Journal of Vascular Surgery

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Comparison of Two Different Techniques for Isolated Left Subclavian Artery Revascularization During Thoracic Endovascular Aortic Repair in Zone 2

January 31, 2019 - 23:00
Retrospective, multicenter, observational study from January 2010 to February 2017.

Aortic Surgery Outcomes of Marfan Syndrome and Ehlers-Danlos Syndrome Patients at Teaching and Non-teaching Hospitals

January 31, 2019 - 23:00
Retrospective review of a National Inpatient Sample from 2000 to 2014.

Regarding “Comparing the efficacy of shunting approaches and cerebral monitoring during carotid endarterectomy using a national database”

January 31, 2019 - 23:00
We reviewed the published report1 with great interest and commend the authors on seeking to complete an analysis of such a large cohort. Protection against hypoperfusion injury offered by shunting in carotid endarterectomy remains a topic around which there is much debate. There is wide variation not only nationally and internationally but between surgeons within individual units. There is conflicting evidence to support and to disparage intraoperative shunt use. Larger scale reviews have been unable to make definitive conclusions to support either standpoint as there is insufficient strong evidence.

Reply

January 31, 2019 - 23:00
Thank you, Drs Fisher, Benson, and Imray, for your interest in our article and for highlighting some of the evidence to support the use of general anesthesia for its neuroprotective effects, which are derived from the uncoupling of cerebral metabolism and blood flow. Although general anesthesia likely provides some neuroprotective effect (so-called luxury perfusion), we found that it does not significantly lower the rate of clinically significant strokes in our study, as evidenced by the equivalent rate of stroke between patients who had local anesthesia and those who were routinely shunted under general anesthesia.

Regarding “Preoperative antihypertensive medication intake and acute kidney injury after major vascular surgery”

January 31, 2019 - 23:00
In a recent article, Duceppe and colleagues1 assessed the association between preoperative antihypertensive medication administration and postoperative acute kidney injury (AKI) in patients undergoing major vascular surgery who had received chronic antihypertensive therapy. The multivariable logistic regression analysis showed that antihypertensive medication intake on the morning of surgery was associated with an increased risk of postoperative AKI. The research conducted is valuable, but there are two issues in their methods and results that need to be discussed and clarified.

Reply

January 31, 2019 - 23:00
Zi Shao et al commented on the variables included in the multivariable analysis of predictors of postoperative acute kidney injury (AKI) after major vascular surgery, noting that an estimated glomerular filtration rate (eGFR) of less than 60 mL/minute and clinically significant intraoperative hypotension were not included in the final model. The authors put forward that this was because they had low incidence and it was not shown to be associated in univariable analysis. We would like to emphasize that the decision to include or not variables in the multivariable model was not based on their prevalence or result of the univariable analyses, but it was rather predefined when designing the statistical analysis plan.

Current status of noninvasive perfusion assessment in individuals with diabetic foot ulceration

January 31, 2019 - 23:00
The global prevalence of diabetic foot ulceration (DFU) has recently been reported as 6.3%.1 The problem is particularly significant in North America, with a prevalence of 13%; in Europe, the rate is 5.5%. In a prospective study of 725 diabetic patients with a mean follow-up of 691.8 days, the mortality of individuals with DFU was more than two-fold higher than diabetic patients without ulceration, irrespective of age, diabetes type, and treatment of diabetes.2 Management of both the foot and the patient as a whole in the context of DFU depends on a coordinated, multidisciplinary team approach: good glycemic control, prompt referral to diabetic foot services with effective pathways in place, adequate pressure offloading, and establishing whether peripheral arterial disease (PAD) exists—and addressing it—are essential.

Stent graft as a bridge to allograft to treat a septic thoracic aortic pseudoaneurysm after spinal fusion

January 31, 2019 - 23:00
A 29-year-old woman was admitted to our institution for severe septic syndrome. Her medical history included a T6-T8 posterior spinal fusion 7 years earlier for tuberculous spondylodiscitis. Contrast-enhanced computed tomography (CT) revealed a 70- × 58-mm pseudoaneurysm of the descending thoracic aorta extending from T6 to T8 level, surrounding the left T6 screw (A/Cover). A T6-T8 spondylodiscitis and bilateral paraspinal collections were also observed. Blood and T7 bone biopsy specimens grew Escherichia coli.

Reply

January 31, 2019 - 23:00
Grazioli et al commented on the utility of mean arterial pressure (MAP) to assess potential hemodynamic compromise. The authors mention that even brief and nonsustained periods of intraoperative decline in MAP are associated with acute kidney injury (AKI), as seen in the study of Walsh et al,1 in which a MAP <55 mm Hg had the strongest association with AKI. In our study, data on lowest intraoperative MAP were collected, and we did not find a significant association between lowest MAP (P = .118) and MAP <55 mm Hg (P = .085) and postoperative AKI.

