Whereas a patent vein graft is important to all vascular surgeons, additional factors should be considered in trying to attain limb salvage for patients with CLI. These factors include intervening surgically before CLI has progressed to a state of gangrene or limited activity and optimizing nutrition, diabetes control, cardiac conditions, and activity level. Revision offers hope for clinical improvement but may be delayed when there is no graft lesion identified. The absence of a graft lesion to revise may also portend amputation despite a patent graft because of nongraft-related factors such as infection. Finally, the experience of a severe (vs mild) adverse event may also result in limb loss despite a patent graft. Systematic efforts to reduce severe adverse events among patients may also lead to increased limb salvage.

Objective Major lower extremity amputation is a common procedure that results in a profound change in a patient's life. We sought to determine the association between social support and outcomes after amputation. We hypothesized that patients with greater social support will have better post amputation outcomes. Methods From November 2011 to May 2013, we conducted a cross-sectional, observational, multicenter study. Social integration was measured by the social integration subset of the Short Form (Craig Handicap Assessment and Reporting Technique (CHART). Systemic social support was assessed by comparing a US and Tanzanian population. Walking function was measured using the 6MWT and quality of life (QoL) was measured using the EQ-5D. Results 102 major lower extremity amputees were recruited. 63 patients were enrolled in the US with a mean age of 58.0. Forty-two (67%) were male. Patients with low social integration were more likely to be unable to ambulate (no walk 39% vs. slow walk 23% vs. fast walk 10%; P=.01) and those with high social integration were more likely to be fast walkers (no walk 10% vs. slow walk 59% vs. fast walk 74%; P=.01). This relationship persisted in a multivariable analysis. Increasing social integration scores were also positively associated with increasing quality of life scores in a multivariable analysis (β .002; SE .0008; P = .02). In comparing the US population with the Tanzanian cohort (39 subjects), there were no significant differences between functional or quality of life outcomes in the systemic social support analysis. Conclusions In the US population, increased social integration is associated with both improved function and quality of life outcomes among major lower extremity amputees. Systemic social support, as measured by comparing the US population with a Tanzanian population, was not associated with improved function or quality of life outcomes. In the US, steps should be taken to identify and aid amputees with poor social integration.

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amputation. The impact of social context is tested by including patients from the US and Tanzania (TNZ).Methods: MLE amputees were recruited from US and TNZ sites in a prospective study. Data collected included demographic, social integration (CHART), walking function (Six Minute Walk Test) and QoL (EQ5D). c 2 and ANOVA tests were used to assess association between social integration and outcomes. Multivariable logistic regression analysis, was performed to assess the role of social context.Results: Of the 90 enrolled patients, 50 (56%) were from the US, 58 (64%) were male, with a mean age of 64.4 years. Patients with high social integration had a trend toward improved function defined by a score of 171 meters or better (36% v 66% v 74%; P ¼ .055) and significantly higher mean EQ5D scores (0.65 v 0.70 v 0.79; P ¼ .021). Findings were more dramatic in the US sub-group for both function (17% v 38% v 74%; P ¼ .008) and QoL (0.52 v 0.58 v 0.79; P ¼ .001). In a multivariate analysis, the TNZ site was not associated with less favorable function (P ¼ .783) or QoL (P ¼ .364).Conclusions: In the US population, increased social integration is associated with both improved function and quality of life outcomes among amputees. This effect is attenuated in TNZ, likely due to differences in social context. Steps should be taken to identify and aid amputees with poor social integration in the US and factors associated with low function elsewhere.

Objective Surgical treatment of acute axillosubclavian vein thrombosis from venous thoracic outlet syndrome (VTOS) traditionally involves first rib resection and scalenectomy (FRRS) followed by interval venography and balloon angioplasty. This approach can lead to an extended need for anticoagulation and a separate anesthesia session. We present outcomes for FRRS with concurrent venography. Methods Retrospective chart review was performed for consecutive patients undergoing FRRS with concurrent venography for VTOS from February 2007 to April 2014. Venography was performed immediately after FRRS with the arm in neutral and provocative positions. The primary outcomes of this study were primary and primary-assisted patency. Secondary outcomes included whether concurrent venography resulted in modification of the procedure, postoperative anticoagulation use, and postoperative complications. Results Thirty patients underwent first rib resection with venography with a mean follow-up time of 24.4 months. The mean age was 29.5 years (range, 17–52 years), and 17 (56.7%) were female. All were maintained on anticoagulation before the procedure. Concurrent venography resulted in modification of the procedure in 28 patients (93.3%). Of these, 27 patients (96.4%) underwent balloon angioplasty and two patients (7.1%) underwent further rib resection. Twenty patients (66.7%) were discharged after the procedure with no anticoagulation. For those receiving postoperative anticoagulation for persistent minor thrombus, median time for anticoagulation duration was 5.0 months (range, 0.8 and 16.7 months). Two patients (6.7%) had postoperative bleeding requiring thoracentesis or video-assisted thoracoscopic evacuation of hemothorax. One patient (3.3%) suffered rethrombosis and was successfully lysed open, resulting in a 2-year subclavian vein (SCV) primary patency of 96.7% and primary-assisted patency of 100%. No patients required reoperation for VTOS, and all reported improvements in symptoms. Three patients (10.0%) later underwent prophylactic first rib resection on the contralateral side for symptoms and SCV stenosis. Conclusions FRRS with concurrent venography is a safe procedure for VTOS that allows effective intraoperative modification of the surgical plan, resulting in excellent patency of the SCV, early cessation of anticoagulation, and durable relief of symptoms.

Right retroperitoneoscopic LDN does not compromise the outcome of transplantation. Surgical complications, long-term graft function and graft survival were comparable in right and left kidneys.

Despite similar preoperative risk factors profiles, patients who were operated on by vascular surgeons had lower mortality, less frequent returns to the operating room, and decreased incidences of postoperative renal failure and cardiac events. These data add weight to the case for further centralization of vascular services.

Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10–707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83–0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17–0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69–0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09–1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation.