Publications by authors named "Rafael D Malgor"

54 Publications

A Systematic Review and Meta-Analysis of Outcomes After Acute Limb Ischemia in Patients with Cancer.

J Vasc Surg 2021 Apr 24. Epub 2021 Apr 24.

Professor of Surgery, Division of Vascular Surgery, University of Colorado, Anschutz medical center, CPC Research, Aurora, CO.

Introduction: Cancer results in a hypercoagulable state that is associated with both venous and arterial thromboses, but little is known about the impact of acute limb ischemia (ALI) in this cohort of patients. The goal of this systematic review and meta-analysis was to analyze the available clinical data on cancer and its association with ALI and to gauge outcomes in these patients following ALI diagnosis.

Methods: Three databases including Pubmed, EMBASE, and Cochrane library were queried. Manuscripts that met the inclusion criteria were included regardless of publication year, language, sample size or length of follow-up. All steps of the meta-analysis were conducted according to PRISMA and MOOSE guidelines.

Results: Seven manuscripts of 6,222 references were included with a total of 2,899 patients. 1,195 (41%) patients were diagnosed with ALI prior to cancer diagnosis, while 1,704 (59%) patients presented following a cancer diagnosis. Nearly three quarters of ALI events were among patients with cancers of skin and soft tissue (19%), genitourinary (18%), lung (17%), and gastrointestinal (16%) systems. ALI recurrence was similar between the two groups, while major amputation was more likely in patients diagnosed with ALI following a cancer diagnosis (7.4% vs 4.6%; p<0.01). The incidence of mortality at one year was significantly greater in patients with established cancers who presented with ALI compared to patients who presented with ALI prior to a cancer diagnosis (50.6% vs 29.9%; p<0.01). After adjusting for study variability under the random effects model, mortality at one year among all patients was 52.3% (95% CI 37.7%-66.5%). There was no significant heterogeneity (p=0.73) between the two groups of ALI patients that varied by timing in relation to cancer diagnosis.

Conclusion: The one-year mortality following ALI in patients with cancer is greater than 50%. In patients presenting with ALI of unclear etiology, an underlying cancer should be considered.
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http://dx.doi.org/10.1016/j.jvs.2021.03.058DOI Listing
April 2021

Iliac Conduits for Endovascular Treatment of Aortic Pathologies: A Systematic Review and Meta-analysis.

J Endovasc Ther 2021 Apr 26:15266028211007468. Epub 2021 Apr 26.

Anschutz Medical Center, Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO, USA.

Purpose: The treatment of thoracoabdominal aortic aneurysm has largely shifted to endovascular techniques. However, severe iliofemoral arterial disease often presents a challenge during these interventions. As a result, iliac conduits have been introduced to facilitate aortic endovascular therapy. The goal of the current study was to gauge utilization and to analyze iliac artery conduit outcomes to facilitate endovascular therapy to treat aortic pathologies.

Materials And Methods: A meta-analysis of 14 studies was conducted with the use of random effects modeling. The incidence of periprocedural adverse events was gauged based on iliac conduit vs nonconduit cases and planned vs unplanned iliac conduit placement. Outcomes of interest included length of hospital stay, morbidity and mortality associated to conduits, and all-cause mortality.

Results: Iliac conduits, either open or endo-conduits, were utilized in 17% (95% CI: 9%-27%) of 16,855 cases, with technical successful rate of 94% (95% CI: 80%-100%). Periprocedural complications occurred in 32% (95% CI: 22%-42%) of the cases, with overall bleeding complication rate being 10% (95% CI: 5%-16%). Female patients, positive history for smoking, pulmonary disease, and peripheral artery disease at baseline were associated with more frequent utilization of iliac conduits. Conduit use was associated with longer hospitalization, higher periprocedural all-cause mortality (OR: 2.85; 95% CI: 1.75-4.64; p<0.001), and bleeding complication rate (OR: 2.38; 95% CI: 1.58-3.58; p<0.001). Sensitivity analysis among conduit cases showed that planned conduits were associated with fewer periprocedural complications compared to unplanned conduits (OR: 0.38; 95% CI: 0.20-0.73; p=0.004).

Conclusion: Iliac conduit placement is a feasible strategy, associated with high technical success to facilitate complex aortic endovascular repair. However, periprocedural adverse event rate, including bleeding complications is not negligible. All-cause mortality and morbidity rates among cases that require iliac conduits should be strongly considered during clinical decision making. High-quality comparative analyses between iliac conduit vs nonconduit cases and between several types of iliac conduit grafts aiming at facilitating endovascular aortic repair are still needed to determine the best strategy to address challenging iliac artery accesses.
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http://dx.doi.org/10.1177/15266028211007468DOI Listing
April 2021

Actions to enhance interactive learning in surgery.

Ann Med Surg (Lond) 2021 Apr 26;64:102256. Epub 2021 Mar 26.

Department of Surgery, Stanford University, USA.

Introduction: Many educational institutions and academic organizations provide concise and highly organized educational material for the trainees and training programs, while others do not. The role of interactive technology-enhanced learning in surgical education is not entirely explored and disseminated despite common knowledge of such interactive educational technology. Utilizing such technology in the place of textbooks could replace a peer trainee and a teacher examiner.

Evidence: Maximizing involvement, participation, and interactivity from both surgical trainees and their faculty has been shown to improve the quality and outcomes of surgical education. Given that there is an increasing trend towards shifting from traditional unidirectional teaching to learner-centered interactive teaching. Improving the educational activities setting from the traditional - didactic unidirectional lecture to multi-directional, interactive, engaging, and stimulating activity can enhance learners' educational outcomes. With the advent of educational technology, interactive and shared learning became more feasible and creative. Various educational technology platforms, instructional designs, and tools serve different educational purposes guided by educational activity's objective. Educational systems have integrated numerous widely technologies such as smartphones, tablets, and cloud-based services that greatly facilitate instructional strategies and teaching methods. Many institutions and programs have embraced the new technologies to enhance the overall learning process. Educational technology offers new concepts and applications in learning beyond faster communication or storage of digital resources. Furthermore, active and interactive learning in surgical education has been found to carry a strong and implied impact depending on how it is structured. To enhance and promote interactive surgical education on a broad scale, the following initiatives will be reviewed; interactive adult learning worldwide, wide sharing of knowledge and skills, and use of educational technology where it is pertinent.

Conclusion: Residents and surgical training programs need assistance with the process of learning amid ongoing technological innovations. This guidance would leverage the training programs' educational efforts toward effective surgery training. Interactive educational learning technology is expected to fulfill this need by promoting knowledge sharing, skills learning to enhance educational outcomes.
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http://dx.doi.org/10.1016/j.amsu.2021.102256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050727PMC
April 2021

Transcervical Carotid Artery Revascularization: a Systematic Review and Meta-analysis of Outcomes.

