Evaluation of computerized tomography utilization in comparison to digital subtraction angiography in patients with peripheral arterial disease

OBJECTIVES

Perform literature review to analyze current practices in imaging patient with peripheral arterial disease (PAD) and examine patterns in our practice in order to assess whether a lower extremity computed tomography angiography (CTA) in addition to digital subtraction angiography (DSA) enhanced the assessment of vessel calcification, percentage of stenosis; and affected outcomes in patients with peripheral arterial disease.

METHODS AND MATERIALS

The study included patients who underwent lower extremity imaging and were followed up to 12 months. This population was divided into cases who had both an angiogram and CTA performed within 30 days (n=20), and controls who underwent angiography only (n=19). Baseline characteristics, imaging results, and clinical outcomes were analyzed.

RESULTS

Thirty-nine patients met study criteria (mean age was 58.4 years, 69.2% were males, and 33.3% had diabetes). Patients mostly presented with tissue loss/rest pain (10.3%), claudication (15.4%), acute limb (10.3%), and trauma (15.4%). We have not observed any statistically significant differences in various examined blood vessels when their features (e.g. vessel diameter, stenosis, calcifications) were assessed by CTA combined with angiography versus angiography alone. The exceptions were external iliac artery, superficial femoral artery and dorsalis pedis vessels. In external iliac artery percentage of stenosis was 1.11% as determined by CT scan versus 30% by angiography (P=.009). For superficial femoral artery stenosis the percentage determined by CT was 48.68% versus 81.41% by angiography, and observed difference between two modalities was statistically significant (P=.025). For dorsalis pedis percentage of stenosis detected by CT scan was 60.63% versus 22.73% by angiography, and the differences in findings by these modalities were statistically significant (P=.039). The most frequent perioperative complication was cardiac-related (35.5%). Nineteen patients were readmitted and 8 had re-interventions within 12 months.

CONCLUSION

Both imaging modalities yielded similar results for assessing vessel calcification and percentage of stenosis regardless of anatomic vessel location. Overall, utilization of CTA in addition to angiography for large vessels above the knee (e.g. iliac artery, superficial femoral artery) and below the knee for dorsalis pedis provided more detailed information on the properties of these vessels. Therefore, during pre-operative assessments, CTA may be helpful in addition to angiography for planning surgical and endovascular interventions for symptomatic PAD treatment in larger vessels.

Characterization of long-term survival in Medicare patients undergoing arteriovenous hemodialysis access

BACKGROUND

Patients undergoing arteriovenous (AV) access creation for hemodialysis often have significant comorbidities. Our goal was to quantify the long-term survival and associated risks factors for long-term mortality in these patients to aid in optimization of goals and expectations.

METHODS

The Vascular Implant Surveillance and Interventional Outcomes Network Vascular Quality Initiative Medicare linked data was used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. Because the majority of hemodialysis patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality.

RESULTS

There were 13,945 AV access patients analyzed including 10,872 (78%) AV fistulas and 3073 (22%) AV grafts. The median age was 67 years and 56% of patients were male. Approximately one-third had a prior AV access and 44.7% had prior tunneled dialysis catheters. Patients receiving an AV fistula, compared with AV grafts, were more often younger, male, White, obese, independently ambulatory, preoperatively living at home, and less often have a prior AV access and tunneled dialysis catheters (P < .05 for all). The 5-year mortality overall was 62.9% with 61.2% for AV fistulas and 68.8% for AV grafts (P < .001). On multivariable analysis for 5 year mortality, nonambulatory status (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.53-1.83; P < .001), lower extremity access (HR, 1.67; 95% CI, 1.35-2.05; P < .001), human immunodeficiency virus or acquired immunodeficiency syndrome (HR, 1.44; 95% CI, 1.13-1.82; P < .001), White race (HR, 1.43; 95% CI, 1.35-1.51; P < .001), congestive heart failure (HR, 1.33; 95% CI, 1.26-1.41; P < .001), chronic obstructive pulmonary disease (HR, 1.23; 95% CI, 1.15-1.31; P < .001), and AV graft placement (HR, 1.12; 95% CI, 1.02-1.23, P = .016) were most associated with poor survival. Factors associated with improved survival were never smoking (HR, .73; 95% CI, 0.67-0.79; P < .001), prior/quit smoking (HR, .78; 95% CI, 0.72-0.84; P < .001), preoperative home living (HR, .75; 95% CI, 0.68-0.83; P < .001), and hypertension (HR, .89; 95% CI, 0.8-0.99; P = .03).

CONCLUSIONS

Long-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. There are many modifiable risk factors that may improve survival in these patients and give an opportunity for transplantation.

Long-term functional outcomes of upper extremity civilian vascular trauma

OBJECTIVE

Civilian analyses of long-term outcomes of upper extremity vascular trauma (UEVT) are limited. Our goal was to evaluate the management of UEVT in the civilian trauma population and explore the long-term functional consequences.

METHODS

A retrospective review and analysis was performed of patients with UEVT at an urban Level 1 trauma center (2001-2022). Management and long-term functional outcomes were analyzed.

RESULTS

There were 150 patients with UEVT. Mean age was 34 years, and 85% were male. There were 42% Black and 27% White patients. Mechanism was penetrating in 79%, blunt in 20%, and multifactorial in 1%. Within penetrating trauma, mechanism was from firearms in 30% of cases. Of blunt injuries, 27% were secondary to falls, 13% motorcycle collisions, 13% motor vehicle collisions, and 3% crush injuries. Injuries were isolated arterial in 62%, isolated venous in 13%, and combined in 25% of cases. Isolated arterial injuries included brachial (34%), radial (27%), ulnar (27%), axillary (8%), and subclavian (4%). The majority of arterial injuries (92%) underwent open repair with autologous vein bypass (34%), followed by primary repair (32%), vein patch (6.6%), and prosthetic graft (3.3%). There were 23% that underwent fasciotomies, 68% of which were prophylactic. Two patients were managed with endovascular interventions; one underwent covered stent placement and the other embolization. Perioperative reintervention occurred in 12% of patients. Concomitant injuries included nerves (35%), bones (17%), and ligaments (16%). Intensive care unit admission was required in 45%, with mean intensive care unit length of stay 1.6 days. Mean hospital length of stay was 6.7 days. Major amputation and in-hospital mortality rates were 1.3% and 4.6% respectively. The majority (72%) had >6-month follow-up, with a median follow-up period of 197 days. Trauma readmissions occurred in 19%. Many patients experienced chronic pain (56%), as well as motor (54%) and sensory (61%) deficits. Additionally, 41% had difficulty with activities of daily living. Of previously employed patients (57%), 39% experienced a >6-month delay in returning to work. Most patients (82%) were discharged with opioids; of these, 16% were using opioids at 6 months.

CONCLUSIONS

UEVT is associated with long-term functional impairments and opioid use. It is imperative to counsel patients prior to discharge and ensure appropriate follow-up and therapy.

Recent evaluation by nephrologists is associated with decreased incidence of tunneled dialysis catheter being used at the time of first arteriovenous access creation

OBJECTIVE

Late primary care provider (PCP) or nephrologist evaluation of patients with progressive kidney disease may be associated with increased morbidity and mortality. Among patients undergoing initial arteriovenous (AV) access creation, we aimed to study the relationship of recent PCP and nephrologist evaluations with perioperative morbidity and mortality.

METHODS

We performed a retrospective review of patients from 2014 to 2022 who underwent initial AV access creation at an urban, safety-net hospital. Univariable and multivariable analyses identified associations of PCP and nephrologist evaluations <1 year and <3 months before surgery, respectively, with hemodialysis initiation via tunneled dialysis catheters (TDCs), 90-day readmission, and 90-day mortality.

