Adverse cardiac events after vascular surgery are prevalent despite negative results of preoperative stress testing.

Objective: Cardiac risk assessment is a critical component of vascular disease management before surgical intervention. The predictive risk reduction of a negative cardiac stress test result remains poorly defined. The objective of this study was to compare the incidence of postoperative cardiac events among patients with negative stress test results vs those who did not undergo testing.

Inferior vena cava filter retrieval provides no advantage in the average patient.

Background: Inferior vena cava (IVC) filter placement is performed to mitigate the risk of pulmonary embolism (PE) when anticoagulation is contraindicated or ineffective. Technical advances now allow catheter-based filter retrieval. Many believe the benefits of retrieval are self-evident, yet retrieval carries an inherent complication risk and cost.

Lesion complexity drives the cost of superficial femoral artery endovascular interventions.

Objective: Patients who undergo endovascular treatment of superficial femoral artery (SFA) disease vary greatly in lesion complexity and treatment options. This study examined the association of lesion severity and cost of SFA stenting and to determine if procedure cost affects primary patency at 1 year.

Methods: A retrospective record review identified patients undergoing initial SFA stenting between January 1, 2010, and February 1, 2012.

Hyperbaric oxygen for patients with above-knee amputations, persistent ischemia, and nonreconstructable vascular disease.

We describe four patients with above-knee amputations whose stump wounds failed to heal. After numerous revascularization attempts, these patients were diagnosed with nonreconstructable pelvic and groin vascular disease and were facing hip disarticulation. With the addition of hyperbaric oxygen treatment to vigilant wound care and negative pressure therapy, these patients healed their amputation stumps and were fit with prostheses.

Endovascular aneurysm repair delivery redesign leads to quality improvement and cost reduction.

Objective: Endovascular aneurysm repair (EVAR) is now a mainstay of therapy for abdominal aortic aneurysm, although it remains associated with significant expense. We performed a comprehensive analysis of EVAR delivery at an academic medical center to identify targets for quality improvement and cost reduction in light of impending health care reform.

Methods: All infrarenal EVARs performed from April 2011 to March 2012 were identified (N = 127).

Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair.

Objective: Management of type II endoleaks after endovascular aneurysm repair can be problematic. This study reports our experience with a relatively novel strategy to treat this complication, transcaval coil embolization (TCCE) of the aneurysm sac.

Methods: We reviewed 29 consecutive patients undergoing TCCE from 2010 to 2013.

Retrospective review of superficial femoral artery stenting in diabetic patients: thiazolidinedione use may decrease reinterventions.

Background: Diabetics are known to have inferior outcomes following peripheral vascular interventions. Thiazolidinediones are oral diabetic agents which improve outcomes following coronary bare metal stenting. No studies have been performed evaluating thiazolidinedione use and outcomes following lower extremity endovascular interventions.

Bone marrow aspirate injection for treatment of critical limb ischemia with comparison to patients undergoing high-risk bypass grafts.

Objective: Bone marrow cell therapy (BMCT) for patients with critical limb ischemia (CLI) is a potential treatment in candidates with poor options for standard revascularization procedures. Whereas clinical trials are ongoing, there are few comparative data to assess its efficacy compared with bypass.

Methods: Patients with poor revascularization options underwent BMCT between 2011 and 2013.

Cilostazol is associated with improved outcomes after peripheral endovascular interventions.

Objective: Although cilostazol is commonly used as an adjunct after peripheral vascular interventions, its efficacy remains uncertain. We assessed the effect of cilostazol on outcomes after peripheral vascular interventions using meta-analytic techniques.

Methods: We searched MEDLINE (1946-2012), Cochrane CENTRAL (1996-2012), and trial registries for studies comparing cilostazol in combination with antiplatelet therapy to antiplatelet therapy alone after peripheral vascular interventions.

The financial implications of endovascular aneurysm repair in the cost containment era.

Objective: Endovascular aneurysm repair (EVAR) is associated with significant direct device costs. Such costs place EVAR at odds with efforts to constrain healthcare expenditures. This study examines the procedure-associated costs and operating margins associated with EVAR at a tertiary care academic medical center.

Functional outcomes following catheter-based iliac vein stent placement.

Objectives: Although previous reports have demonstrated the efficacy of catheter-directed thrombolytic therapy and iliac vein stent placement for the management of iliofemoral deep vein thrombosis (DVT), functional outcomes remain undefined. The purpose of this study was to determine midterm outcomes and functional quality of life among patients treated with iliac vein stenting.

Methods: Records of all the patients treated with iliac vein stent placement between March 2004 and March 2011 were examined for primary patency, assisted primary patency, and secondary patency.

Lean principles optimize on-time vascular surgery operating room starts and decrease resident work hours.

Objective: Lean process improvement techniques are used in industry to improve efficiency and quality while controlling costs. These techniques are less commonly applied in health care. This study assessed the effectiveness of Lean principles on first case on-time operating room starts and quantified effects on resident work hours.

Clinical effectiveness of secondary interventions for restenosis after renal artery stenting.

Objective: Secondary interventions for renal artery restenosis (RAS) after renal artery stenting are common, despite limited data about their effectiveness. This study was designed to evaluate the outcomes of endovascular treatment of recurrent RAS.