J Vasc Surg 2021 Apr 14. Epub 2021 Apr 14.

First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece.

Objective: Carotid artery stenosis is a determinant factor accused for cerebrovascular events, estimated to be the cause of 10-20% of all ischemic strokes. Trans-cervical carotid artery revascularization (TCAR) has been offered as an alternative to transfemoral carotid artery stenting and carotid endarterectomy.

Methods: A systematic review and meta-analysis of prospective and retrospective studies reporting on outcomes of patients undergoing TCAR for carotid stenosis was conducted. The incidence of periprocedural adverse events is calculated.

Results: In total, 49 studies including 14,588 patients met the predefined eligibility criteria and were included in this meta-analysis. Technical success was 99% (95% CI: 98%-99%). Reasons for technical failure included inability to cross the lesion and/or failure to deploy the stent. Access site complications occurred in 2% (30 studies; 95% CI: 1%-2%) of all the cases. Overall, cranial nerve (CN) injuries were very rare, with only 33 patients out of 8,994 experiencing neurologic deficits attributed to CN involvement. Bleeding complications were reported by 20 studies and occurred in 2% (95% CI: 1%-3%) of all cases. Overall periprocedural all-cause mortality and stroke was 0.5% and 1.3% respectively. In-stent restenosis was observed in 4 out of 260 patients (7 studies; 1.5%), while early (30-day) re-occlusion/acute thrombosis of the target lesion occurred in approximately 1% (11 studies; N=12/1,243).

Conclusion: This study provided significant evidence that TCAR is a very promising and safe carotid revascularization approach demonstrating favorable technical success rates associated with low periprocedural stroke and CN injury rates.
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http://dx.doi.org/10.1016/j.jvs.2021.03.032DOI Listing
April 2021

Feasibility and acceptability of virtual mock oral examinations for senior vascular surgery trainees and implications for the certifying exam.

Ann Vasc Surg 2021 Apr 7. Epub 2021 Apr 7.

Division of Vascular and Endovascular Surgery, Saint Louis University, Saint Louis, MO. Electronic address:

Objectives: The COVID-19 pandemic resulted in the cancellation of in-person testing across the country. We sought to understand the feasibility of conducting virtual oral examinations as well as solicit opinions of vascular surgery program directors (PD) regarding the use of virtual platforms to conduct both low stakes mock oral examinations with their trainees and potentially "real" high stakes certifying examinations (CE) moving forward.

Methods: Forty-four senior vascular surgery trainees from 17 institutions took part in a virtual mock oral examination conducted by 38 practicing vascular surgeons via Zoom. Each examination lasted 30 minutes with four clinical scenarios. An anonymous survey pertaining to the conduct of the examination and opinions on feasibility of using virtual examinations for the vascular surgery CE was sent to all examiners and examinees. A similar survey was sent to all vascular surgery program directors.

Results: The overall pass rate was 82% (36/44 participants) with no correlation with training paradigm. 32/44 (73%) of trainees, 29/38 (76%) of examiners and 49/103 (48%) of PDs completed the surveys. Examinees and examiners thought the experience was beneficial and PDs also thought the experience would be beneficial for their trainees. While the majority of trainees and examiners believed they were able to communicate and express (or evaluate) knowledge and confidence as easily virtually as in person, PDs were less likely to agree confidence could be assessed virtually. The majority of respondents thought the CE of the Vascular Surgery Board of the American Board of Surgery could be offered virtually, although no groups thought virtual exams were superior to in person exams. While cost benefit was perceived in virtual examinations, the security of the examination was a concern.

Conclusions: Performing virtual mock oral examinations for vascular surgery trainees is feasible. Both vascular surgery trainees as well as PDs feel that virtual CEs should be considered by the Vascular Surgery Board.
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http://dx.doi.org/10.1016/j.avsg.2021.03.005DOI Listing
April 2021

A network meta-analysis of direct factor Xa inhibitors for the treatment of cancer-associated venous thromboembolism.

Vascular 2021 Apr 1:17085381211002726. Epub 2021 Apr 1.

Medical School of Sao Paulo State University, Division of Vascular and Endovascular Surgery, Botucatu Campus, Brazil.

Introduction: Treatment of cancer-associated venous thromboembolism (CAVTE) remains challenging. The aim of this study was to assess the outcomes of direct acting oral anticoagulants (DOAs) for the treatment of CAVTE.

Materials And Methods: A network meta-analysis of randomized clinical trials comparing DOAs (Apixaban, Rivaroxaban, and Edoxaban) versus Dalteparin for the treatment of CAVTE was performed. Outcomes of interest included, VTE recurrence, all-cause mortality, event-free survival, major bleeding, and clinically relevant non-major bleeding (CRNMB). Analysis was based on a random effects model and Bayesian Markov-chain Monte Carlo method was used for indirect comparisons.

Results: Four RCTs involving 2894 patients were included. Overall certainty of evidence was moderate regarding all outcomes. DOAs exhibited lower risk of VTE (RR 0.62; 95% CI 0.44, 0.87;  = 0.007), similar risk of major bleeding (RR 1.33; 95% CI 0.84, 2.11;  = 0.23), and higher risk of CRNMB (RR 1.66, 95% CI 1.08, 2.56;  = 0.02), compared with Dalteparin. Risk of all-cause mortality and event-free survival were similar between groups with RR 0.99 (95% CI 0.84, 1.16) and RR 1.03 (95% CI 0.94, 1.13), respectively. Apixaban ranked first for recurrent VTE (42.4%) and major bleeding (62.3%) and Dalteparin ranked first for CRNMB (54.7%). Rivaroxaban ranked best considering all-cause mortality (58.7%); Apixaban ranked best for event-free survival (83.6%).

Conclusions: DOAs presented a reduced risk of recurrent VTE with similar risk of major bleeding compared to Dalteparin. However, a higher risk of CRNMB is expected when this cohort of patients are treated with DOAs instead of Dalteparin.
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http://dx.doi.org/10.1177/17085381211002726DOI Listing
April 2021

Sharp Recanalization with the Upstream GoBack Catheter for Chronic Occlusive Ilio-Caval Thrombosis.

Ann Vasc Surg 2021 Feb 5. Epub 2021 Feb 5.

University of Colorado-Anschutz Medical Campus, Division of Vascular Surgery, Denver, Colorado. Electronic address:

Recanalization of chronic iliofemoral deep vein thrombosis is indicated to reduce symptoms and improve quality of life. However, recanalization is dependent on the ability to cross chronic obstructions. We present a case of chronically thrombosed inferior vena cava and common iliac veins that failed conventional crossing techniques but were successfully recanalized using the recently approved Upstream GoBack Crossing Catheter.
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http://dx.doi.org/10.1016/j.avsg.2020.12.045DOI Listing
February 2021

Vascular Surgeons Should be Valued by Contemporarily Derived Productivity Metrics.

Ann Vasc Surg 2021 Jan 21. Epub 2021 Jan 21.

Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, CO.

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http://dx.doi.org/10.1016/j.avsg.2021.01.058DOI Listing
January 2021

The Impact of the COVID-19 Pandemic on Vascular Surgery Trainees in the United States.

Ann Vasc Surg 2021 Apr 3;72:182-190. Epub 2020 Nov 3.

Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA. Electronic address:

Background: The impact of the coronavirus disease 19 (COVID-19) pandemic on health care workers has been substantial. However, the impact on vascular surgery (VS) trainees has not yet been determined. The goals of our study were to gauge the impact of COVID-19 on VS trainees' personal and professional life and to assess stressors, coping, and support structures involved in these trainees' response to the COVID-19 pandemic.

Methods: This was an anonymous online survey administered in April 12-24, 2020 during the surge phase of the global COVID-19 pandemic. It is a subset analysis of the cross-sectional Society for Vascular Surgery Wellness Committee Pandemic Practice, Anxiety, Coping, and Support Survey. The cohort surveyed was VS trainees, integrated residents and fellows, in the United States of America. Assessment of the personal impact of the pandemic on VS trainees and the coping strategies used by them was based on the validated Generalized Anxiety Disorder 7-item (GAD-7) scale and the validated 28-time Brief Coping Orientation to Problems Experienced inventory.

Results: A total of 145 VS trainees responded to the survey, with a 23% response rate (145/638). Significant changes were made to the clinical responsibilities of VS trainees, with 111 (91%) reporting cancellation of elective procedures, 101 (82%) with call schedule changes, 34 (24%) with duties other than related to VS, and 29 (24%) participation in outpatient care delivery. Over one-third (52/144) reported they had performed a procedure on a patient with confirmed COVID-19; 37 (25.7%) reported they were unaware of the COVID-19 status at the time. The majority continued to work after exposure (29/34, 78%). Major stressors included concerns about professional development, infection risk to family/friends, and impact of care delay on patients. The median score for GAD-7 was 4 (interquartile range 1-8), which corresponds to no or low self-reported anxiety levels. VS trainees employed mostly active coping and rarely avoidant coping mechanisms, and the majority were aware and used social media and online support systems. No significant difference was observed between integrated residents and fellows, or by gender.

Conclusions: The pandemic has had significant impact on VS trainees. Trainees reported significant changes to clinical responsibilities, exposure to COVID-19, and pandemic-related stressors but demonstrated healthy coping mechanisms with low self-reported anxiety levels. The VS community should maintain awareness of the impact of the pandemic on the professional and personal development of surgeons in training. We recommend adaptive evolution in training to accommodate the changing learning environment for trainees.
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http://dx.doi.org/10.1016/j.avsg.2020.09.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608023PMC
April 2021

Brazilian vascular surgeons experience during the coronavirus (COVID-19) pandemic.

Vascular 2020 Oct 6:1708538120954961. Epub 2020 Oct 6.

Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA, USA.

Background: The COVID-19 pandemic has made a significant impact on all spheres of society. The objective of this study was to examine the impact of COVID-19 on the practices, finances, and social aspects of Brazilian vascular surgeons' lives.

Methods: This is a descriptive analysis of the responses from Brazilian vascular surgeons to the cross-sectional anonymous Society for Vascular Surgery Wellness Task Force Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons disseminated 14-24 April 2020. Survey dissemination in Brazil occurred mainly via the Brazilian Society of Angiology and Vascular Surgery (SBACV) and social media. The survey evaluated the impact of the COVID-19 pandemic on vascular surgeons' lives by assessing COVID-19-related stressors, anxiety using theGeneral Anxiety Disorder (GAD)-7 scale, and coping strategies using the Brief Coping Orientation to Problems Experienced (Brief-COPE) inventory.

Results: A total of 452 responses were recorded from Brazil, with 335 (74%) respondents completing the entire survey. The majority of respondents were males ( = 301, 67%) and practiced in an urban hospitals. The majority of respondents considered themselves at high risk to be infected with COVID-19 ( = 251, 55.8%), and just over half the respondents noted that they had adequate PPE at their primary hospital ( = 171, 54%). One hundred and nine (35%) surgeons confirmed that their hospitals followed professional surgical society guidelines for prioritizing surgeries during the pandemic. At the time of the survey, only 33 (10%) surgeons stated they have pre-operative testing of patients for COVID-19 available at their hospital. Academic vascular surgeons reported being redeployed more often to help with other non-vascular duties compared to community-based or solo practitioners (43% vs. 30% vs. 21% respectively,  = .01). Severe anxiety due to pandemic-related financial concerns was similar in those surgeons practicing solo compared to those in community- or academic-based/group practice (46% vs. 38% vs. 22%;  = .54). The respondents reported their anxiety levels as mild based on the stressors investigated instead of moderate-severe (54% vs. 46%;  = .04). Social media was utilized heavily during the pandemic, with video gatherings being the most commonly used tool (76%). Self-distraction (60%) and situational acceptance (81%) were the most frequently reported coping mechanisms used among Brazilian vascular surgeons.

Conclusion: The COVID pandemic has greatly affected healthcare providers around the world. At the time of this survey, Brazilian vascular surgeons are reporting low anxiety levels during this time and are using mostly active coping mechanisms.
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http://dx.doi.org/10.1177/1708538120954961DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7539231PMC
October 2020

Classification and treatment of endothermal heat-induced thrombosis: Recommendations from the American Venous Forum and the Society for Vascular Surgery.

J Vasc Surg Venous Lymphat Disord 2021 01 1;9(1):6-22. Epub 2020 Oct 1.

Yourveins of AZ, Scottsdale, Ariz.