RESULTS

Among 558 patients receiving initial AV access, mean age was 59.7 ± 14 years, 59% were female gender, and 60.6% were Black race. Recent PCP and nephrology evaluations occurred in 386 (69%) and 362 (65%) patients, respectively. On multivariable analysis, unemployed and uninsured statuses were associated with decreased likelihood of PCP evaluation (unemployment: odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77; uninsured status: OR, 0.05; 95% CI, 0.01-0.45) and nephrologist evaluation (unemployment: OR, 0.63; 95% CI, 0.43-0.91; uninsured status: OR, 0.22; 95% CI, 0.06-0.83) (all P < .05). Social support was associated with increased likelihood of PCP evaluation (OR, 1.81; 95% CI, 1.07-3.08) (all P < .05). Hemodialysis was initiated with TDCs in 304 patients (55%). Older age (OR, 0.98; 95% CI, 0.96-0.99), obesity (OR, 0.38; 95% CI, 0.25-0.58), and nephrologist evaluation (OR, 0.12; 95% CI, 0.08-0.19) were independently associated with decreased hemodialysis initiation with TDCs in patients receiving an initial AV access (all P < .05). Ninety-day readmission occurred in 270 cases (48%). Cirrhosis (OR, 2.5; 95% CI, 1.03-6.03; P = .04), coronary artery disease (OR, 2.31; 95% CI, 1.5-3.57), prosthetic AV access (OR, 1.84; 95% CI, 1.04-3.26), and impaired ambulation (OR, 1.75; 95% CI, 1.15-2.66) were independently associated with increased readmission (all P < .05). Older age (OR, 0.98; 95% CI, 0.97-0.99), prior TDC (OR, 0.65; 95% CI, 0.45-0.94), and unemployment (OR, 0.58; 95% CI, 0.39-0.86) were associated with decreased readmission (all P < .05). Ninety-day mortality occurred in 1.6% of patients. Neither PCP nor nephrologist evaluation was associated with readmission or mortality.

CONCLUSIONS

Recent nephrology evaluation was associated with reduced hemodialysis initiation with TDCs among patients undergoing initial AV access creation. Unemployed and uninsured statuses posed barriers to accessing nephrology care.

Outcomes of lower extremity revascularization in octogenarians and nonagenarians for intermittent claudication

OBJECTIVE

Revascularization for intermittent claudication (IC) due to infrainguinal peripheral arterial disease (PAD) is dependent on durability and expected benefit. We aimed to assess outcomes for IC interventions in octogenarians and nonagenarians (age ≥80 years) and those younger than 80 years (age <80 years).

METHODS

The Vascular Quality Initiative was queried (2010-2020) for peripheral vascular interventions (PVIs) and infrainguinal bypasses (IIBs) performed to treat IC. Baseline characteristics, procedural details, and outcomes were analyzed (comparing age ≥80 years and age <80 years).

RESULTS

There were 84,210 PVIs (12.1% age ≥80 years and 87.9% age <80 years) and 10,980 IIBs (7.4% age ≥80 years and 92.6% age <80 years) for IC. For PVI, patients aged ≥80 years more often underwent femoropopliteal (70.7% vs 58.1%) and infrapopliteal (19% vs 9.3%) interventions, and less often iliac interventions (32.1% vs 48%) (P < .001 for all). Patients aged ≥80 years had more perioperative hematomas (3.5% vs 2.4%) and 30-day mortality (0.9% vs 0.4%) (P < .001). At 1-year post-intervention, the age ≥80 years cohort had fewer independently ambulatory patients (80% vs 91.5%; P < .001). Kaplan-Meier analysis showed patients aged ≥80 years had lower reintervention/amputation-free survival (81.4% vs 86.8%), amputation-free survival (87.1% vs 94.1%), and survival (92.3% vs 96.8%) (P < .001) at 1-year after PVI. Risk adjusted analysis showed that age ≥80 years was associated with higher reintervention/amputation/death (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.1-1.35), amputation/death (HR, 1.85; 95% CI, 1.61-2.13), and mortality (HR, 1.92; 95% CI, 1.66-2.23) (P < .001 for all) for PVI. For IIB, patients aged ≥80 years more often had an infrapopliteal target (28.4% vs 19.4%) and had higher 30-day mortality (1.3% vs 0.5%), renal failure (4.1% vs 2.2%), and cardiac complications (5.4% vs 3.1%) (P < .001). At 1 year, the age ≥80 years group had fewer independently ambulatory patients (81.7% vs 88.8%; P = .02). Kaplan-Meier analysis showed that the age ≥80 years cohort had lower reintervention/amputation-free survival (75.7% vs 81.5%), amputation-free survival (86.9% vs 93.9%), and survival (90.4% vs 96.5%) (P < .001 for all). Risk-adjusted analysis showed age ≥80 years was associated with higher amputation/death (HR, 1.68; 95% CI, 1.1-2.54; P = .015) and mortality (HR, 1.85; 95% CI, 1.16-2.93; P = .009), but not reintervention/amputation/death (HR, 1.1; 95% CI, 0.85-1.44; P = .47) after IIB.

CONCLUSIONS

Octogenarians and nonagenarians have greater perioperative morbidity and long-term ambulatory impairment, limb loss, and mortality after PVI and IIB for claudication. Risks of intervention on elderly patients with claudication should be carefully weighed against the perceived benefits of revascularization. Medical and exercise therapy efforts should be maximized in this population.

Functional Impairment is Associated with Poor Long-Term Outcomes after Arteriovenous Access Creation

BACKGROUND

Functional impairment affects outcomes after a variety of procedures. However, the impact of functional impairment on outcomes of arteriovenous (AV) access creation is unclear. We aimed to evaluate the association of patients' ability to ambulate and perform activities of daily living (ADL) with AV access outcomes.

METHODS

We retrospectively reviewed patients undergoing AV access creation at an urban, safety-net hospital from 2014 to 2022. We evaluated associations of impaired ambulatory and assisted ADL status with 90-day readmission, 1-year primary patency, and 5-year mortality.

RESULTS

Among the 689 patients receiving AV access, mean age was 59.6 ± 13.9 years, 59% were male, and 60% were Black. Access types included brachiocephalic (42%), brachiobasilic (26%), radiocephalic (14%), other autogenous (5%) fistulas, and prosthetic grafts (13%). Impaired ambulatory status was identified in 35% and assisted ADL status, when assessed, was identified in 21% of patients. Ninety-day readmission was more likely in patients with impaired ambulatory (58% vs. 39%, P < 0.001) and assisted ADL (56% vs. 41%, P = 0.004) status. On Kaplan-Meier analysis, 1-year primary patency was lower for patients with impaired ambulatory status (44% ± 3% vs. 29% ± 3%, P = 0.001), but was not significantly different for patients with assisted ADL status (41% ± 3% vs. 32% ± 5%, P = 0.12). Five-year survival was lower for patients with impaired ambulatory status (53% ± 5% vs. 74% ± 4%, P < 0.001), but was not significantly different for patients with assisted ADL status (45% ± 9% vs. 71% ± 4%, P = 0.1). On multivariable analysis, increased likelihood of 90-day readmission was significantly associated with impaired ambulatory status (odds ratio (OR) 2.03, 95% confidence interval (CI) 1.4-2.94, P < 0.001) and assisted ADL status (OR 1.66, 95% CI 1.07-2.57, P = 0.02). One-year primary patency was not significantly associated with impaired ambulatory (hazard ratio (HR) 1.25, 95% CI 0.98-1.6, P = 0.07) or assisted ADL status (HR 1.13, 95% CI 0.87-1.48, P = 0.36). Increased likelihood of 5-year mortality was associated with impaired ambulatory (HR 1.65, 95% CI 1.04-2.62, P = 0.04) and assisted ADL status (HR 2.63, 95% CI 1.35-5.11, P = 0.004).

CONCLUSIONS

Impaired ambulatory and assisted ADL statuses were associated with increased readmissions and long-term mortality after AV access creation. Approximately half of patients with functional impairment were not alive at 5 years. Setting outcome expectations as well as prospectively examining the impact of physical therapy and visiting nursing services for functionally impaired patients undergoing AV access creation are warranted.

Analysis of Early Death after Elective Open Abdominal Aortic Aneurysm Repair

BACKGROUND

Mortality after open abdominal aortic aneurysm repair is a quality measure and early death may represent a technical complication or poor patient selection. Our objective was to analyze patients who died in the hospital within postoperative day (POD) 0-2 after elective abdominal aortic aneurysm repair.

METHODS

The Vascular Quality Initiative was queried from 2003-2019 for elective open abdominal aortic aneurysm repairs. Operations were categorized as in-hospital death on POD 0-2 (POD 0-2 Death), in-hospital death beyond POD 2 (POD ≥3 Death), and those alive at discharge. Univariable and multivariable analyses were performed.

RESULTS

There were 7,592 elective open abdominal aortic aneurysm repairs with 61 (0.8%) POD 0-2 Death, 156 (2.1%) POD ≥3 Death, and 7,375 (97.1%) alive at discharge. Overall, median age was 70 years and 73.6% were male. Iliac aneurysm repair and surgical approach (anterior/retroperitoneal) were similar among groups. POD 0-2 Death, compared to POD ≥3 Death and those alive at discharge, had the longest renal/visceral ischemia time, more commonly had proximal clamp placement above both renal arteries, an aortic distal anastomosis, longest operative time, and largest estimated blood loss (all P < 0.05). Postoperative vasopressor usage, myocardial infarction, stroke, and return to the operating room were most frequent in POD 0-2 Death and extubation in the operating room was least frequent (all P < 0.001). Postoperative bowel ischemia and renal failure occurred most commonly among POD ≥3 Death (all P < 0.001).On multivariable analysis, POD 0-2 Death was associated with congestive heart failure, prior peripheral vascular intervention, female sex, preoperative aspirin use, lower center volume quartile, renal/visceral ischemia time, estimated blood loss, and older age (all P < 0.05).

