 4 treatable risk factors (nonsmoking, control of non-high density lipoprotein cholesterol and blood pressure, and aspirin use) was associated with substantial protection against incident cardiovascular events in older men even after adjustment for competing causes of mortality.

Abstract P339: Benefits of Achieving Optimal Risk Factor Levels for the Primary Prevention of Cardiovascular Disease in Elderly Men

Context: Most cardiovascular disease (CVD) occurs after age 65. The additive benefits of aggressive risk factor management with advancing age are not well established. Objective: Evaluate the relationship between the intensity of control of 4 modifiable risk factors [smoking, non-high density lipoprotein cholesterol (non-HDL-C), blood pressure, and aspirin use] and the risk of CVD in a primary prevention population of men ≥65 years. Methods: The study population was comprised of 4203 U.S. male physicians from the Physicians' Health Study who in 1997 were aged ≥65 years, free of CVD and diabetes, and had lipids available. The primary endpoint was first of any CVD event, defined as cardiovascular death, non-fatal myocardial infarction, angina, coronary revascularization, non-fatal stroke, transient ischemic attack, carotid artery surgery, and other peripheral vascular disease surgery. Age and risk factor adjusted Cox proportional hazard models were adjusted for competing causes of death. Results: Mean age was 73 years and 96% were nonsmokers; 28% experienced a CVD event during the mean 9 year follow-up. Few had optimal levels of all 4 modifiable risk factors (6%): 18% had an untreated non-HDL-C<130 mg/dl; 54% had an untreated blood pressure <140/90 mm Hg; and 51% used aspirin; <1% had none of the 4 risk factors controlled. Compared to when all 4 risk factors were controlled (6%), CVD risk increased by 55% when 3 of 4 risk factors (36%) were controlled (event rate 25%; HR 1.55, 95% CI 1.08-2.22), 75% when 2 of 4 risk factors (44%) were controlled (event rate 28%; HR 1.74, 95% CI 1.22-2.49), and more than doubled when 1 of 4 risk factors (14%) were controlled (event rate 35%; HR 2.29, 95% CI 1.57-3.34); p for trend p=0.0002. The number-needed to control to prevent one CVD event over 9 years ranged from 4 to 11 depending on the number of risk factors controlled. Conclusion: In elderly men, not smoking, control of non-HDL-C and blood pressure, and aspirin use conferred substantial protection against incident CVD events. Nonetheless, the CVD event remained high even in those with well-controlled risk factors ≥65, emphasizing the need for optimal risk factor control throughout adulthood.

Class I Obesity is Associated With Decreased Risk of Stroke After Carotid Endarterectomy

Although obesity is a risk factor for vascular disease, previous studies have shown an obesity paradox, with decreased death in obese patients undergoing vascular surgery. This study examined the relationship between body mass index (BMI) and outcomes after carotid endarterectomy (CEA). The 2005 to 2009 American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) database was queried to evaluate 30-day outcomes after isolated CEA across National Institutes of Health-defined obesity classes, defined by body mass index (BMI) in kg/m2 as underweight, BMI <18.5; normal weight, BMI 18.5 to 24.9; overweight, BMI 25.0 to 29.9; class I obese, BMI 30.0 to 34.9; class II obese, BMI 35.0 to 39.9; or class III obese, BMI ≥40). The association of BMI with morbidity and death was assessed with multivariable logistic regression, adjusting for preoperative and operative characteristics and polyvascular disease. In the cohort of 23,663 CEA, the overall stroke and mortality rates were 1.4% and 0.6%, respectively. On multivariable analysis, class I obesity was the only variable associated with decreased risk of stroke (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.34-0.84; P = .006). Independent risk factors for stroke were female sex (OR, 1.37; P = .018), previous transient ischemic attack (OR, 1.38; P = .02), previous stroke with (OR, 1.59; P = .02) or without (OR, 1.73; P = .008) neurologic deficit, and hemiplegia (OR, 2.17; P = .002). Class II (OR, 2.41; 95% CI, 1.18-4.89; P = .015) and III obesity (OR, 2.58; 95% CI, 1.11-6.03; P = .028) were associated with increased risk of surgical site infection. Obesity was not an independent predictor of death or myocardial infarction. Independent predictors of death were increasing age (OR, 1.18, P = .005), previous stroke with neurologic deficit (OR, 1.71; P = .035), previous surgery for peripheral vascular disease (OR, 2.23; P = .002), chronic obstructive pulmonary disease (OR, 3.13; P < .001), dependent status (OR, 3.74; P < .001), previous myocardial infarction (OR, 5.07; P < .001), and acute renal failure (OR, 9.66; P = .005). An obesity paradox exists for stroke, but not death, after CEA. Reduced risk of stroke in class I obese patients was independent of polyvascular disease, preoperative comorbidities, and operative variables.