The American Venous Forum (AVF) and the Society for Vascular Surgery set forth these guidelines for the management of endothermal heat-induced thrombosis (EHIT). The guidelines serve to compile the body of literature on EHIT and to put forth evidence-based recommendations. The guidelines are divided into the following categories: classification of EHIT, risk factors and prevention, and treatment of EHIT. One major feature is to standardize the reporting under one classification system. The Kabnick and Lawrence classification systems are now combined into the AVF EHIT classification system. The novel classification system affords standardization in reporting but also allows continued combined evaluation with the current body of literature. Recommendations codify the use of duplex ultrasound for the diagnosis of EHIT. Risk factor assessments and methods of prevention including mechanical prophylaxis, chemical prophylaxis, and ablation distance are discussed. Treatment guidelines are tailored to the AVF EHIT class (ie, I, II, III, IV). Reference is made to the use of surveillance, antiplatelet therapy, and anticoagulants as deemed indicated, and the recommendations incorporate the use of the novel direct oral anticoagulants. Last, EHIT management as it relates to the great and small saphenous veins is discussed.
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http://dx.doi.org/10.1016/j.jvsv.2020.06.008DOI Listing
January 2021

The impact of the COVID-19 pandemic on vascular surgery practice in the United States.

J Vasc Surg 2021 Mar 1;73(3):772-779.e4. Epub 2020 Sep 1.

Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash. Electronic address:

Background: The coronavirus disease 2019 (COVID-19) pandemic has led to widespread postponement and cancelation of elective surgeries in the United States. We designed and administered a global survey to examine the impact of COVID-19 on vascular surgeons. We describe the impact of the pandemic on the practices of vascular surgeons in the United States.

Methods: The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons is an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force disseminated April 14 to 24, 2020. This analysis focuses on pattern changes in vascular surgery practices in the United States including the inpatient setting, ambulatory, and vascular laboratory setting. Specific questions regarding occupational exposure to COVID-19, adequacy of personal protective equipment, elective surgical practice, changes in call schedule, and redeployment to nonvascular surgery duties were also included in the survey. Regional variation was assessed. The survey data were collected using REDCap and analyzed using descriptive statistics.

Results: A total of 535 vascular surgeons responded to the survey from 45 states. Most of the respondents were male (73.1%), white (70.7%), practiced in urban settings (81.7%), and in teaching hospitals (66.8%). Almost one-half were in hospitals with more than 400 beds (46.4%). There was no regional variation in the presence of preoperative COVID-19 testing, COVID-19 OR protocols, adherence to national surgical standards, or the availability of personal protective equipment. The overwhelming majority of respondents (91.7%) noted elective surgery cancellation, with the Northeast and Southeast regions having the most case cancellations 94.2% and 95.8%, respectively. The Northeast region reported the highest percentage of operations or procedures on patients with COVID-19, which was either identified at the time of the surgery or later in the hospital course (82.7%). Ambulatory visits were performed via telehealth (81.3%), with 71.1% having restricted hours. More than one-half of office-based laboratories (OBLs) were closed, although there was regional variation with more than 80% in the Midwest being closed. Cases performed in OBLs focused on critical limb ischemia (42.9%) and dialysis access maintenance (39.9%). Call schedules modifications were common, although the number of call days remained the same (45.8%).

Conclusions: Vascular surgeons in the United States report substantial impact on their practices during the COVID-19 pandemic, and regional variations are demonstrated, particularly in OBL use, intensive care bed availability, and COVID-19 exposure at work.
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http://dx.doi.org/10.1016/j.jvs.2020.08.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462594PMC
March 2021

Global vascular surgeons' experience, stressors, and coping during the coronavirus disease 2019 pandemic.

J Vasc Surg 2021 03 31;73(3):762-771.e4. Epub 2020 Aug 31.

Division of Vascular Surgery, University of California, Los Angeles, Los Angeles, Calif.

Background: The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges for health care systems globally. We designed and administered a global survey to examine the effects of COVID-19 on vascular surgeons and explore the COVID-19-related stressors faced, coping strategies used, and support structures available.

Methods: The Pandemic Practice, Anxiety, Coping, and Support Survey for Vascular Surgeons was an anonymous cross-sectional survey sponsored by the Society for Vascular Surgery Wellness Task Force. The survey analysis evaluated the effects of COVID-19-related stressors on vascular surgeons measured using the Generalized Anxiety Disorder 7-item scale. The 28-item Brief Coping Orientation to Problems Experienced inventory was used to assess the active and avoidant coping strategies. Survey data were collected using REDCap (Research Electronic Data Capture) from April 14, 2020 to April 24, 2020 inclusive. Additional qualitative data were collected using open-ended questions. Univariable and multivariable analyses of the factors associated with the anxiety levels and qualitative analysis were performed.

Results: A total of 1609 survey responses (70.5% male; 82.5% vascular surgeons in practice) from 58 countries (43.4% from United States; 43.4% from Brazil) were eligible for analysis. Some degree of anxiety was reported by 54.5% of the respondents, and 23.3% reported moderate or severe anxiety. Most respondents (∼60%) reported using active coping strategies and the avoidant coping strategy of "self-distraction," and 20% used other avoidant coping strategies. Multivariable analysis identified the following factors as significantly associated with increased self-reported anxiety levels: staying in a separate room at home or staying at the hospital or a hotel after work (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.08-1.79), donning and doffing personal protective equipment (OR, 1.81; 95% CI, 1.41-2.33), worry about potential adverse patient outcomes due to care delay (OR, 1.47; 95% CI, 1.16-1.87), and financial concerns (OR, 1.90; 95% CI, 1.49-2.42). The factors significantly associated with decreased self-reported anxiety levels were hospital support (OR, 0.83; 95% CI, 0.76-0.91) and the use of positive reframing as an active coping strategy (OR, 0.88; 95% CI, 0.81-0.95).

Conclusions: Vascular surgeons globally have been experiencing multiple COVID-19-related stressors during this devastating crisis. These findings have highlighted the continued need for hospital systems to support their vascular surgeons and the importance of national societies to continue to invest in peer-support programs as paramount to promoting the well-being of vascular surgeons during and after the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.jvs.2020.08.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457940PMC
March 2021

Inadequacies and pitfalls of network meta-analysis applied to femoropopliteal endovascular interventions.

Vascular 2021 Apr 24;29(2):311-312. Epub 2020 Aug 24.

Division of Vascular Surgery and Endovascular Therapy, University of Colorado, Aurora, USA.

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http://dx.doi.org/10.1177/1708538120949676DOI Listing
April 2021

The utilization of intravascular lithotripsy to facilitate transcarotid artery revascularization.

J Cardiovasc Surg (Torino) 2020 Dec 1;61(6):759-762. Epub 2020 Jul 1.

Division of Vascular and Endovascular Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA.

Carotid artery disease and stroke account for the second cause of mortality in worldwide. Recently, transcarotid artery stenting (TCAR) has emerged as a treatment modality that carries a very low stroke rate. However, there are limitations to TCAR, such as heavily calcified plaques that might preclude optimal stent expansion. We describe a successful transcarotid artery stenting with flow reversal performed in an independent and active nonagenarian with focal, circumferentially calcified carotid artery plaque, for which intravascular lithotripsy was utilized.
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http://dx.doi.org/10.23736/S0021-9509.20.11421-6DOI Listing
December 2020

A systematic review of diagnosis and treatment of acute limb ischemia during pregnancy and postpartum period.