CONCLUSIONS

POD 0-2 Death was associated with comorbidities, center volume, renal/visceral ischemia time, and estimated blood loss. Referral to high-volume aortic centers could improve outcomes.

Brachiocephalic and Radiocephalic Arteriovenous Fistulas in Patients with Tunneled Dialysis Catheters Have Similar Outcomes

BACKGROUND

Patients with tunneled dialysis catheters (TDCs) have a time-sensitive need for a functional permanent access due to high risk of catheter-associated morbidity. Brachiocephalic arteriovenous fistulas (BCF) have been reported to have higher maturation and patency compared to radiocephalic arteriovenous fistulas (RCF), although more distal creation is encouraged when possible. However, this may lead to a delay in establishing permanent vascular access and, ultimately, TDC removal. Our goal was to assess short-term outcomes after BCF and RCF creation for patients with concurrent TDCs to see if these patients would potentially benefit more from an initial brachiocephalic access to minimize TDC dependence.

METHODS

The Vascular Quality Initiative hemodialysis registry was analyzed from 2011 to 2018. Patient demographics, comorbidities, access type, and short-term outcomes including occlusion, reinterventions, and access being used for dialysis, were assessed.

RESULTS

There were 2,359 patients with TDC, of whom 1,389 (58.9%) underwent BCF creation and 970 (41.1%) underwent RCF creation. Average patient age was 59 years, and 62.8% were male. Compared with RCF, those with BCF were more often older, of female sex, obese, nonindependently ambulatory, have commercial insurance, diabetes, coronary artery disease, chronic obstructive pulmonary disease, be on anticoagulation, and have a cephalic vein diameter of ≥3 mm (all P < 0.05). Kaplan-Meier analysis for 1-year outcomes for BCF and RCF, respectively, showed that primary patency was 45% vs. 41.3% (P = 0.88), primary assisted patency was 86.7% vs. 86.9% (P = 0.64), freedom from reintervention was 51.1% vs. 46.3% (P = 0.44), and survival was 81.3% vs. 84.9% (P = 0.02). Multivariable analysis showed that BCF was comparable to RCF with respect to primary patency loss (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.91-1.36, P = 0.316), primary assisted patency loss (HR 1.11, 95% CI 0.72-1.29, P = 0.66), and reintervention (HR 1.01, 95% CI 0.81-1.27, P = 0.92). Access being used at 3 months was similar but trending towards RCF being used more often (odds ratio 0.7, 95% CI 0.49-1, P = 0.05).

CONCLUSIONS

BCFs do not have superior fistula maturation and patency compared to RCFs in patients with concurrent TDCs. Creation of radial access, when possible, does not prolong TDC dependence.

The Effect of Chronic and End Stage Renal Disease on Long-term Outcomes after Infrainguinal Bypass

OBJECTIVES

Patients undergoing infrainguinal bypass for chronic limb threatening ischemia (CLTI) with renal dysfunction are at an increased risk for perioperative and long-term morbidity and mortality. Our goal was to examine perioperative and 3-year outcomes after lower extremity bypass for CLTI stratified by kidney function.

METHODS

A retrospective, single-center analysis of lower extremity bypass for CLTI was performed between 2008 and 2019. Kidney function was categorized as normal (estimated glomerular filtration rate (eGFR) ≥60ml/min/1.73m²), chronic kidney disease (CKD) (eGFR15-59ml/min/1.73m²), and end stage renal disease (ESRD) (eGFR<15ml/min/1.73m²). Kaplan-Meier and multivariable analysis were performed.

RESULTS

There were 221 infrainguinal bypasses performed for CLTI. Patients were classified by renal function as normal (59.7%), CKD (24.4%), and ESRD (15.8%). Average age was 66 years and 65% were male. Overall, 77% had tissue loss with 9%, 45%, 24%, and 22% being Wound, Ischemia, and foot Infection (WIfI) stages 1-4, respectively. The majority (58%) of bypass targets were infrapopliteal and 58% used ipsilateral greater saphenous vein. The 90-day mortality and readmission rates were 2.7% and 49.8%, respectively. ESRD, compared to CKD and normal renal function, respectively, had the highest 90-day mortality (11.4% vs. 1.9% vs. .8%, P=.002) and 90-day readmission (69% vs. 55% vs. 43%, P=.017). On multivariable analysis, ESRD, but not CKD, was associated with higher 90-day mortality (OR 16.9, 95% CI 1.83-156.6, P=.013) and 90-day readmission (OR 3.02, 95% CI 1.2-7.58, P=.019). Kaplan Meier 3-year analysis showed no difference between groups for primary patency or major amputation, however ESRD, compared to CKD and normal renal function, respectively, had worse primary-assisted patency (60% vs. 76% vs. 84%, P=.03) and survival (72% vs. 96% vs. 94%, P=.001). On multivariable analysis, ESRD and CKD were not associated with 3-year primary patency loss/death, but ESRD was associated with higher primary-assisted patency loss (HR 2.61, 95% CI 1.23-5.53, P=.012). ESRD and CKD were not associated with 3-year major amputation/death. ESRD was associated with higher 3-year mortality (HR 4.95, 95% CI 1.52-16.2, P=.008) while CKD was not.

CONCLUSION

ESRD, but not CKD, was associated with higher perioperative and long-term mortality after lower extremity bypass for CLTI. Although ESRD was associated with lower long-term primary-assisted patency, there were no differences in loss of primary patency or major amputation.

Qualitative Analysis of Length of Stay and Readmission after Carotid Endarterectomy

BACKGROUND

Length of stay (LOS) and readmissions are common measures to evaluate quality of health care. The objective of this study was to evaluate factors related to hospital LOS and readmission within 90 days following carotid endarterectomy (CEA) in patients who have not had a stroke.

METHODS

Using a single institution database, patients who underwent CEA for carotid stenosis between 2014 and 2019 were identified. Asymptomatic carotid stenosis (no history of any stroke or transient ischemic attack (TIA) within 6 months prior to CEA), and patients who had a TIA without stroke were included. Demographic and perioperative factors were collected. Primary outcomes analyzed were increased LOS (>1 day) and readmission within 90 days after surgery.

RESULTS

There were 125 patients identified who underwent CEA for 133 carotid stenosis, and 8 patients had bilateral CEA; of which 36.8% were asymptomatic carotid stenosis with the remaining being operated on for TIA without any stroke. The mean age was 68 years old and 36.1% of cases were female. The median postoperative LOS was 2 days. Increased LOS occurred in 81 cases (60.9%). Increased LOS, compared to no increased LOS, occurred more often in patients with diabetes (48.1% vs. 30.8%, P = 0.047), in those with operations starting after 12:00 pm (45.7% vs. 21.2%, P = 0.004) and those with any minor complications such as neck swelling, neck pain, and urinary retention (30.9% vs. 15.4%, P = 0.044). Readmission within 90 days after CEA occurred in 24 (18%) of cases. Readmission within 90 days, compared to no readmission within 90 days, occurred more often in patients with a history of coronary artery disease (58.3% vs. 27.5%, P = 0.004), congestive heart failure (37.5% vs. 11%, P = 0.001), and atrial fibrillation (29.2% vs. 8.3%, P = 0.004).

CONCLUSIONS

More than half of patients undergoing CEA for carotid stenosis were discharged after postoperative day 1. Interventions on modifiable clinical risk factors, such as morning CEA scheduling and management of comorbidities, may decrease LOS and 90-day readmission rates.

Unplanned Shunting Is Associated with Higher Stroke Risk after Eversion Carotid Endarterectomy

BACKGROUND

Shunting during eversion carotid endarterectomy (eCEA) may be technically challenging. Whether shunting practice patterns modify perioperative stroke risk after eCEA is unclear. We aimed to compare eCEA outcomes based on shunting practice.

METHODS

The Vascular Quality Initiative (2011-2019) was queried for eCEAs performed for symptomatic and asymptomatic carotid stenosis. Univariable and multivariable analyses compared outcomes based on whether shunting was routine practice, preoperatively-indicated, intraoperatively-indicated, or not performed.