The Economics of Limb Salvage in Diabetes

Limb salvage requires early prevention therapy, knowledgeable use of wound care technology, and active management of peripheral vascular disease. This field has changed considerably over the past decade, with new advanced wound healing products and minimally invasive surgery for peripheral vascular disease. Treatment can be very costly in terms of medical and human resources. Evaluation of the clinical and economic impact of medical care is becoming more important as the population with diabetes and the need to contain the cost of health care simultaneously increase. The aim of this study was to review the economic impact of prevention therapies, wound care, and peripheral vascular disease interventions to prevent major lower extremity amputations. The authors reviewed the economic impact of prevention therapy, wound care, and peripheral vascular disease interventions to prevent lower extremity amputations. Length of stay in the hospital and intensive care drive the cost of treatment. Surgical intervention and complications for foot ulcers, amputations, and peripheral vascular disease are significant factors in the cost of limb salvage. Not surprisingly, prevention and evidenced-based treatments are the most cost-effective way of reducing the use of medical resources and improving and prolonging productive lifestyles. Future prospective studies need to be conducted to more accurately understand the financial impact of limb salvage.

Antithrombotische Therapie beim femoropoplitealen Venenbypass

BACKGROUND: Postoperative oral antithrombotic therapy in patients after femoro-popliteal saphenous vein bypass still remains a matter of debate. Aim of this study was to evaluate bypass patency, morbidity and mortality in patients treated by primary saphenous femoro-popliteal vein bypasses with either postoperative oral antiaggregation or oral anticoagulation. METHODS: Retrospective analysis of prospectively maintained database in a university tertiary care hospital. Patients underwent surgery for peripheral vascular disease. The only procedure investigated was primary reversed femoro-popliteal saphenous vein bypass. RESULTS: Between January 2000 and December 2003 two-hundred-and-thirty-four patients received 243 primary femoro-popliteal saphenous vein bypass procedures. Postoperatively either oral antiaggegants (Aspirin® 100 mg/day) or oral anticoagulants (phenprocoumon or acenocoumarol, INR: 2–4) were prescribed. There was no significant difference in patency rates between the antiaggregation group (AGG) and the oral anticoagulation group (AC) at all time intervals studied. After 1 year, the primary patency rate of femoro-popliteal vein bypasses in the AGG was 90% as compared to 91% in the AC, and after 6 years it was 86 and 91%, respectively (p = 0.26). There were 69 deaths of 195 patients in the AGG and 17 deaths of 39 patients in the AC (risk ratio 80%; confidence interval 0.5–1.2; p > 0.05). Major hemorrhagic events with fatal outcome occurred in 3 patients (all of them in the AGG, p = 0.59). Limb salvage was achieved in 97% in the AGG and in 93% in the AC. CONCLUSIONS: We could not show a significant difference between patients who received postoperative aspirin or oral anticoagulation in terms of bypass graft patency, morbidity and mortality after femoro-popliteal saphenous vein bypass procedures.

Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft

Although the use of endoscopic vein harvest (EVH) in coronary artery bypass grafting is accepted, few studies have documented the implementation of EVH in peripheral vascular disease surgery. We hypothesized that EVH improves outcomes compared with open vein harvest (OVH) in patients undergoing femoral to below the knee arterial bypass surgery. The charts of 144 consecutive patients undergoing infrainguinal bypass surgery over the course of 27 months were reviewed. A femoral to below the knee arterial bypass with saphenous vein was done in 88 patients (29 had EVH, 59 had OVH). The preoperative characteristics evaluated were age, gender, renal function, history of diabetes, hypertension, tobacco use, and previous infrainguinal bypass surgery on the affected side. End points included wound complications, length of hospital stay, operative time, angiographic and operative interventions for graft occlusion, patency rates, limb salvage, acute renal failure, myocardial infarction, and death. Patient characteristics and demographics were similar in the EVH and OVH groups. No operative intervention for occlusion was required in the EVH group (0/29) compared with 13.4% in the OVH group (8/59) (P = .03). At the mean follow-up time of 21 months, primary patency rate was 92.8% in the EVH group and 80.6% in the OVH group (P = .12). No significant differences were found between the EVH and OVH groups in postoperative complications, length of hospital stay, operative time, patency rates, limb salvage, and death. Despite our initial concerns of damaging the venous conduit with a minimally invasive approach to saphenous vein harvest, EVH in our experience has resulted in a trend toward improved patency rates and decreased infectious wound complications while affording the benefit of improved cosmesis. An endoscopic approach results in smaller incisions, decreased interventions for occlusion, and improved outcomes compared with OVH. EVH is the procedure of choice for harvesting saphenous vein for femoral to below the knee arterial bypass surgery.

Alterations of Thrombogenesis, Endothelial Damage and Oxidative Stress with Reperfusion during Femoral Artery Bypass Surgery for Peripheral Vascular Disease

Peripheral vascular disease (PVD) is a significant cause of cardiovascular morbidity. We hypothesised that there would be significant alterations of thrombogenesis, platelet activation and endothelial damage, which could be associated with abnormal oxidative stress during femoral artery bypass surgery for PVD, where the femoral artery is cross-clamped (causing acute ischaemia) and reperfused (following revascularisation). To test this hypothesis, we measured sequential changes in von Willebrand factor (vWF, and index of endothelial damage/dysfunction), tissue factor (TF, an index of thrombogenesis) and soluble P-selectin (sP-sel, an index of platelet activation) as well as lipid hydroperoxides (LPO, an index of oxidative stress) in 28 consecutive patients undergoing elective peripheral artery bypass surgery. Mean baseline vWF and sP-sel levels in PVD patients (before clamping) were significantly higher compared with age- and sex-matched controls (unpaired t test, both p < 0.05), but there were no significant differences in TF and LPO levels. There was a correlation between TF and vWF (Spearman’s, r = 0.374, p = 0.05), as well as between sP-sel and vWF at the start of surgery (r = 0.467, p = 0.012). The patients undergoing peripheral artery bypass surgery had a mean femoral artery clamp time of 28 min (standard deviation 14 min; range 11–65 min). There were no significant overall changes in sP-sel, vWF, TF and LPO with femoral artery cross-clamping and reperfusion (repeated measures ANOVA, p = NS). In conclusion, we found that during ischaemia-reperfusion during peripheral arterial bypass surgery, thrombogenesis (as measured by plasma TF) and oxidative damage (as measured by LPO) within the affected leg does not increase in the immediate perioperative period. Further studies are required to assess the mechanism(s) of ischaemia-reperfusion injury in PVD, and the contributory role(s) of the endothelium and platelets.

Alterations of Thrombogenesis, Endothelial Damage and Oxidative Stress with Reperfusion during Femoral Artery Bypass Surgery for Peripheral Vascular Disease

Peripheral vascular disease (PVD) is a significant cause of cardiovascular morbidity. We hypothesised that there would be significant alterations of thrombogenesis, platelet activation and endothelial

Long-term Survival (up to 21 Years) After Coronary Artery Bypass Surgery: Importance of Previous Surgery for Peripheral Vascular Disease

Long-term Survival (up to 21 Years) After Coronary Artery Bypass Surgery: Importance of Previous Surgery for Peripheral Vascular Disease

Long-term survival (up to 21 years) after coronary artery bypass surgery: importance of previous surgery for peripheral vascular disease

Long-term survival (up to 21 years) after coronary artery bypass surgery: importance of previous surgery for peripheral vascular disease

1013-108 Is Persantine Thallium Scintigraphy Cost Effective and Reliable in the Preoperative Evaluation of Patients Referred for Peripheral Vascular Surgery?