J Vasc Surg 2020 11 20;72(5):1793-1801.e1. Epub 2020 May 20.

CPC Research, Aurora, Colo; Division of Vascular Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colo.

Background: Acute limb ischemia (ALI) carries significant overall morbidity and mortality. Pregnant and postpartum women are physiologically hypercoagulable, but little is known about the impact of ALI in this cohort of patients. The goal of this systematic review was to gather available data on diagnosis and treatment of ALI during pregnancy and the postpartum period.

Methods: A systematic review of studies on patients with ALI during pregnancy and the puerperium was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases including PubMed MEDLINE, Embase, and Cochrane Library were queried. Manuscripts that provided data on diagnosis and treatment of ALI in pregnant and postpartum patients were included regardless of language or study design. Outcomes of interest included type of treatment for ALI (open and endovascular), morbidity, and mortality.

Results: Fourteen manuscripts of 6222 references were included with a total of 14 patients. The median age of patients was 31.5 years. Embolism, present in eight (57%) patients, was slightly more common than thrombosis. All patients had a pregnancy complication or concomitant medical condition that might have predisposed to arterial occlusion either directly or indirectly by leading to iatrogenic arterial injury; peripartum cardiomyopathy, the most common, occurred in six (43%) patients. Open surgery was the preferred treatment option in 11 (79%) patients, followed by anticoagulation alone. No endovascular procedures were described. One patient underwent major amputation on presentation, and an additional patient required major amputation for recurrent ALI. No deaths occurred. Twelve (86%) patients had complete recovery with no other ALI-associated sequelae.

Conclusions: ALI is rare in pregnant and postpartum women despite their transient physiologic hypercoagulability and is almost uniformly associated with pregnancy complications. Open surgical revascularization or anticoagulation alone appears to have acceptable outcomes as most patients present with embolism or thrombosis without underlying systemic arterial disease.
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http://dx.doi.org/10.1016/j.jvs.2020.04.516DOI Listing
November 2020

Percutaneous Endovascular Repair of a Ruptured Extent III Thoracoabdominal Aortic Aneurysm with Bilateral Large Common Iliac Aneurysms and Aortocaval Fistula.

Ann Vasc Surg 2020 Aug 20;67:563.e1-563.e5. Epub 2020 Mar 20.

Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO.

Ruptured thoracoabdominal aneurysms (rTAAAs) are rare and carry a significant rate of morbidity and mortality. Aortocaval fistula secondary to rTAAA is even more infrequent. We describe an urgent and staged endovascular treatment of a ruptured extent III thoracoabdominal aortic aneurysm with an aortocaval fistula by performing vena cava stenting to treat aortocaval fistula as a damage control maneuver prior to transfer and subsequent TAAA repair with a physician-modified endograft at a quaternary level hospital.
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http://dx.doi.org/10.1016/j.avsg.2020.02.032DOI Listing
August 2020

A systematic review of outcomes of upper extremity access for fenestrated and branched endovascular aortic repair.

J Vasc Surg 2020 05 15;71(5):1763-1770.e2. Epub 2019 Nov 15.

Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany.

Objective: Upper extremity access (UEA) is an important component of complex fenestrated and branched endovascular aneurysm repair (F/BEVAR). Open and percutaneous UEA approaches have been reported during these procedures. The aim of this review was to assess the outcomes of UEA done to facilitate F/BEVAR.

Methods: A systematic review of studies focusing on upper extremity arterial access during F/BEVAR was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Three databases including PubMed MEDLINE, Embase, and Cochrane Library were queried. Outcomes of interest included UEA-related and other unrelated early and late morbidity and mortality, such as arterial occlusion, neurologic deficit, bleeding complications, and stroke, in patients undergoing UEA during F/BEVAR.

Results: Five full-text manuscripts and one abstract met criteria to be included, accounting for a total of 495 patients. The median age of patients who underwent UEA during F/BEVAR was 73.4 years. Predominantly male patients (371 [74.9%]) were treated. Indications for F/BEVAR were thoracoabdominal aortic aneurysms in 325 (65.6%), pararenal aneurysms in 96 (19.4%), juxtarenal aneurysms in 44 (8.9%), and suprarenal aortic aneurysms in 30 (6.1%). Axillary conduits were created in 29 (5.8%) patients. A total of 41 (8.2%) UEA-related complications were reported. Of those 41 complications, 17 (41.5%) were access bleeding, 10 (24.4%) were ischemic strokes, 7 (17.1%) were arterial occlusions, 4 (9.7%) were upper extremity neurologic deficits, 2 (4.9%) were arterial stenoses, and 1 (2.4%) was pseudoaneurysm. UEA-related complications were reported in 15 of 56 (26.8%) patients undergoing percutaneous UEA and 26 of 439 (5.9%) undergoing open UEA (P < .001).

Conclusions: The overall complication rate associated with UEA during F/BEVAR is low, with 2% stroke rate reported. The percutaneous approach showed a higher UEA-related complication rate compared with open UEA. More studies on percutaneous UEA and randomized studies comparing open vs percutaneous UEA during F/BEVAR are warranted to determine the safest and most efficient UEA approach strategy during complex aortic procedures.
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http://dx.doi.org/10.1016/j.jvs.2019.09.028DOI Listing
May 2020

Are Risks Reduced by Delaying Thoracic Endovascular Aneurysm Repair in Patients with Acute Type B Dissection: Who Can Wait?

Eur J Vasc Endovasc Surg 2019 Nov 26;58(5):639-640. Epub 2019 Sep 26.

University Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany.

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http://dx.doi.org/10.1016/j.ejvs.2019.07.020DOI Listing
November 2019

Mortality in open abdominal aortic surgery in patients with morbid obesity.

Surg Obes Relat Dis 2019 Jun 4;15(6):958-963. Epub 2019 Apr 4.

Department of Surgery, College of Medicine, University of Oklahoma, Tulsa, Oklahoma.

Background: Open abdominal aortic surgery is among procedures with high morbidity and mortality. Adverse postoperative complications may be more common in morbidly obese patients.

Objectives: This study compared the outcomes of open abdominal aortic surgeries in patients with and without morbid obesity.

Setting: A retrospective analysis of 2007-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.

Methods: We included patients who underwent open abdominal aortic aneurysm (AAA) repair or open aorta-iliac-femoral (AIF) bypass. Demographic factors, morbid obesity, co-morbidities, and emergent versus elective surgery were considered for univariate and multivariate analyses.