RESULTS

There were 13,207 eCEAs identified. Average age was 71.4 years and 59.4% of patients were male sex. Ipsilateral carotid stenosis was >80% in 45.6% and there was severe contralateral carotid stenosis in 8.6%. Early ipsilateral symptoms within 14 days of eCEA were transient ischemic attack in 5.6% and stroke in 7%. The majority of cases were performed under general anesthesia (82.7%). Electroencephalogram monitoring and stump pressures were utilized in 30.9% and 14.7%, respectively. Shunting was routine (25.4%), preoperatively-indicated (1.9%), intraoperatively-indicated (4.7%), or not implemented (68%). Preoperatively-indicated shunting was more often performed in patients with early symptomatic carotid stenosis or severe contralateral carotid stenosis. After routine shunting, preoperatively-indicated shunting, intraoperatively-indicated shunting, and no shunting, median operative duration was 110, 101, 112, and 97 min, respectively (P < 0.001), and ipsilateral perioperative stroke prevalence was 0.6%, 1.2%, 1.9%, and 0.7%, respectively (P = 0.004). On multivariable analysis, longer operative time was associated with routine shunting (MR 1.17, 95% CI 1.15-1.19, P < 0.001), preoperatively-indicated shunting (MR 1.09, 95% CI 1.04-1.15, P < 0.001), and intraoperatively-indicated shunting (MR 1.12, 95% CI 1.09-1.16, P < 0.001) compared with no shunting. Compared with no shunting, routine shunting (OR 0.91, 95% CI 0.54-1.54, P = 0.74) and preoperatively-indicated shunting (OR 1.53, 95% CI 0.47-4.99, P = 0.48) were not associated with stroke; however, intraoperatively-indicated shunting was associated with increased stroke (OR 2.74, 95% CI 1.41-5.3, P = 0.003). Shunting type was not associated with perioperative mortality.

CONCLUSIONS

Intraoperatively-indicated shunting during eCEA was associated with longest operative duration and increased perioperative stroke risk. Surgeon familiarity with shunting and planning to shunt in advance may permit more expeditious shunting and prevent stroke.

Access Site Complications Are Uncommon with Vascular Closure Devices or Manual Compression after Lower Extremity Revascularization

OBJECTIVE

Vascular closure devices (VCD) and manual compression (MC) are used to achieve hemostasis following peripheral vascular interventions (PVI). We sought to compare perioperative outcomes between MC and four VCDs following PVI in a multicenter setting.

METHODS

The Vascular Quality Initiative was queried for all lower extremity (LE) PVIs with common femoral artery access performed from 2010-2020. VCDs included were MynxGrip® (Cordis, Santa Clara, CA, USA), StarClose SE™ (Abbott, Redwood City, CA, USA), Angio-Seal® (Terumo, Somerset, NJ, USA), and Perclose ProGlide™ (Abbott, Redwood City, CA, USA). In a blinded fashion, these four VCDs (A, B, C, D) were compared to MC for baseline characteristics, procedural details, and outcomes (access site hematoma and stenosis/occlusion). Sheath size >8 Fr were excluded. Propensity score matching (1:1) was performed. Univariable and multivariable analyses were completed for unmatched and matched data.

RESULTS

There were 84,172 LE PVIs identified: 32,013 (38%) used MC and 52,159 (62%) used VCDs (A-12,675;B-6,224;C-19,872;D-13,388). Overall, average age was 68.7 years and 60.4% were male; indications for intervention were most commonly claudication (43.8%) and tissue loss (40.1%). When compared to MC, VCDs were utilized more often in patients with obesity, diabetes, and end stage renal disease (all P<.001). VCDs were used less often in patients with hypertension, chronic obstructive pulmonary disease, coronary artery disease, prior percutaneous coronary and extremity interventions, and major amputation (all P<.001). VCD use was more common, compared to MC, during femoral-popliteal (73% vs. 63.8%) and tibial interventions (33.8% vs. 22.3%), but less common with iliac interventions (20.6% vs. 34.7%) (all P<.001). Protamine was used less often after VCDs (19.1% vs. 25.6%, P<.001). Overall, there were 2,003 (2.4%) hematomas of which 278 (13.9%) required thrombin/surgical intervention. When compared to MC, any VCD use had fewer hematomas (1.7% vs. 3.6%, P<.001) and hematomas requiring intervention (.2% vs. .5%, P<.001). When divided by hemostatic technique, any hematoma were MC-3.6%; A-1.4%; B-1.2%; C-2.3%; D-1.1%, P<.001. Hematomas requiring intervention were MC-.5%; A-.2%; B-.2%; C-.3%; D-.1%, P<.001. Access site stenosis/occlusion was similar between MC and any VCDs (.2% vs. .2%, P=.12). Multivariable analysis demonstrated that any VCDs and individual VCDs, vs. MC, were independently associated with fewer hematomas. Access site stenosis/occlusion was similar between any VCDs and MC. Matched analysis revealed similar findings.

CONCLUSIONS

Although overall rates of hematomas requiring intervention were low regardless of hemostatic technique, VCD use, irrespective of type, compared favorably to MC with significantly fewer access site complications after PVI.

Outcomes of Axillofemoral Bypass for Intermittent Claudication

OBJECTIVE

While endovascular therapy is often first-line treatment for medically refractory intermittent claudication (IC) caused by aorto-femoral disease, suprainguinal bypass is commonly performed. Although this is often aorto-femoral bypass (AoFB), axillo-femoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC.

METHODS

The Vascular Quality Initiative (2009-2019) was queried for suprainguinal bypass performed for IC. Univariable and multivariable analyses were used to compare perioperative and one-year outcomes between AxFB and a comparison cohort of AoFB.

RESULTS

We identified 3,261 suprainguinal bypasses performed for IC: 436 AxFB and 2,825 AoFB. Overall, mean age was 61.4 ± 9.1 years, 58.8% of patients were male sex, and 59.7% currently smoked. Patients undergoing AxFB, compared with AoFB, were more often older, male, never-smokers, and ambulated with assistance (all P<.001). They more often had hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, end-stage renal disease, previous outflow peripheral endovascular interventions, and previous inflow or outflow bypass. AxFB, compared with AoFB, were more often uni-femoral (all P<.05). Patients undergoing AxFB, compared with AoFB, had shorter postoperative length of stay (median 4 vs. 6 days) and fewer perioperative pulmonary (3% vs. 7.9%) and renal complications (5.5% vs. 9.9%), but more perioperative ipsilateral major amputations (.9% vs. 0.04%) (all P<.05). There were no significant differences in perioperative myocardial infarction (2.8% vs. 2.7%), stroke (.7% vs. 1.1%), and death (1.8% vs. 1.7%) rates, respectively. At one year, Kaplan-Meier analysis demonstrated that the AxFB, compared with AoFB cohort, exhibited higher rates of death (7.3% vs. 3.6%, P=.002); graft occlusion or death (14.3% vs. 7.2%, P=.001); ipsilateral major amputation or death (12.5% vs. 5.6%, P<.001); and reintervention, amputation, or death (19% vs. 8.6%, P<.001). On multivariable analysis, AxFB was independently associated with increased risk of one-year reintervention, amputation, or death (HR 1.6, 95% CI 1.03-2.4, P=.04).

CONCLUSIONS

This retrospective analysis suggests that long-term complications were more frequent in patients who underwent AxFB as compared to AoFB, although patients treated with AxFB were at higher risk with more comorbidities. Since AxFB is associated with significant perioperative morbidity, mortality, and long-term complications, serious consideration should be given prior to its use for IC.

Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU

BACKGROUND

Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU use with perioperative and long-term outcomes after EVAR.

STUDY DESIGN

The Vascular Quality Initiative (2003-2019) was queried for index elective EVARs. Included centers were categorized by percentage of patients with EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and nonroutine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers.

RESULTS

Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers - 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all p > 0.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2 ± 3.6 vs 2 ± 4.2 days, p < 0.001). One-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs 95.4%, p = 0.085). When compared with nrICU centers, rICU centers had similar 1-year mortality risk (hazard ratio [HR] 1.15, 95% CI 0.99-1.34, p = 0.076), but were associated with longer postoperative LOS (means ratio 1.1, 95% CI 1.08-1.13, p < 0.001).

CONCLUSIONS

Routine ICU use after EVAR was associated with prolonged postoperative LOS, without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.

Vascular surgery-related violations of the Emergency Medical Treatment and Labor Act

OBJECTIVE

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law established in 1986 to ensure that patients who present to an emergency department receive medical care regardless of means. Violations are reported to the Centers for Medicare and Medicaid Services and can result in significant financial penalties. Our objective was to assess all available EMTALA violations for vascular-related issues.