Asymptomatic CAD has been shown to be associated with a high risk of perioperative cardiac events in patients (pts) undergoing surgery for peripheral vascular disease (PVD). Dipyridamole thallium (SPECT) scintigraphy (DTS) is considered the most useful screening test for stratification of these pts. Comparative prospective evaluation of various noninvasive tests for detection of latent CAD in PVD pts is lacking. In this study, 100 consecutive patients referred for PVD surgery were evaluated by DTS, low work load exercise treadmill test (ETT) and ambulatory ECG monitoring (AEM). Pts with abnormal findings on any of the three noninvasive tests were evaluated with coronary angiography (angio) for further stratification. Fifty-five pts had reversible perfusion defects on DTS. Of the 55 + pts with DTS, 49 had data on AEM with 39% having evidence of ambulatory ischemia; 48 of the 55 pts performed ETT with ischemia induced in 13%. Of the 41 pts with normal DTS findings, 12 (29%) had ischemia during ETT (n = 6) or AEM (n = 6); 64% of these pts had multi-vessel CAD by angio. Statistical modeling and analysis of important clinical variables, AEM ischemia, and angio findings were compared with DTS for predicting CAD. These analyses revealed that family hx of CAD, chest pain, smoking, age ≥ 65 years, and ischemia on AEM were highly predictive of CAD with a positive predictive value of 89% and a specificity of 92%. These findings suggest that a careful evaluation of clinical parameters and AEM results can provide reliable and clinically meaningful data predictive of significant CAD in pts referred for PVD surgery. Our data have demonstrated that the findings on DTS are not always reliable and its routine use might not be warranted in preoperative evaluation of patients with asymptomatic CAD referred for peripheral vascular surgery.

Post-Tachycardia T-Wave Syndrome

Figure 1. Serial electrocardiograms (lead V4) were obtained in a 67-year-old man taking digoxin for paroxysmal supraventricular tachycardia. An electrocardiogram obtained on June 28, 1983, showed no abnormalities. About six weeks later on August 15, while awaiting surgery for peripheral vascular disease, the patient had an episode of paroxysmal supraventricular tachycardia (first electrocardiogram in second row) that responded to carotid-sinus massage. An electrocardiogram obtained shortly after conversion to sinus rhythm showed atrial premature beats and minor T-wave inversions (second electrocardiogram in second row), which became deeper over the next 24 hours (third electrocardiogram in second row). The patient . . .

End-stage renal disease—Is infrainguinal limb revascularization justified?

Reports of reconstructive surgery for peripheral vascular disease have been relatively uncommon in patients with end-stage renal disease. Between 1980 and 1989, 39 patients with end-stage renal disease underwent revascularization of 56 limbs. Fifty-two primary infrainguinal and four secondary infrainguinal bypass grafts were performed. In addition, nine thrombectomies were performed. At the time of surgery 37 patients were on dialysis; three had functioning kidney transplants. The indications for revascularization were gangrene, rest pain, or ulceration in all except three limbs with disabling claudication. Reversed, nonreversed, or in situ vein was used in 25 of the 52 primary infrainguinal revascularizations performed. Polytetrafluoroethylene was used in 25. Two procedures used a combination of polytetrafluoroethylene and vein. The primary patencies for all infrainguinal procedures at 1 and 2 years were 77% and 68%, respectively. Four perioperative deaths occurred in the infrainguinal group (7.7%). An additional death occurred after thrombectomy for late graft closure. Three deaths were a result of myocardial infarction. One patient on peritoneal dialysis developed uncontrolled sepsis. At 3 years 39% of patients were alive, and 84% of the limbs were salvaged. Among the cases studied no group was identified that represented unacceptable operative risk. Results compared well with reported patencies for patients subjected to infrainguinal revascularization procedures. Limb revascularization in patients with end-stage renal disease may be performed by use of similar criteria to those used for other patients with peripheral vascular disease.