Results: A total of 29,340 patients (13,443 AAA repair and 15,897 AIF bypass) were included (age 66.3 ± 10.8 years, 65.7% male). The mortality was 9.1% in 536 patients with morbid obesity compared with 7.1% in patients without morbid obesity. Based on multivariate analysis, age, existing co-morbidities, emergent versus elective setting, and morbid obesity were found to be independent predictors of mortality. Patients with morbid obesity had an odds ratio of 3.61 (95% CI, 1.50-8.68; P = .004) for mortality, longer mean length of stay (11.2 versus 9.3 days, P < .001), and higher total hospital charges ($99,500 versus $73,700, P < .001).

Conclusions: Morbid obesity is an independent risk factor of mortality in patients undergoing open AAA repair and AIF bypass. Weight loss strategies should be considered for morbidly obese patients with an anticipation of open abdominal aortic procedures.
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http://dx.doi.org/10.1016/j.soard.2019.03.044DOI Listing
June 2019

Rescue of proximal failure of endovascular abdominal aortic aneurysm repair with standard and fenestrated grafts.

J Cardiovasc Surg (Torino) 2019 Apr 18;60(2):159-166. Epub 2019 Jan 18.

Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany -

Background: This study aimed to assess the outcomes of standard and fenestrated grafts to treat proximal failure of previous endovascular aneurysm repair (EVAR) in a tertiary referral center.

Methods: All patients undergoing elective implantation of a standard or fenestrated graft after proximal failure of a previous EVAR between April 2010-November 2018 were included. Data were collected prospectively.

Results: Fifty procedures were performed in 49 patients (45 male; mean age 74.6±7 years). A fenestrated proximal cuff was used in 24 (48%) cases, a composite bifurcated configuration in 21 (42%) cases, and EVAR in 5 (10%) cases. Technical success was achieved in all 5 EVAR cases and 41 of 45 FEVAR cases (91.1%). Iliac artery access problems due to the presence of the previous graft were encountered in eight (16%) procedures and renal artery catheterization difficulties in grafts with suprarenal fixation in seven (15.6%) procedures. There was one (2%) early death due to retroperitoneal bleeding. Early major complications occurred in three (6%) patients. Median follow-up was 26 months (range 1-77). Late occlusion occurred in two (1.3%) of the 151 targeted vessels. One patient needed permanent dialysis. Nine patients died during follow-up, one (2%) of them aneurysm-related. Ten (20.4%) patients presented with major complications during follow-up of which nine (18.4%) needed reintervention. Estimated freedom from reintervention at 1 and 3 years was 89.3±5.1% and 78.8±7.3%, respectively.

Conclusions: Repair with fenestrated grafts represents a safe and effective treatment option. Increased technical challenges are to be expected due to the previous graft.
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http://dx.doi.org/10.23736/S0021-9509.19.10872-5DOI Listing
April 2019

Concomitant Staple Aneurysmorrhaphy and Flow-Calibrated Arteriovenous Fistula Banding Over a Coronary Dilator to Treat Hand Steal Syndrome.

Vasc Endovascular Surg 2017 Jul 20;51(5):307-311. Epub 2017 Mar 20.

1 Division of Vascular and Endovascular Surgery, The University of Oklahoma School of Community Medicine, Tulsa, OK, USA.

Background: True venous aneurysm formation can occur in patients with arteriovenous fistulas (AVFs) for hemodialysis but association with steal syndrome is uncommon.

Methods: To describe a case of a patient on chronic hemodialysis through a right brachiocephalic fistula, who presents with associated steal syndrome and true arteriovenous access aneurysm.

Results: A 34-year-old female with true AVF aneurysm presented with hand steal syndrome confirmed by noninvasive studies. The patient underwent a successful vein aneurysmorrhaphy with a commercially available stapler device and duplex ultrasound flow-calibrated banding. At 1-year follow-up, she remains pain free and the fistula remains functional with no recurrence of venous aneurysmal degeneration.

Conclusion: The use of a commercially available surgical stapler devices along with flow-calibrated banding guided by duplex ultrasound over a coronary dilator during the same operation is an elegant, efficacious, and a durable alternative for patients with hand steal syndrome and concomitant AVF aneurysms.
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http://dx.doi.org/10.1177/1538574417699140DOI Listing
July 2017

Perception of Chemical Venous Thromboprophylaxis for Oncologic Lung Resections among Thoracic Surgeons.

Ann Vasc Surg 2017 Oct 5;44:299-306. Epub 2017 May 5.

Division of Vascular Surgery, Department of Surgery, The University of Oklahoma, Tulsa, OK.

Background: Controversies on chemical venous thromboembolic (VTE) prophylaxis in patients undergoing lung resection for malignancy exist. The available guidelines on VTE do not specifically address its prophylaxis in patients undergoing oncologic lung resections. The goal of this survey was to evaluate the perception of VTE prophylaxis among thoracic surgeons performing these operations.

Methods: A self-reported online survey was distributed to 267 active members of the General Thoracic Surgical Club between July and September 2015. The survey consisted of 22 questions related to the use of chemical venous thromboprophylaxis in patients undergoing oncologic lung resection and their impact on outcomes.

Results: Fifty-six thoracic surgeons replied to the survey. The majority of these surgeons (57%) perform both open and thoracoscopic surgery for lung cancer. All respondents stated that treatment modality and extent of surgical resection have no influence on their decision to use chemical VTE prophylaxis. Twenty-two (39%) respondents do not use chemical VTE prophylaxis prior to their oncologic lung resections, while the remaining 34 (61%) reported use of anticoagulants prior to them. None of the respondents prescribe extended 30-day VTE prophylaxis to these patients. Forty-nine (87%) respondents believe that chemical VTE prophylaxis is not related to major postoperative bleeding episodes. Forty-five (81%) respondents reported that none of their reoperations for bleeding were secondary to VTE prophylaxis or if it was, that isolated event could be successfully managed nonoperatively.

Conclusions: The majority of thoracic surgeons surveyed believe that chemical VTE prophylaxis is safe and should be used regardless of the magnitude of oncologic lung resections whenever possible. Extended 30-day VTE prophylaxis is not yet used by the survey respondents.
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http://dx.doi.org/10.1016/j.avsg.2017.03.188DOI Listing
October 2017

Variability in leg compression provided by gradient commercial stockings.

J Vasc Surg Venous Lymphat Disord 2015 Oct;3(4):431-437

Department of Surgery, University of Oklahoma College of Medicine, Tulsa, Okla.