METHODS

EMTALA violations in the Centers for Medicare and Medicaid Services publicly available hospital violations database from 2011 to 2018 were evaluated for vascular-related issues. Details recorded were case type, hospital type, hospital region, reasons for violation, disposition, and mortality.

RESULTS

There were 7001 patients identified with any EMTALA violation and 98 (1.4%) were deemed vascular related. The majority (82.7%) of EMTALA violations occurred at urban/suburban hospitals. Based on the Association of American Medical Colleges United States region, vascular-related EMTALA violations occurred in the Northeast (7.1%), Southern (56.1%), Central (18.4%), and Western (18.4%) United States. Case types included cerebrovascular (28.6%), aortic related (22.4%; which consisted of ruptured aortic aneurysms [8.2%], aortic dissection [11.2%], and other aortic [3.1%]), vascular trauma (15.3%), venous-thromboembolic (15.3%), peripheral arterial disease (9.2%), dialysis access (5.1%), bowel ischemia (3.1%), and other (1%) cases. Patients were transferred to another facility in 41.8% of cases. The most common reasons for violation were specialty refusal or unavailability (30.6%), inappropriate documentation (29.6%), misdiagnosis (18.4%), poor communication (17.3%), inappropriate triage (13.3%), failure to obtain diagnostic laboratory tests or imaging (12.2%), and ancillary or nursing staff issues (7.1%). The overall mortality was 19.4% and 31.6% died during the index emergency department visit. Vascular conditions associated with death were venous thromboembolism (31.6%), ruptured aortic aneurysm (21.1%), aortic dissection (21.1%), other aortic causes (10.5%), vascular trauma (10.5%), and bowel ischemia (5.3%).

CONCLUSIONS

Although the frequency of vascular-related EMTALA violations was low, improvements in communication, awareness of vascular disease among staff, specialty staffing, and the development of referral networks and processes are needed to ensure that patients receive adequate care and that institutions are not placed at undue risk.

The Association of the Day of the Week with Outcomes of Infrainguinal Lower Extremity Bypass

BACKGROUND

The day of the week (DOW) for performing procedures and operations has been shown to affect clinical and resource utilization outcomes. Limited published data are available on vascular surgery operations. Our primary objective was to assess outcomes by DOW for infrainguinal lower extremity bypass (LEB) performed for claudication or rest pain. The secondary objective was to assess outcomes by DOW for LEBs performed for tissue loss.

METHODS

The Vascular Quality Initiative was queried from 2003 to 2018 for all elective index infrainguinal LEBs performed for claudication or rest pain. Cases performed for acute limb ischemia as well as concomitant peripheral vascular intervention, nonelective LEBs, sequential grafts, and weekend cases were excluded. LEBs were grouped by DOW: Monday-Tuesday (early weekdays) versus Wednesday-Friday (later weekdays). Baseline data, operative details, and outcomes were collected. Univariate and multivariable analyses were performed. LEBs performed for claudication/rest pain were analyzed together while tissue loss was assessed separately.

RESULTS

There were 12,084 LEBs identified-44.5% performed on Monday-Tuesday and 55.5% on Wednesday-Friday. Overall, the mean age was 65.6 years, 68.6% were male, and 82.8% were Caucasian. LEBs were performed for claudication in 57.4% of cases. An autogenous great saphenous vein was used in 58.8% of cases, whereas a prosthetic graft was used in 35.1% of cases. The most common bypass origin was the femoral artery (94.1%), and target was the popliteal artery (70.1%). Significant differences between Monday-Tuesday versus Wednesday-Friday, respectively, were mean body mass index (27.8 kg/m² vs. 28 kg/m²), preoperative aspirin use (74.2% vs. 72.5%), continuous vein harvest technique (41.9% vs. 44%), and mean operative time (mins) (216.2 vs. 222.6) (all P < 0.05). Univariate postoperative outcomes were significantly different between Monday-Tuesday versus Wednesday-Friday, respectively, for mean length of stay (LOS) (days) (3.9 vs. 4.3), cardiac complications (myocardial infarction/dysrhythmia/congestive heart failure) (3.5% vs. 4.9%), stroke (0.3% vs. 0.6%), and respiratory complications (0.8% vs. 1.3%) (all P < 0.05). Multivariable analysis demonstrated that LEBs performed on Wednesday-Friday versus Monday-Tuesday for claudication/rest pain were independently associated with cardiac complications and prolonged LOS. There were also 8,491 LEBs performed for tissue loss which overall had similar findings to LEBs performed for claudication/rest pain such as increased LOS for LEBs performed for tissue loss on Wednesday-Friday (P < 0.001) and similar likeliness for respiratory complication, wound complication, return to the operating room, and mortality (all P > 0.05). However, LEBs performed for tissue loss on Wednesday-Friday versus Monday-Tuesday had similar cardiac complications (P > 0.05).

CONCLUSIONS

Elective LEBs performed on later weekdays for claudication/rest pain were associated with cardiac complications and prolonged LOS, whereas tissue loss confirmed association with prolonged LOS. Further investigations are needed to identify whether increased resources or allocation of resources should be focused on later weekdays to optimize patient outcomes.

Selective Nonoperative and Delayed Management of Severe Asymptomatic Carotid Artery Stenosis

OBJECTIVES

Although intervention is generally the standard of care for severe (80-99%) asymptomatic carotid stenosis, conservative management may be appropriate for a subset of patients. Our goal was to assess reasons for and outcomes of nonoperative/delayed operative management of asymptomatic severe carotid stenosis.

METHODS

Institutional vascular laboratory data from 2010 to 2018 was queried for all patients who underwent a carotid duplex ultrasonography. Patients with severe asymptomatic carotid stenosis (80-99%) were included. Such stenosis was defined by an end diastolic velocity >140 cm/sec on duplex ultrasound in patients without transient ischemic attacks (TIA)/strokes ≤6 months prior to imaging. Nonoperative/delayed operative management was defined as not undergone carotid endarterectomy (CEA) or carotid artery stent (CAS) ≤6 months after imaging. Reasons for nonoperative management or delayed intervention as well as subsequent TIA/stroke and survival were determined. Kaplan-Meier analysis was performed to evaluate survival.

RESULTS

Among 211 patients with severe carotid stenosis, 35 (16.6%) were managed nonoperatively or with delayed operation. Mean age in this subset was 72.6 ± 11.4 years and the majority were female (57.1%), had a smoking history (74.3%), and were on statins (91.4%) at the time of index duplex ultrasound. Reasons for no/delayed intervention were classified as severe medical comorbidities (37.1%), advanced age (17.1%), no referral for intervention (14.3%), patient refusal (14.3%), other severe concomitant cerebrovascular disease (11.4%), and active/advanced cancer (5.7%). Over a median follow-up of 35.2 months, no patients experienced TIAs/strokes attributable to carotid stenosis. One patient had a multifocal bilateral stroke after a cardiac arrest and prolonged resuscitation. A subset of patients underwent delayed CEA (8.6%) or CAS (2.9%). Four-year survival after initial imaging was 79%.

CONCLUSIONS

Reasons for nonoperative and delayed operative management in our cohort of asymptomatic carotid stenosis were commonly due to comorbidities and advanced age. However, a subset of patients was never referred to vascular surgeons/interventionalists. Adverse neurologic events due to carotid stenosis were not observed during follow-up and patients had relatively high long-term survival.

Factors associated with a tunneled dialysis catheter in place at initial arteriovenous access creation

OBJECTIVE

Arteriovenous (AV) access is the preferred hemodialysis modality to avoid the complications associated with tunneled dialysis catheters (TDCs). Despite efforts to create timely AV access, many patients still initiate hemodialysis through TDCs. Our goal was to determine the patient factors associated with having a TDC present at initial AV access creation and how this affects survival.

METHODS

We performed a single-center, retrospective review of all patients who had undergone initial AV fistula creation from 2014 to 2019. Patients with previous peritoneal or AV access were excluded. Univariable and multivariable analyses were used to identify associations with a TDC present at initial AV access creation and patient survival.