The Loneliness of the Long-Acting Nitrator

To the Editor.— In an effort to improve patient compliance and facilitate medication administration, many physicians select long-acting, once-a-day drug regimens. This commendable practice can have detrimental effects on selected patients, as illustrated in the following case report. Report of A Case. — An 89-year-old alert woman residing in a nursing home was evaluated by a cardiologist before undergoing reconstructive bypass surgery for peripheral vascular disease. The consultant recommended that long-acting topical transdermal nitrate preparation be substituted for her usual oral nitrate preparation that had been administered four times a day. During the next 3 days, the patient complained of nonspecific chest discomfort and anxiety. Through questioning, it became apparent that the woman missed the regular visits by the nursing staff who came to administer the oral medication around the clock; she resented the new once-a-day schedule, which she interpreted as disinterest on the part of the nursing staff. The

11 The Use of Antithrombotic Drugs in Artery Disease

Evaluating the use of antithrombotic drugs in artery disease has been a long and difficult process, which is far from complete. The aims of treatment have ranged from the primary prevention of myocardial infarction or stroke, through the restoration of blood flow to ischaemic organs in order to salvage threatened tissue, to the prevention of recurrent vascular occlusion. Drugs studied in depth by clinical trial include the oral anticoagulants, antiplatelet drugs (especially aspirin), and thrombolytic agents. Their results are considered under the headings of coronary artery disease, cerebral ischaemia, and peripheral vascular disease. Aspirin, with or without dipyridamole, prevents progression of unstable angina to myocardial infarction or death, probably reduces long-term mortality after myocardial infarction, and prevents aortocoronary bypass graft occlusion. It decreases the risks of stroke or death in patients with transient cerebral ischaemia, diminishes cardiovascular morbidity after a thrombotic stroke, and may improve the outcome after some kinds of surgery for peripheral vascular disease. The benefits of oral anticoagulant treatment to prevent artery occlusion remain poorly defined. Oral anticoagulants prevent systemic embolism in many groups of high-risk patients, and probably reduce the risk of recurrence after embolism has occurred. Whether their long-term use to prevent reinfarction in patients with a previous myocardial infarct can be justified remains uncertain. They are of little or no proven value in patients with transient cerebral ischaemia or thrombotic stroke. On the other hand, there is increasing support for early thrombolytic treatment after myocardial infarction, especially since two multicentre trials have now shown reduced mortality in patients treated with intracoronary streptokinase within 4-6 hours of infarction and a further large multicentre study also demonstrated reduced mortality in patients treated with early intravenous streptokinase. In addition, the local infusion of streptokinase leads to recanalization in a high proportion of patients with a recent peripheral artery occlusion who are poor candidates for surgery.

Intravenous digital subtraction angiography in patients with suspected bypass graft occlusion following surgery for peripheral vascular disease.

Intravenous digital subtraction angiography has been used to investigate 40 patients with suspected bypass graft occlusion. Its accuracy and clinical impact have been assessed.

Surgery for peripheral vascular disease

AORN JournalVolume 33, Issue 5 p. 849-853 Department Surgery for peripheral vascular disease Thomas R Winston MD, Thomas R Winston MDSearch for more papers by this authorWalter S Henly MD, Walter S Henly MDSearch for more papers by this authorRichard C Geis MD, Richard C Geis MDSearch for more papers by this author Thomas R Winston MD, Thomas R Winston MDSearch for more papers by this authorWalter S Henly MD, Walter S Henly MDSearch for more papers by this authorRichard C Geis MD, Richard C Geis MDSearch for more papers by this author First published: April 1981 https://doi.org/10.1016/S0001-2092(07)62645-3AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume33, Issue5April 1981Pages 849-853 RelatedInformation

ARTERIAL OXYGENATION AND PHYSIOLOGICAL DEADSPACE DURING ANAESTHESIA: Effects of ventilation with a pressure preset ventilator

SUMMARY The effects of IPPV with a pressure preset ventilator on alveolar-arterial oxygen tension difference, arterial oxygen tension and physiological deadspace were studied in eleven patients undergoing surgery for peripheral vascular disease. No significant difference in these values was found over a period of 2½ hours, but in five of the eleven patients studied, the VD/VT ratio rose by more than 4.7 per cent during the period of study. Possible reasons for this, and for the large increase in A-a Po2 found after induction of anaesthesia, are discussed.