Vascular and Endovascular Surgery

The aim of this study is to examine the predictive value of the Lee revised cardiac risk index (RCRI) for a standard vascular intensive care unit (ICU) population as well as assessing the utility of transthoracic echocardiography and the impact of prior coronary artery disease (CAD) and coronary revascularization on patient outcome.

This is a retrospective review of prospectively maintained Vascubase and prospectively collected ICU data.

Data from 363 consecutive vascular ICU admissions were collected. Findings were used to calculate the RCRI, which was then correlated with patient outcomes. All patients were on optimal medical therapy (OMT) in the form of cardioselective β-blocker, aspirin, statin, and folic acid.

There was no relationship found between a reduced ejection fraction and patient outcome. Mortality was significantly increased for patients with left ventricular hypertrophy (LVH) as identified on echo (14.9% vs 6.5%, P = .028). The overall complication rates were significantly elevated for patients with valvular dysfunction. Discrimination for the RCRI on receiver–operating characteristic analysis was poor, with an area under the receiver–operating characteristic curve of .621. Model calibration was reasonable with an Hosmer-Lemeshow Ĉ statistic of 2.726 (P = .256). Of those with known CAD, 41.22% of the patients receiving best medical treatment developed acute myocardial infarction (AMI) compared to 35.3% of those who previously underwent percutaneous cardiac intervention and 23.5% of those who had undergone coronary artery bypass grafting. There was 3-fold increase in major adverse clinical events in patients with troponin rise and LVH.

The RCRI’s discriminatory capacity is low, and this raises difficulties in assessing cardiac risk in patients undergoing vascular intervention. The AMI is highest in the OMT group without prior cardiac intervention, which mandates protocols to identify patients requiring cardiac intervention prior to vascular procedures.

Concern about allogeneic blood product cost and complications has prompted interest in blood conservation techniques. Intraoperative autotransfusion (IAT) is currently not used routinely by vascular surgeons in open elective infrareanl abdominal aortic aneurysm (AAA) repair. The objective of this study is to review our experience with IAT and its impact on blood transfusion.

We retrospectively reviewed the medical records of consecutive patients treated electively over a 4-year period and compared 2 strategy related to IAT, routine use IAT (rIAT) versus on-demand IAT (oIAT). Outcomes measured were number of units of allogeneic red blood cells and autologous red blood cells transfused intraoperatively and postoperatively, preoperative, postoperative, and discharge hemoglobin levels; postoperative infections; length of postoperative intensive care stay; and length of hospital stay. T-independent and Fisher exact test were used.

A total of 212 patients were included, 38 (18%) in the rIAT and 174 (82%) in the oIAT. Groups were similar except for an inferior creatinine and a superior mean aneurysm diameter for the rIAT group. Patients in the rIAT group had a lower rate of transfusion (26% vs 54%, P = .002) and a lower mean number of blood unit transfused (0.8 vs 1.8, P = .048). These findings were still more significant for AAA larger than 60 mm (18% rIAT vs 62% oIAT, P = .0001). Postoperative hemoglobin was superior in the rIAT group (107 vs 101 g/L, P = .01). Mean postoperative intensive care length of stay was shorter for the rIAT group (1.1 vs 1.8 days, P = .01). No difference was noted for infection, mortality, or hospital length of stay.

The rIAT reduced the exposure to allogeneic blood products by more than 50%, in particular for patients with AAA larger than 60 mm. These results support the use of rIAT for open elective infrarenal AAA repair.

To determine the incidence of recanalization of the occluded internal carotid artery (ICA) and establish its natural history.

Patients with duplex-confirmed ICA occlusions were identified, and a subgroup offered repeat scanning. The antemortem condition and cause of death of patients who died were recorded.

Of 153 patients identified, 77 underwent follow-up at a median of 35 months (interquartile range [IQR]: 14-61).In all, 8 (10.3%) demonstrated recanalization at a median of 53 months (IQR: 35-114). Of 8, 7 underwent carotid endarterectomy with histopathological confirmation of recanalization. Of the 153 patients, 45 (29%) had further neurological events, and 38 (25%) were within the territory of the occluded ICA. In all, 76 patients died, and of the 53 with a confirmed cause of death, 12 (23%) were attributed to a cerebrovascular accident corresponding to the territory of the occluded artery.

Recanalization of ICA occlusion is common and leads to significant neurological events. Duplex ultrasound follow-up appears mandatory.

Tissue loss or gangrene in the setting of lower extremity peripheral artery disease (PAD) may result in amputation. Previous studies have demonstrated elevated mortality rates after major transtibial and transfemoral amputation. Also, amputation of 1 leg may be associated with subsequent major amputation of the contralateral leg. The aim of our study was to identify patient variables associated with mortality and contralateral amputation.

We reviewed the medical records of patients who underwent transfemoral or transtibial amputation secondary to PAD from 2004 to 2009. A total of 454 consecutive major amputations were performed on 391 patients, with 63 of these having a subsequent contralateral amputation. Standard demographic information, comorbidities, prior vascular interventions, and relevant procedural information were extracted from patient records. Kaplan-Meier estimates of survival were calculated. Cox proportional hazard models were used to estimate the risk of death and contralateral amputation. Multivariate Cox proportional hazards models were fit for all variables shown to be marginally associated in the univariate model.