RESULTS

Of 509 patients who had undergone initial AV access creation, a TDC was present in 280 (55%). The mean patient age was 59.7 ± 14.1 years. The access types were brachiocephalic (47.2%), brachiobasilic (22.4%), radiocephalic (15.5%), and prosthetic (12.6%). The patients with a TDC compared with those without a TDC were less likely to be obese (68.9% vs 54.2%), more likely to be homeless (10.4% vs 4.8%), and more likely to be an inpatient (44.6% vs 18.8%). They were less likely to have seen a primary care physician within 1 year preoperatively (54.3% vs 88.6%) and a nephrologist within 3 months preoperatively (39.3% vs 93%; P < .05 for all). On multivariable analysis, the presence of a TDC at initial AV access creation was associated with no nephrology visit within 3 months preoperatively (odds ratio [OR], 25; 95% confidence interval [CI], 12.5-50; P < .001), homeless status (OR, 2.6; 95% CI, 1.1-6.2; P = .03), and the absence of obesity (OR, 1.8; 95% CI, 1.1-2.9; P = .02). The 1-year survival was similar for patients with (95%) and without (94.8%) a TDC (P = .36) as confirmed by multivariable analysis (hazard ratio, 1.2; 95% CI, 0.65-2.1; P = .63).

CONCLUSIONS

The absence of a preoperative nephrology visit, homeless status, and the absence of obesity were associated with a TDC present at initial AV access creation. However, the presence of a TDC did not appear to confer changes in short-term survival. Targeted improvements in high-risk populations such as increasing the frequency of preoperative subspecialty evaluation might be warranted to reduce TDC placement before AV access creation at urban safety-net hospitals.

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications

BACKGROUND

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS.

METHODS

The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality.

RESULTS

There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts.

CONCLUSIONS

Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.

Tibial bypass in patients with intermittent claudication is associated with poor outcomes

OBJECTIVE

Given that intermittent claudication (IC) rarely progresses to chronic limb-threatening ischemia and limb loss, safety and durability of elective interventions for IC are essential. Whether patients with IC benefit from tibial intervention is controversial, and data supporting its utility are limited. Despite endovascular therapy expansion, surgical bypass is still commonly performed. We sought to assess outcomes of bypass to tibial arteries for IC.

METHODS

The Vascular Quality Initiative (2003-2018) was queried for infrainguinal bypasses performed for IC. Perioperative and 1-year outcomes were compared between bypasses constructed to tibial and popliteal arteries.

RESULTS

Of 5347 infrainguinal bypasses, 1173 (22%) and 4184 (78%) were tibial and popliteal bypasses, respectively. Overall, mean age was 65 ± 10 years, and patients were often men (72%) and current smokers (42%). Tibial bypasses commonly targeted posterior tibial (40%), tibioperoneal trunk (23%), and anterior tibial (19%) arteries. Great saphenous vein was more often used for tibial bypass than for popliteal bypass (78% vs 54%; P < .001). Patients undergoing tibial compared with popliteal bypass more often had impaired ambulation and prior ipsilateral bypasses and were less often taking antiplatelets and statins (all P < .05). In the perioperative period, tibial bypass patients had longer postoperative length of stay (4.5 ± 3.5 vs 3.5 ± 2.8 days), more pulmonary complications (1.3% vs 0.6%), and higher return to the operating room (7% vs 4%; all P < .05). Perioperative myocardial infarction (1.2% vs 0.8%; P = .19), stroke (0.4% vs 0.4%; P = .91), and mortality (0.3 vs 0.3%; P = .86) rates were similar between the cohorts. At 1 year, tibial compared with popliteal bypasses exhibited lower freedom from occlusion/death (81% vs 89%; P < .001), ipsilateral major amputation/death (90% vs 94%; P < .001), and reintervention/amputation/death (73% vs 80%; P < .001), but patient survival was similar (96% vs 97%; P = .07). On multivariable analysis, tibial compared with popliteal bypass was independently associated with increased occlusion/death (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.28-2.11; P < .001), major ipsilateral amputation/death (HR, 1.6; 95% CI, 1.12-2.19; P = .003), and ipsilateral reintervention/amputation/death (HR, 1.51; 95% CI, 1.28-1.79; P < .001), with similar patient survival.

CONCLUSIONS

In patients with IC, tibial bypass was associated with poor outcomes, including major amputation. Surgeons should exhaust nonoperative therapies and present realistic outcome expectations to their patients before offering such intervention.

Reasons for long-term tunneled dialysis catheter use and associated morbidity

OBJECTIVE

Tunneled dialysis catheters (TDCs) are generally used as a temporary means to provide hemodialysis until permanent arteriovenous (AV) access is established. However, some patients may have long-term catheter-based hemodialysis because of the lack of alternatives for other dialysis access. Our objective was to evaluate characteristics of patients with, reasons for, and mortality associated with long-term TDC use.

METHODS

A retrospective single-institution analysis was performed. Long-term TDC use was defined as >180 days without more than a 7-day temporary removal time. Reasons for long-term TDC use and complications were recorded. Summary statistics were performed. Kaplan-Meier analysis compared mortality between patients with long-term TDC use and a comparison cohort who underwent AV access creation with subsequent TDC removal.

RESULTS

We identified 50 patients with long-term TDC use from 2013 to 2018. The average age was 63 years, 44% were male, and 76% were African American. Previous TDC use was found in 42% of patients with subsequent removal after alternative access was established. Median TDC duration was 333 days (range, 185-2029 days). The primary reasons for long-term TDC use were failed (occluded) AV access (34%), nonmaturing AV (nonoccluded) access (32%), delayed AV access placement (14%), no AV access options (10%), patient refusal for AV access placement (6%), and medically high risk for AV access placement (4%). In 46% of patients, TDC complications including central venous stenosis (33.4%), TDC-related infections (29.6%), TDC displacement (27.8%), and thrombosis (7.9%) occurred. Overall, 47.6% required a catheter exchange during the prolonged TDC period. The majority (76.4%) had the catheter removed because of established alternative access during follow-up. The long-term TDC group, in relation to the comparator group (n = 201), had fewer male patients (44% vs 61.2%; P = .028) and higher proportion of congestive heart failure (66% vs 40.3%; P = .001). Kaplan-Meier analysis showed no significant difference in survival at 24 months for the long-term TDC group compared with the comparator group (93.6% vs 92.7%; P = .28).

CONCLUSIONS

Patients with long-term TDCs experienced significant TDC-related morbidity. Whereas permanent access is preferable, some patients may require long-term TDC use because of difficulty in establishing a permanent access, limited access options, and patient preference. There was no difference in survival between the groups.

Access Type for Endovascular Repair in Ruptured Abdominal Aortic Aneurysms Does Not Affect Major Morbidity or Mortality

BACKGROUND

There are limited data on access type when treating ruptured abdominal aortic aneurysms (AAAs) with endovascular aneurysm repair (EVAR). Our study's objective was to evaluate if the type of access in ruptured AAAs affected outcomes.

METHODS

The Vascular Quality Initiative was queried from 2009 to 2018 for all ruptured AAAs treated with an index EVAR. Procedures were grouped by access type: percutaneous, open, and failed percutaneous that converted to open access. Patients with iliac access, both percutaneous and open access, and concurrent bypass were excluded. Baseline characteristics, procedure details, and outcomes were collected. Univariable and multivariable analyses were performed.

RESULTS

There were 1,206 ruptured AAAs identified-739 (61.3%) was performed by percutaneous access, 416 (34.5%) by open access, and 51 (4.2%) by failed percutaneous that converted to open access. Percutaneous access, compared with open access and failed percutaneous access, respectively, had the shortest operative time (min, median) (111 vs. 138 vs. 180, P < 0.001) and was most often performed under local anesthesia (16.7% vs. 5% vs. 9.8%, P < 0.001). The amount of contrast used was similar between the approaches. Univariable analysis comparing percutaneous access, open access, and failed percutaneous access showed differences in 30-day mortality (19.9% vs. 24.8% vs. 39.2%, P = 0.002), postoperative complications (33.7% vs. 40.2% vs. 54%, P = 0.003), and cardiac complications (18.2% vs. 19.8% vs. 34.7%, P = 0.018). However, multivariable analysis did not show access type to have a significant effect on cardiac complications, pulmonary complications, any complications, return to the operating room, or perioperative mortality. Open access was independently associated with a prolonged length of stay (means ratio 1.17, 95% confidence interval (CI) 1.04-1.33, P = 0.012). Factors independently associated with failed percutaneous were prior bypass (odds ratio (OR) 9.77, 95% CI 2.44-39.16, P = 0.001) and altered mental status (OR 2.45, 95% CI 1.17-5.15, P = 0.018).

CONCLUSIONS

Access type for ruptured AAAs was not independently associated with major morbidity or mortality but did have a differential effect on length of stay. Access during these emergent procedures should be based on surgeon preference and experience.