Background: Compression stockings are commonly prescribed by physicians for lower extremity edema and venous insufficiency. However, no data are available for clinicians to assess the relative quality of various brands, particularly low-cost generics now available directly to consumers through the Internet. We examined the actual compression provided by gradient stockings from multiple manufacturers.

Methods: A total of 36 class 2 (20-30 mm Hg) men's medium-sized below-knee compression stockings from six different manufacturers (n = 6 of each brand) with approximately the same quality and materials were chosen to be studied. Identifying brand names were removed, and they were randomly and blindly tested by a technician in accordance with accepted industry standards. A calibrated constant rate of extension tensile instrument (Zwick Z010; Zwick Roell, Ulm, Germany) was used, and the tension generated by the stockings at the ankle and calf was measured using minimum, average, and maximum circumference sizes. All measurements were performed in duplicate.

Results: The compression pressures generated by the stockings were almost all within the stated range of 20 to 30 mm Hg at the ankle, but all except one were below 20 mm Hg at the calf. There were also significant differences between manufacturers at both the ankle and the calf (P < .0001). The expected pressure reduction between the two locations varied, but one stocking had only a minimal 2 mm Hg (8%) gradient, which was significantly less than all of the other tested brands and below the recommended 20% to 50% reduction. Cost analysis demonstrated that the discount brands were significantly lower in price but provided absolute compression and pressure gradients similar to those of the more expensive brands.

Conclusions: There is significant variability among stockings, both in the absolute pressures and in the pressure gradients generated from the ankle to the calf, thought to be functionally important for venous flow. The cheaper stockings offered the same degree of compression and pressure gradient as the more expensive brands. These results suggest the need for manufacturing standards in the United States and a revision in labeling requirements to mandate more accurate and complete pressure disclosures.
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http://dx.doi.org/10.1016/j.jvsv.2015.07.001DOI Listing
October 2015

Surgical treatment of varicose veins and venous malformations in Klippel-Trenaunay syndrome.

Phlebology 2016 Apr 17;31(3):209-15. Epub 2015 Mar 17.

Vascular Malformation Clinic, Gonda Vascular Center, Mayo Clinic, Rochester, USA.

Background: Klippel-Trenaunay syndrome (KTS) is a mixed mesenchymal malformation characterised by varicose veins, venous and capillary malformations, and hypertrophy of soft tissue and bone. The purpose of this study was to evaluate the surgical outcomes in KTS patients to provide standards for comparison with endovenous therapy.

Methods: The clinical data of consecutive patient with KTS who underwent open venous surgical treatment between January 1987 and December 2008 were reviewed. Demographics, clinical presentation, operative data, and clinical outcomes were recorded. Follow-up information was obtained from the medical records, mailed questionnaires and phone calls. Descriptive statistics, the Kaplan-Meier method and Log-rank statistics were used where appropriate.

Results: Twenty-seven females and 22 males, (mean age 26.5 years, range 7.7-55.8) were included in this study. All had varicose veins, 36 (73%) had limb hypertrophy, and 33 (67%) had capillary malformations, with two of three clinical features present in all. The most frequent symptom was pain (N = 43, 88%). Forty-nine patients underwent operations on 53 limbs. Stripping of the GSV, small and accessory saphenous and lateral embryonic veins was performed in 17 (32%), 10 (19%), 9 (17%), and 15 (28%) limbs, respectively. Two patients developed deep vein thrombosis, one had pulmonary embolism (PE), and one patient had peroneal nerve palsy. Freedom from disabling pain at 1, 3 and 5 years was 95%, 77% and 59%, respectively, and freedom from secondary procedures was 78% at 3 years, and 74% at 5 years. At the last follow-up visit, the venous clinical severity score had decreased from 9.48 ± 3.27 to 6.07 ± 3.20 (P < 0.001).

Conclusions: In selected symptomatic patients with KT syndrome, open surgical treatment is safe and durable. Three-fourths of the patients remain free of disabling pain at five years, but secondary procedures are required in one-fourth of the patients. These data can serve as standards for comparison of endovenous therapy for KT syndrome.
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http://dx.doi.org/10.1177/0268355515577322DOI Listing
April 2016

A systematic review of treatment of intermittent claudication in the lower extremities.

J Vasc Surg 2015 Mar 23;61(3 Suppl):54S-73S. Epub 2015 Feb 23.

Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, Minn; Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minn. Electronic address:

Background: Peripheral arterial disease is common and is associated with significant morbidity and mortality.

Methods: We conducted a systematic review to identify randomized trials and systematic reviews of patients with intermittent claudication to evaluate surgery, endovascular therapy, and exercise therapy. Outcomes of interest were death, amputation, walking distance, quality of life, measures of blood flow, and cost.

Results: We included eight systematic reviews and 12 trials enrolling 1548 patients. Data on mortality and amputation and on cost-effectiveness were sparse. Compared with medical management, each of the three treatments (surgery, endovascular therapy, and exercise therapy) was associated with improved walking distance, claudication symptoms, and quality of life (high-quality evidence). Evidence supporting superiority of one of the three approaches was limited. However, blood flow parameters improved faster and better with both forms of revascularization compared with exercise or medical management (low- to moderate-quality evidence). Compared with endovascular therapy, open surgery may be associated with longer length of hospital stay and higher complication rate but resulted in more durable patency (moderate-quality evidence).

Conclusions: In patients with claudication, open surgery, endovascular therapy, and exercise therapy were superior to medical management in terms of walking distance and claudication. Choice of therapy should rely on patients' values and preferences, clinical context, and availability of operative expertise.
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http://dx.doi.org/10.1016/j.jvs.2014.12.007DOI Listing
March 2015

A systematic review for the screening for peripheral arterial disease in asymptomatic patients.

J Vasc Surg 2015 Mar 23;61(3 Suppl):42S-53S. Epub 2015 Feb 23.

Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, Minn; Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minn. Electronic address:

Background: Peripheral arterial disease (PAD) is common and associated with significant morbidity and mortality. PAD can be detected through a noninvasive measurement of the ankle-brachial index (ABI).

Methods: We conducted a systematic review of several electronic bibliographic databases for studies that evaluated ABI as a screening test for PAD in asymptomatic individuals. We conducted random-effects meta-analysis, reporting pooled hazard ratios (HRs) when appropriate.

Results: We included 40 individual studies, 2 systematic reviews, and 1 individual-patient data meta-analysis. We found no studies comparing ABI screening with no screening in terms of patient-important outcomes (mortality, amputations). The yield of PAD screening averaged 17% (range, 1%-42%) and was 1% to 4% in lower risk populations. Patients with PAD had higher adjusted risk of all-cause mortality (HR, 2.99; 95% confidence interval, 2.16-4.12) and of cardiovascular mortality (HR, 2.35; 95% confidence interval, 1.91-2.89). Data on benefits, harms, and cost-effectiveness of screening were limited; however, ABI screening was associated with additional prognostic information and risk stratification for heart disease. The overall quality of evidence supporting screening was low.