In 391 amputees, the mean age was 67.3 years, 63% were male and 62% were caucasian. Patients had high rates of diabetes (63%), hypertension (83%), renal insufficiency (35%), hyperlipidemia (51%), and prior ipsilateral vascular intervention (75%). Seventy percent of patients had below-knee amputations. Perioperative mortality was 9.2% (n = 36). Survival at 12 and 24 months was 70% (95% confidence interval [CI], 65%-74%) and 60% (95% CI, 55%-65%), respectively. Multivariate analysis demonstrated that several independent factors were detrimental to survival including chronic obstructive pulmonary disease (hazard ratio [HR] 1.82, P = .002), dialysis dependence (HR 2.50, P < .001), high cardiac risk (HR 2.20, P < .001), and guillotine amputation (HR 2.49, P = .004). Dialysis (HR 2.42, P = .002) and revision of the index ipsilateral amputation to a higher level (HR 2.02, P = .014) were associated with a subsequent contralateral amputation.

Patients with advanced PAD that require lower extremity amputation have diminished survival and significant contralateral amputation rates. Elderly patients on dialysis are particularly prone to dying or losing the other leg after a major amputation. These data support strategies to enhance limb preservation and optimize medical comorbidities in these patients.

To determine whether a correlation exists between chronic cerebrospinal venous insufficiency (CCSVI) and multiple sclerosis (MS).

A meta-analysis of the current literature was performed to evaluate the frequency of CCSVI, diagnosed by echo color Doppler criteria, in patients with MS and in normal controls.

In all, 19 studies were identified from January 2005 through February 2013; however, 3 studies were excluded due to duplicate data and 3 additional studies because 0 patients fulfilled CCSVI criteria in both MS and control groups. In order to improve homogeneity, 4 outlier studies were also removed from the analysis. Analysis of the remaining 9 studies demonstrated a significant correlation between CCSVI and MS (odds ratio 1.885, P < .0001) with no significant heterogeneity of the studies (I ² = 18, P = .279).

The meta-analysis demonstrated a correlation between CCSVI and MS. However, there was no evidence that CCSVI has a causative role in MS.

To evaluate hemodynamic changes during aneurysmal dilatation in chronic type B aortic dissections compared to hemodynamic parameters in the healthy aorta with the use of computational fluid dynamics (CFD).

True lumen (TL)/false lumen (FL) dimensional changes, changes in total pressure (TP), and wall shear stress (WSS) were evaluated at follow-up (FU) compared to initial examination (IE) with transient CFD simulation with geometries derived from clinical image data and inflow boundary conditions from magnetic resonance images. The TL/FL pressure gradient between ascending and descending aorta (DAo) and maximum WSS at the site of largest dilatation was compared to values for the healthy aorta.

Hemodynamic changes at site of largest FL dilatation included 77% WSS reduction and 69% TP reduction. Compared to the healthy aorta, pressure gradient between ascending and DAo was a factor of 1.4 higher in the TL and a factor of 1.5 in the FL and increased at FU (1.6 and 1.7, respectively). Maximum WSS at the site of largest dilatation was a factor of 3 lower than that for the healthy aorta at IE and decreased by more than a factor of 2 at FU.

The FL dilatation at FU favorably reduced TP. In contrast, unfavorable increase in pressure gradient between ascending and DAo was observed with higher values than in the healthy aorta. Maximum WSS was reduced at the site of largest dilation compared to healthy aorta.

To investigate the effect of Iodixanol on kidney proximal tubular cell line human kidney 2 (HK-2).

The HK-2 cells were treated with Iodixanol. A Terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) assay was used to evaluate apoptosis. Cell viability was measured by proliferation assay kit. Cell permeability changes were assessed by transwell assay and intercellular gaps measurement. Expression of claudin-2 was assessed by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) and Western blot.

Iodixanol reduced tubule cell viability (P < .01) but did not cause apoptosis. The intercellular gap formation (P < .01) and transwell (P < .05) assays revealed that cell permeability significantly increased after Iodixanol treatment of monolayer cells. Western blot and qRT-PCR showed significant upregulation of claudin-2 protein (P < .05) and messenger RNA expression (P < .01).

Our in vitro data do not support the hypothesis that direct kidney cell death from Iodixanol is a major mechanism of contrast-induced nephropathy (CIN). However, increased permeability of proximal tubule epithelium caused by Iodixanol may play an important role in CIN.

To determine the short- and mid-term outcomes of percutaneous endovascular common femoral artery (CFA) revascularization (eCFR) of the CFA.

A review of patients who underwent eCFR for limb ischemia between 2006 and 2012 was performed. Limb salvage, patient survival, survival free from reintervention, and survival free from amputation rates were determined. Median (range) follow-up was 28 (1-71) months.

In all, 115 patients underwent 121 eCFR for CFA occlusion (n = 13) or stenosis (n = 108); 109 (90%) were technically successful and 7 (6%) had significant perioperative complications; access site hematoma (n = 2) and thromboembolism (n = 5). Thirty-day mortality and amputation rates were 2.5% and 0.8%, respectively. The 1- and 3-year limb salvage rates were 97% and 97%, respectively. The 1- and 3-year survival free from reintervention rates were 77% and 57%, respectively. The 1- and 3-year survival free from amputation rates were 84% and 70%, respectively.

These novel data demonstrate that eCFR is a durable treatment for patients with limb ischemia associated with CFA disease.