Contemporary Analysis of Senior Level Case Volume Variation between Traditional Vascular Surgery Fellows and Integrated Vascular Surgery Chief Residents

BACKGROUND

The present study compares the senior level operative experience of graduates from the traditional vascular surgery fellowship (5 + 2) and integrated vascular surgery training programs (0 + 5) using contemporary operative case log data.

METHODS

The Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018 were queried for vascular surgery procedures. "Senior" cases were categorized as cases logged as "surgeon fellow" by 5 + 2 trainees or "surgeon chief" (post graduate year-4,5) by 0 + 5 trainees. Overall case volume was defined as the combined volume of cases logged as "surgeon junior," "surgeon chief," "surgeon fellow," "teach assist," "first assist," or "secondary procedure." To reflect total vascular experience, all vascular cases done during general surgery residency were combined with cases performed during vascular surgery fellowship. Mean case volumes were compared for all operations/procedures.

RESULTS

The 5 + 2 trainees had higher mean volume of open repair of suprarenal aortic aneurysms (2.4 vs. 1.4, P = 0.0026) and open repair of thoracic aortic aneurysms (0.5 vs. 0.3, P = 0.004) at the fellow level compared to 0 + 5 surgeon chief cases. Additionally, 5 + 2 trainees performed more endovascular repair of abdominal aortoiliac aneurysm (44.7 vs. 28.4, P < 0.0001), endovascular repair of iliac artery aneurysm (1.9 vs. 1.2, P = 0.0003), and endovascular repair of thoracic aortic aneurysm (14.9 vs. 8.4, P < 0.0001). The 5 + 2 fellows performed more vein bypasses than 0 + 5 chief residents (femoral-popliteal 9.8 vs. 6.4, P = 0.002; infrapopliteal 13.9 vs. 8.8, P = 0.0490), extra-anatomic bypasses (axillofemoral 4.2 vs. 2.9, P = 0.0004; femoral-femoral 5.6 vs. 3.1, P = 0.034), carotid endarterectomies (47.3 vs. 29.3, P < 0.0001), carotid artery stenting (9.6 vs. 4.5, P = 0.0001), celiac/SMA endarterectomy or bypass (3.7 vs. 1.9, P < 0.0001), renal artery balloon angioplasty/stenting (5.0 vs. 2.5, P = 0.0006), thoracic outlet decompression (5.4 vs. 1.9, P < 0.0001), traumatic repairs [thoracic vessels (0.5 vs. 0.1, P < 0.0001), neck vessels (0.7 vs. 0.3, P = 0.0004), abdominal vessels (3.0 vs. 1.7, P = 0.0005), and peripheral vessels (6.6 vs. 3.1, P = 0.034)], as well as a higher mean volume of arteriovenous (AV) fistulas (30.7 vs. 15.7, P < 0.0001), AV grafts (10.7 vs. 5.1, P < 0.0001), and revision of AV access (16.1 vs. 8.0, P = 0.0003).

CONCLUSIONS

Although both pathways graduate trainees with a similar overall surgical experience, 5 + 2 trainees log significantly more "Senior" cases. Further studies investigating potential variation in operative autonomy between both pathways are necessary.

Intravenous drug use history is not associated with poorer outcomes after arteriovenous access creation

OBJECTIVE

Rising intravenous drug use (IVDU) paralleled with an increasing dialysis-dependent end-stage renal disease population may pose a challenge for creating and maintaining arteriovenous (AV) access for hemodialysis. We aimed to elucidate baseline characteristics and outcomes of AV access creation in the IVDU population.

METHODS

The Vascular Quality Initiative (2011-2018) was queried for patients undergoing AV access placement. Univariable and multivariable analyses comparing outcomes of patients with and without IVDU history were performed.

RESULTS

Of 33,404 patients undergoing AV access creation, 601 (1.8%) had IVDU history (21.8% current and 78.2% past users). IVDU patients receiving AV access were more often younger, male, nonwhite, smokers, homeless, Medicaid recipients, and hospitalized at the time of surgery (P < .001 for all). They exhibited higher rates of congestive heart failure, chronic obstructive pulmonary disease, and human immunodeficiency virus/acquired immunodeficiency syndrome (P < .05 for all). They more frequently had tunneled catheters at the time of access creation (53.6% vs 42%; P < .001) and had a previous AV access (25.3% vs 21.7%; P = .002). IVDU patients more often received prosthetic AV grafts (28.6% vs 18%; P < .001) and more often had anastomoses created to basilic veins (33.1% vs 23.2%; P < .001) but less often to cephalic veins (36.8% vs 57.7%; P < .001). IVDU patients had longer postoperative length of stay (2 ± 6 days vs 0.9 ± 5 days; P < .001) but no significant difference in 30-day mortality (1.7% vs 1.2%; P = .3). Comparing IVDU vs no IVDU cohorts, 1-year access infection-free survival (85.4% vs 86.6%; P = .382), primary patency loss-free survival (39.5% vs 37.9%; P = .335), endovascular/open reintervention-free survival (58% vs 57%; P = .705), and overall survival (89.7% vs 88.9%; P = .635) were similar. On multivariable analysis, IVDU was independently associated with postoperative length of stay (odds ratio, 1.64; 95% confidence interval, 1.35-2; P < .001) but not with 30-day mortality or 1-year infection-free survival, primary patency loss-free survival, reintervention-free survival, and all-cause mortality. The null results were confirmed in a propensity score-matched cohort.

CONCLUSIONS

IVDU history was uncommon among patients undergoing AV access creation at Vascular Quality Initiative centers and was not independently associated with major morbidity or mortality postoperatively. IVDU patients more often received grafts or autogenous access with anastomoses to basilic veins. Although these patients frequently have more comorbidities, IVDU should not deter AV access creation.

Higher body mass index is associated with reinterventions and lower maturation rates after upper extremity arteriovenous access creation

OBJECTIVE

A patient's body mass index (BMI) can affect both perioperative and postoperative outcomes across all surgical specialties. Given that obesity and end-stage renal disease are growing in prevalence, we aimed to evaluate the association between BMI and outcomes of upper extremity arteriovenous (AV) access creation.

METHODS

A retrospective single-institution review was conducted for AV access creations from 2014 to 2018. Patient demographics, comorbidities, and AV access details were recorded. BMI groups were defined as normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), obese (30-39.9 kg/m²), and morbidly obese (>40 kg/m²). Perioperative complications and long-term outcomes including access maturation (defined as access being used for hemodialysis or the surgeon's judgment that access was ready for use in patients not yet on hemodialysis), occlusion, and reintervention were evaluated.

RESULTS

A total of 611 upper extremity AV access creations were performed on patients who were normal weight (29.6%), overweight (31.3%), obese (29.6%), and morbidly obese (9.5%). Access type included brachiocephalic (43.2%), brachiobasilic (25.5%), and radiocephalic (14.2%) fistulas and AV grafts (14.2%). Median age was 60.9 years, and 59.6% were male. Univariable analysis showed no difference between BMI groups for perioperative steal, hematoma, home discharge, or 30-day primary patency. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (44.5% ± 4.6% normal weight, 29% ± 3.8% overweight, 39.8% ± 4.3% obese, 34.7% ± 8% morbidly obese; P = .041). There was no difference in 2-year freedom from new access creation or survival. AV access maturity within 180 days differed between BMI groups (74.3% normal weight, 66% overweight, 65.7% obese, 46.6% morbidly obese; P < .001). On multivariable analysis, failure to mature within 180 days was associated with overweight (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.14-3.29; P = .002), obese (OR, 2.12; 95% CI, 1.19-3.47; P = .009), and morbidly obese (OR, 3.68; 95% CI, 1.85-7.3; P < .001) relative to normal weight BMI. AV access reintervention was associated with overweight (hazard ratio [HR], 1.83; 95% CI, 1.34-2.5), obese (HR, 1.56; 95% CI, 1.12-2.16), and morbidly obese (HR, 1.69; 95% CI, 1.1-2.58; P = .02) relative to normal weight BMI. BMI was not independently associated with long-term readmission or survival.

CONCLUSIONS

Obesity is associated with higher rates of AV access failure to mature and reintervention. Surgeons performing access creation on obese patients must consider this for planning and setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms.

Perioperative and long-term outcomes after percutaneous thrombectomy of arteriovenous dialysis access grafts

OBJECTIVE

Maintenance of functional arteriovenous grafts (AVGs) for dialysis is difficult secondary to low primary patency, need for reinterventions, and limited alternative dialysis access options. We assessed our experience with percutaneous thrombectomy for treatment of occluded AVGs.