Regarding “Preoperative antihypertensive medication intake and acute kidney injury after major vascular surgery”

January 31, 2019 - 23:00
We read with great interest the article entitled “Preoperative antihypertensive medication intake and acute kidney injury after major vascular surgery” in the June 2018 issue of Journal of Vascular Surgery. This retrospective study of 406 patients undergoing major vascular surgery finds that in chronically hypertensive patients, the number of antihypertensive drugs administered on the morning of surgery is independently associated with an increased risk of postoperative acute kidney injury (AKI).

The BEST-CLI trial is nearing the finish line and promises to be worth the wait

January 31, 2019 - 23:00
There is significant variability and equipoise in the management of critical limb ischemia (CLI). The Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial, funded by the National Heart, Lung, and Blood Institute, is a prospective, open label, multicenter, multispecialty randomized controlled trial designed to compare treatment efficacy, functional outcomes, cost-effectiveness, and quality of life for 2100 patients suffering from CLI. BEST-CLI is enrolling those patients who are determined to be candidates for open surgical or endovascular revascularization and is designed to be comprehensive, pragmatic, and balanced.

BEST-CLI trial on the homestretch

January 31, 2019 - 23:00
Persistent, widespread clinical uncertainty about the best means by which to revascularize patients with chronic limb-threatening ischemia (CLTI, or critical limb ischemia [CLI]) and the striking paucity of comparative effectiveness data led to efforts by the authors in 2007 to design a randomized, controlled trial that would address these questions. There are huge variations in the clinical management of affected patients. The Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial, funded by the National Heart, Lung, and Blood Institute, is a prospective, multicenter, multispecialty randomized controlled trial designed to compare treatment efficacy, functional outcomes, cost-effectiveness, and quality of life for 2100 patients suffering from CLI.

Α systematic review and meta-analysis of the efficacy of aortic anastomotic devices

January 31, 2019 - 23:00
One of the factors contributing to complications related to open repair of the aorta is the construction of a hand-sewn anastomosis. Aortic anastomotic devices (AADs), such as the intraluminal ringed graft (IRG), and the anastomotic stenting technique have been developed to perform a sutureless and less complicated anastomosis. This study performed a systematic review and meta-analysis of the literature reporting clinical use of AADs and aimed to assess, primarily, the effect of each device on 30-day overall and operation-related mortality and aortic cross-clamping time and, secondarily, the rate of successful two-sided application of the IRG device and the operation-related morbidity for each device.

Invited commentary

January 31, 2019 - 23:00
The use of administrative databases to study surgical outcomes has led to vast improvements in patient care. These databases are wide ranging, cover a diverse array of diseases and surgical procedures, and report differing outcomes at varying intervals. Furthermore, these databases include a significant amount of data, allowing researchers to overcome power limitations of single-surgeon or single-center experiences. They also give a better understanding of regional and national variations that can lead to improved patient outcomes through standardization of patient care.

Thoracic endovascular repair for acute complicated type B aortic dissections

January 31, 2019 - 23:00
This study retrospectively assessed in-hospital mortality and long-term results of emergency thoracic endovascular aortic repair (TEVAR) for patients with life-threatening acute complicated type B aortic dissection (acTBD).

Invited commentary

January 31, 2019 - 23:00
In their article, “Variability in hospital costs for carotid artery revascularization,” Drs Mell and colleagues examined variations in hospital costs for patients undergoing carotid revascularization at a regional referral center in California. The found that costs were lower in asymptomatic patients by more than a third; that surgeon specialties who commonly perform carotid revascularization tended to have lower costs; and that operating room expenses, such as devices, supplies, and materials, made up more than three-quarters of the expenses surrounding the episode of care.

Invited commentary

January 31, 2019 - 23:00
Postoperative groin complications continue to be the bane of vascular surgeons, often resulting in patients' increased morbidity (or mortality if associated with prosthetic material) and resource utilization with longer lengths of stay, higher rates of readmissions or returns to the operating room, and increased overall costs. Current literature supports a rate of up to nearly 40% of vascular surgery patients' developing groin wound infections after their procedures, and multiple studies have outlined ways to curb these events ranging from negative pressure dressings to perioperative care paths.

Variation in timing and type of groin wound complications highlights the need for uniform reporting standards

January 31, 2019 - 23:00
Groin wound infections represent a substantial source of patients' morbidity and resource utilization. Definitions and reporting times of groin infections are poorly standardized, which limits our understanding of the true scope of the problem and potentially leads to event under-reporting. Our objective was to investigate the timing and variation of groin wound complications after vascular surgery.

Vascular access for hemodialysis in the elderly

January 31, 2019 - 23:00
The objective of this study was to compare the outcomes of arteriovenous fistulas (AVFs) with arteriovenous grafts (AVGs) in a large population-based cohort of elderly patients in the United States.

Long-term durability of multibranched endovascular repair of thoracoabdominal and pararenal aortic aneurysms

January 31, 2019 - 23:00
The objective of this study was to assess the durability of multibranched endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms by examining the rates of late-occurring (beyond 30 days) complications.