Conclusions: The current available evidence demonstrates that PAD is common in patients with multiple cardiovascular risk factors and is associated with significant morbidity and mortality, but it does not support the benefit of routine ABI screening.
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http://dx.doi.org/10.1016/j.jvs.2014.12.008DOI Listing
March 2015

Morbidity and mortality after thermal venous ablations.

Int Angiol 2016 Feb 12;35(1):57-61. Epub 2015 Feb 12.

Division of Vascular Surgery, The University of Oklahoma, Tulsa, OK, USA -

Background: The treatment of saphenous vein reflux has evolved over the years with the development of thermal ablation techniques. This study was designed to analyze the complications of endovenous ablation (EVA) using data from an open, voluntary national database.

Methods: We analyzed 349 adverse events of endovenous laser (EVLT) and radiofrequency ablation (RFA) reported in the Manufacturer and User Facility Device Experience (MAUDE) database from January 2000 to June 2012. Outcomes of interest were pulmonary embolism (PE), deep vein thrombosis (DVT), death, and device failures (i.e. broken laser tip, broken sheath).

Results: Two hundred and three (58%) reports were patient-related injuries and the other 146 (42%) device-related failures. More complications were related to RFA compared to EVLT (216 vs. 133 procedures). Thirty (8%) non-fatal PEs and 123 (35%) DVTs were described. There were 7 (2%) periprocedural deaths, all from PE. Of the 135 device failure reports, 41(30%) required surgical intervention. Despite an increasing number of procedures, reported events peaked around 2008 and stabilized since then. Over the past 5 years, the incidence of adverse events reported for EVLT and RFA were 1 and 2 per 10,000 procedures. The complication ratio over the years was <1:2500 for DVT, <1:10,000 for PE, <1:50,000 for death.

Conclusion: EVA has gained high acceptance worldwide but the risks tend to be overlooked. Despite a very low complication rate, mortality has been reported. The complications found in MAUDE represent only a fraction as the majority of the practitioners are not aware of this database. Further investigation by a large national registry is warranted to better define the real magnitude of EVA complications.
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February 2016

The natural history and treatment outcomes of symptomatic ovarian vein thrombosis.

J Vasc Surg Venous Lymphat Disord 2015 Jan 15;3(1):42-7. Epub 2014 Aug 15.

Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, NY.

Background: Information on ovarian vein thrombosis (OVT) is limited to some retrospective studies. The purpose of this prospective study was to evaluate the natural history and treatment outcomes of OVT.

Methods: Patients with documented symptomatic OVT who were treated with anticoagulation and had at least 3 months of follow-up were included. Outcomes of interest were recanalization rates, pain resolution, pelvic congestion syndrome, recurrent deep venous thrombosis (DVT), and mortality. All patients underwent clinical examination and duplex ultrasound; computed tomography venography was selectively performed.

Results: There were 23 women with a mean age of 44 years (range, 23-68 years). Fifteen (65%) right, 5 (22%) left, and 3 (23%) bilateral OVTs were detected. The median follow-up was 27 months (range, 3 months-7 years). The most common presentation was abdominal pain in nine patients (39%), followed by flank pain in six (26%). Two patients (9%) presented with dyspnea due to pulmonary embolism. The most prevalent condition was the puerperium (n = 9; 39%). Complete recanalization occurred in 16 veins (61%), partial recanalization in four veins (15%), and occlusion in six veins (24%) while patients were receiving anticoagulation. Four patients (17%) had lower extremity DVT during follow-up after the interruption of anticoagulation. Three patients (13%) developed pelvic congestion syndrome. All four deaths (17%) were due to cancer-related complications.

Conclusions: Symptomatic OVT is rare. Patients fare well with anticoagulation; complete recanalization occurs in about two thirds of the patients. Recurrent DVT is found in lower extremity veins after the interruption of anticoagulation in 17% of patients; mortality was seen only in cancer patients.
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http://dx.doi.org/10.1016/j.jvsv.2014.07.008DOI Listing
January 2015

Outcomes of blunt thoracic aortic injury in adolescents.

Ann Vasc Surg 2015 Apr 22;29(3):502-10. Epub 2014 Nov 22.

Division of Vascular Surgery, Department of Surgery, Stony Brook University Medical Center, Stony Brook, NY.

Background: Blunt traumatic aortic injury (BTAI) is of very rare occurrence in adolescents. The purpose of our study was to assess the clinical presentation and treatment outcomes of BTAI in this subset of patients.

Methods: We reviewed prospective data of 18 patients who were 20 years or younger with BTAI among 28,000 trauma patients from January 1993 to December 2011. Outcomes of interest were the trends on the type of repair (nonoperative [NOP], open repair [OR], or endovascular treatment [ET]) and the impact of concomitant injuries using the Injury Severity Score (ISS) on early morbidity and mortality.

Results: Thirteen (72%) patients with BTAI were male with a cohort median age of 16 ± 3 years. The mechanism of trauma was car accident in 12 patients, pedestrian struck by car in 5, and motorcycle crash in 1. The total ISS was 46.2 ± 15.3 being the highest score of the thoracic component (4.6 ± 0.6) followed by the head score (4 ± 1.2). Two (11%) patients were pronounced dead in the emergency department and other 2 succumbed within 24 hr from admission. Of those 14 (78%) patients who survived longer than 24 hr, the ISS was significantly lower compared with those pronounced dead earlier (37.8 ± 10.7 vs. 59.6 ± 11.6; P = 0.0009). Ten patients (71%) underwent OR, 3 (17%) ET, and other 2 (28%) patients were treated nonoperatively. The ISS was similar among all 3 treatment groups (OR: 33 ± 8 vs. ET: 53 ± 9 vs. NOP: 51 ± 6; P = nonsignificant). No paraplegia or renal failure was noted in either ET or OR group. In-hospital and overall mortality were 21% and 39%. Of those who survived hospitalization, 8 (73%) patients were discharged home and 3 (27%) to a rehabilitation center.

Conclusions: The incidence of BTAI is very low in adolescents. Mortality rate is considerable even in young patients and it is associated with high ISS and degree of aortic wall disruption. Young patients with BTAI who survive hospitalization have a lower ISS and are often discharged home rather than to a rehabilitation facility.
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http://dx.doi.org/10.1016/j.avsg.2014.10.012DOI Listing
April 2015