METHODS

We performed a retrospective analysis of all percutaneous thrombectomies for AVGs from 2015 to 2017. These were generally performed using mechanical thrombectomy and occasional chemical tissue plasminogen activator thrombolysis, over-the-wire balloon embolectomy for inflow, and adjunctive inflow and outflow interventions as necessary. Perioperative outcomes, long-term patency, reinterventions, and need for new permanent access placement were analyzed.

RESULTS

There were 218 percutaneous thrombectomies performed on 86 AVGs in 77 patients. Approximately half (53.2%) of the patients were male and 68.8% were black. Mean age was 61.1 ± 13.0 years. At the time of thrombectomy, 73.8% underwent venous outflow interventions and 4.5% underwent arterial inflow interventions. Within 30 days, 24.8% of declotted grafts underwent repeated percutaneous thrombectomy, 14.3% required tunneled dialysis catheter placement, 4% developed minor access site or graft infections, and one patient underwent surgical arterial thrombectomy for arm ischemia. There were no venous thromboembolic, cardiopulmonary, or cerebrovascular complications or clinically significant pulmonary embolism. At 1 year and 3 years after percutaneous thrombectomy, freedom from repeated thrombosis was 37% and 18%, respectively, and freedom from new dialysis access placement was 66% and 51%, respectively. Overall patient survival was 82% at 3 years.

CONCLUSIONS

Percutaneous thrombectomy of AVGs is safe and is associated with acceptable patency rates. This minimally invasive method extends AVG use for these high-risk patients with limited dialysis access options.

Patients with human immunodeficiency virus infection do not have inferior outcomes after dialysis access creation

OBJECTIVE

Despite improvements in treating human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), the risk of end-stage renal disease and need for long-term arteriovenous (AV) access for hemodialysis remain high in HIV-infected patients. Associations of HIV/AIDS with AV access creation complications have been conflicting. Our goal was to clarify short- and long-term outcomes of patients with HIV/AIDS undergoing AV access creation.

METHODS

The Vascular Quality Initiative registry was queried from 2011 to 2018 for all patients undergoing AV access creation. Documentation of HIV infection status with or without AIDS was recorded. Data were propensity score matched (4:1) between non-HIV-infected patients and HIV/AIDS patients. Subsequent multivariable analysis and Kaplan-Meier analysis were performed for short- and long-term outcomes.

RESULTS

There were 25,711 upper extremity AV access creations identified: 25,186 without HIV infection (98%), 424 (1.6%) with HIV infection, and 101 (.4%) with AIDS. Mean age was 61.8 years, and 55.8% were male. Patients with HIV/AIDS were more often younger, male, nonwhite, nonobese, and current smokers; they were more often on Medicaid and more likely to have a history of intravenous drug use, and they were less often diabetic and less likely to have cardiac comorbidities (P < .05 for all). There was no significant difference in autogenous or prosthetic access used in these cohorts. Wound infection requiring incision and drainage or explantation within 90 days was low for all groups (0.6% vs 1.9 vs 0%; P = .11) of non-HIV-infected patients vs HIV-infected patients vs AIDS patients. Kaplan-Meier analysis showed no significant difference in 1-year freedom from primary patency loss (43.9% vs 46.3%; P =.6), 1-year freedom from reintervention (61% vs 60.7%,; P = .81), or 3-year survival (83% vs 83.8%; P = .57) for those with and without HIV/AIDS, respectively. Multivariable analysis demonstrated that patients with HIV/AIDS were not at significantly higher risk for access reintervention (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.76-1.24; P = .81), occlusion (HR, 1.06; 95% CI, 0.86-1.29; P = .6), or mortality (HR, 1.08; 95% CI, 0.83-1.43; P = .57).

CONCLUSIONS

Patients with HIV/AIDS undergoing AV access creation have outcomes similar to those of patients without HIV infection, including long-term survival. Patients with HIV/AIDS had fewer traditional end-stage renal disease risk factors compared with non-HIV-infected patients. Our findings show that the contemporary approach for creation and management of AV access in patients with HIV/AIDS should be continued; however, further research is needed to identify risk factors in this population.

Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk

OBJECTIVE

Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke.

METHODS

The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches.

RESULTS

There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022).

CONCLUSIONS

In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.

Hypoalbuminemia Predicts Increased Readmission and Emergency Department Visits After Lower Extremity Bypass

INTRODUCTION

Preoperative hypoalbuminemia is associated with poor outcomes across many surgical fields. However, the effects on outcomes after lower extremity bypass (LEB), particularly over the 90-day global surgical period, are unclear. Our goal was to analyze the effect of hypoalbuminemia within 90 days after LE bypass.

METHODS

We performed a single-center retrospective review of all infrainguinal LEBs from 2007 to 2017. Patients were categorized into 3 preoperative albumin groups: severe hypoalbuminemia (SH; albumin ≤2.8g/dL), mild-moderate hypoalbuminemia (MH; albumin >2.8-3.5g/dL), and normal albumin (albumin >3.5g/dL). Patient and procedural details were recorded. Outcomes analyzed included wound infection, myocardial infarction (MI), pulmonary complications, early graft occlusion (≤30 days), mortality, and emergency department (ED) presentation and readmissions within 30 and 90 days. Multivariable analysis was performed.

RESULTS

We identified 313 patients undergoing LEB-45 (14.4%) with SH, 133 (42.5%) with MH, and 135 (43.1%) with normal albumin. Overall, the mean age was 65.7 years, and 63.3% were male. The SH group more frequently had tissue loss, diabetes, hypertension, end-stage renal disease, preoperative hematocrit <30%, and patients admitted preoperatively (all P < .05). There were no significant differences in wound complications, MI, pulmonary complications, early graft occlusion, 30-day or 90-day mortality, and 30-day ED presentation. Severe hypoalbuminemia compared to MH and normal albumin, respectively, had significantly higher rates of 30-day readmission (40% vs 30.8% vs 17.8%, P = .005), 90-day ED presentation (55.6% vs 33.8% vs 29.6%, P = .006), and 90-day readmission (66.7% vs 48.9% vs 35.6%, P = .001). Multivariable analysis showed that SH was independently associated with 90-day ED presentation (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.23-6.36, P = .014) and 90-day readmission (OR: 2.63, 95% CI: 1.21-5.71, P = .015).

CONCLUSION

Our study suggests that patients with SH undergoing LEB had similar perioperative complication rates compared to normal albumin and MH groups, and SH was independently associated with 90-day ED presentation and readmission. Further studies are needed to assess other factors associated with ED visits and readmission.

Risk assessment of significant upper extremity arteriovenous graft infection in the Vascular Quality Initiative

OBJECTIVE

Infectious complications of arteriovenous grafts (AVGs) are a major source of morbidity. Our aim was to characterize contemporary risk factors for upper extremity AVG infection.

METHODS

The Vascular Quality Initiative (2011-2018) was queried for all patients undergoing upper extremity AVG creation. AVG infection was classified as an infection treated with antibiotics, incision and drainage, or graft removal. Multivariable analyses were used to evaluate risk factors for short- and long-term AVG infection.

RESULTS

Of 1758 upper extremity AVGs, 49 (2.8%) developed significant infection within 3 months, resulting in incision and drainage in 24% and graft removal in 76% of cases. None were managed with antibiotics alone in the study sample. Patients with significant AVG infection were more likely to be white, to be insured, to have a history of coronary artery bypass graft and intravenous (IV) drug use, to be undergoing a concomitant vascular procedure, and to be discharged on an anticoagulant. In multivariable analysis, significant AVG infection within 3 months was associated with IV drug use history (odds ratio [OR], 5; 95% confidence interval [CI], 1.75-14.3; P = .003), discharge to a health care facility (OR, 2.66; 95% CI, 1.07-6.63; P = .035), discharge on an anticoagulant (OR, 2.31; 95% CI, 1.13-4.72; P = .021), white race (OR, 2.3; 95% CI, 1.21-4.34; P = .011), and female sex (OR, 2.02; 95% CI, 1.06-3.85; P = .033). Kaplan-Meier analysis showed that freedom from graft site infection at 1 year was 96.4%. Longer term graft infection at 1 year was independently associated with IV drug use history (hazard ratio [HR], 1.98; 95% CI, 1.06-3.68; P = .032), initial discharge to a health care facility (HR, 1.88; 95% CI, 1.19-2.97; P = .007), and white race (HR, 1.64; 95% CI, 1.23-2.19; P = .001).

CONCLUSIONS

Although significant AVG infection was uncommon in the Vascular Quality Initiative, the majority were treated with graft removal. In select high-risk patients, extra care should be taken and alternative forms of arteriovenous access may be considered.