Methods: We conducted a retrospective review of patients who underwent renal artery stenting between 2001 and 2011 at Dartmouth-Hitchcock Medical Center.

Severity of chronic obstructive pulmonary disease is associated with adverse outcomes in patients undergoing elective abdominal aortic aneurysm repair.

Introduction: Although chronic obstructive pulmonary disease (COPD) has been implicated as a risk factor for abdominal aortic aneurysm (AAA) rupture, its effect on surgical repair is less defined. Consequently, variation in practice persists regarding patient selection and surgical management. The purpose of this study was to analyze the effect of COPD on patients undergoing AAA repair.

Carotid endarterectomy in asymptomatic patients with limited life expectancy.

Background And Purpose: Data from randomized trials assert that asymptomatic patients undergoing carotid endarterectomy (CEA) must live 3 to 5 years to realize the benefit of surgery. We examined how commonly CEA is performed among asymptomatic patients with limited life expectancy.

Methods: Within the American College of Surgeons National Quality Improvement Project we identified 8 conditions associated with limited life expectancy based on survival estimates using external sources.

Variation in thromboembolic complications among patients undergoing commonly performed cancer operations.

Objective: There is widespread evidence that cancer confers an increased risk of deep venous thrombosis (DVT). This risk is thought to vary among different cancer types. The purpose of this study is to better define the incidence of thrombotic complications among patients undergoing surgical treatment for a spectrum of prevalent cancer diagnoses in contemporary practice.

The impact of adjunctive iliac stenting on femoral-femoral bypass in contemporary practice.

Objectives: Most reports of femoral-femoral bypass (FFB) were published before the era of endovascular intervention. This study examines the utilization and impact of adjunctive endovascular intervention on FFB in contemporary practice.

Methods: We reviewed 253 FFB performed in 247 patients between 1984 and 2010.

A meta-analysis of anticoagulation for calf deep venous thrombosis.

Objective: This meta-analysis was initiated to assess the efficacy and safety of anticoagulation therapy for adult patients with isolated calf vein deep venous thrombosis (DVT).

Methods: We searched MEDLINE (1950-October 2010), the Cochrane Library (1993-October 2010), trial registries, meeting abstracts, and selected references, using no limits. Included studies compared the results of anticoagulation (vitamin K antagonist or therapeutic heparin) for a minimum of 30 days vs the results of no anticoagulation in adults with calf vein DVT proved by ultrasound imaging or venograph who were monitored for at least 30 days.

Completion duplex ultrasound predicts early graft thrombosis after crural bypass in patients with critical limb ischemia.

Objective: To determine if intraoperative distal graft end-diastolic velocity (EDV) using completion duplex ultrasound (CDU) predicts patency of crural bypass in patients with critical limb ischemia (CLI).

Methods: Records of 116 non-consecutive patients who underwent crural revascularization with vein conduit and CDU between 1998 and 2008 were reviewed. Bypass grafts were performed for rest pain (34%) or tissue loss (66%), while 56% of the reported cases were categorized as "disadvantaged" because of compromised vein quality or diseased arterial outflow.

Long-term results of open and endovascular revascularization of superficial femoral artery occlusive disease.

Background: First-line treatment for patients with superficial femoral arterial (SFA) occlusive disease has yet to be determined. This study compared long-term outcomes between primary SFA stent placement and primary femoral-popliteal bypass. Periprocedural patient factors were examined to determine their effect on these results.

National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice.

Objectives: Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use.

Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery.

Objectives: Persistent variation in practice surrounds preoperative clopidogrel management at the time of vascular surgery. While some surgeons preferentially discontinue clopidogrel citing a perceived risk of perioperative bleeding, others will proceed with surgery in patients taking clopidogrel for an appropriate indication. The purpose of this study was to determine whether preoperative clopidogrel use was associated with significant bleeding complications during peripheral arterial surgery.

Completion imaging after carotid endarterectomy in the Vascular Study Group of New England.

Objectives: We studied surgeons' practice patterns in the use of completion imaging (duplex or arteriography), and their association with 30-day stroke/death and 1-year restenosis after carotid endarterectomy (CEA).

Methods: Using a retrospective analysis of 6115 CEAs, we categorized surgeons based on use of completion imaging as rarely (<5% of CEAs), selective (5% to 90%), or routine (≥90%). Crude and risk-adjusted 30-day stroke/death and 1-year restenosis rates were examined across surgeon practice patterns.

Aggressive treatment of idiopathic axillo-subclavian vein thrombosis provides excellent long-term function.

Objective: While much attention has been devoted toward treatment paradigms for idiopathic axillo-subclavian vein thrombosis (ASVT), little has focused on long-term durability of aggressive treatment and its associated functional outcomes. The purpose of this study was to review our own surgical therapeutic algorithm and its associated durability and functional outcomes.

Methods: All patients treated with combined endovascular and open surgery at Dartmouth-Hitchcock Medical Center for ASVT from 1988 to 2008 were identified.

Endovascular management of congenital atresia of the infrarenal IVC.

This case illustrates the feasibility of endovascular treatment for chronic venous insufficiency attributable to congenital atresia of the infrarenal inferior vena cava (IVC). Three-dimensional computed tomography (CT) venography can elucidate alternate sites of drainage and identify other venous pathology, such as dominant stenoses that may be amenable to venoplasty and/or stent placement.