Seminars In Vascular Surgery[JOURNAL]
Sun
200 papers
Entrustable professional activity assessments in vascular surgery training.
Weaver ML, Smith BK
Semin Vasc Surg · 2025 Jun · PMID 40523702 · Publisher ↗
Entrustable professional activity (EPA) assessments are an assessment tool designed to integrate multiple competencies and subcompetencies across all clinical settings and phases of care. These assessments are important...
Entrustable professional activity (EPA) assessments are an assessment tool designed to integrate multiple competencies and subcompetencies across all clinical settings and phases of care. These assessments are important in the shift toward competency-based medical education, as they allow for holistic assessment of the core competencies expected of vascular surgery trainees preparing for independent practice. This manuscript serves to describe the process by which vascular surgery EPAs were developed and implemented nationally in a pilot study, and outlines training challenges addressed by EPA implementation, as well as future directions for EPA development and use.
Autonomy, entrustment, self-efficacy, and decision-making: The current state of training independent surgeons.
Kariya C, Boutrous M, Amankwah KS
Semin Vasc Surg · 2025 Jun · PMID 40523701 · Publisher ↗
Operative autonomy, entrustment, self-efficacy, and decision-making are fundamental aspects of surgical resident education. Over the past few decades, trainee operative autonomy in surgical subspecialties has been declin...
Operative autonomy, entrustment, self-efficacy, and decision-making are fundamental aspects of surgical resident education. Over the past few decades, trainee operative autonomy in surgical subspecialties has been declining. Most retrospective studies evaluating clinical outcomes with increasing levels of trainee independence have found no significant rise in patient morbidity and mortality. To provide more autonomy, attendings assess their relationship with the trainee, along with the trainee's skill level, the complexity of the case, and their own confidence. Identified barriers include a desire for efficiency and expectations from patients and the hospital that the procedure be performed by the attending. Consequently, trainees can enhance their self-efficacy by fostering a relationship with the attending, demonstrating clinical competence to encourage the delegation of clinical responsibilities, and adapting to the attending's teaching style. Techniques to improve autonomy include longitudinal evaluations of trainee independence with a variety of teaching applications and role reversal. It is essential for patients, hospital administrators, and legislators to recognize the significance of demonstrating operative independence during training to cultivate competent, self-sufficient surgeons.
Assessment in the era of competency-based surgical education.
Mitchell EL
Semin Vasc Surg · 2025 Jun · PMID 40523700 · Publisher ↗
Competency-based medical education (CBME) has emerged as a transformative approach to medical and surgical training. Competency-based assessments (CBAs) are assessments associated with a CBME curricula, and drive CBME cu...
Competency-based medical education (CBME) has emerged as a transformative approach to medical and surgical training. Competency-based assessments (CBAs) are assessments associated with a CBME curricula, and drive CBME curricula administration, implementation, and development. This review article provides an overview of CBME, the educational theory behind its underlying principles, and evolving implementation strategies in the United States. The key foundational concepts related to assessment in the era of CBME are discussed, beginning with an historical overview, followed by definitions and rationale for the adoption of differing CBA frameworks for surgical training, and terminating in the current state of CBAs for surgical training in the United States. Finally, the strengths and challenges of CBAs are discussed.
Diabetes-Related Extremity Amputation Depression and Distress (DREADD): A Multimethod Study.
Brooks LM, Brooks BM, Arp AS … +7 more , Dove CR, Rogers LC, Michel R, Clinton V, Labovitz J, Brooks BM, Armstrong DG
Semin Vasc Surg · 2025 Mar · PMID 40086927 · Publisher ↗
Of the roughly 38 million people diagnosed with type 2 diabetes mellitus in the United States, up to 34% will develop a diabetic foot ulcer at some point, up to 75% of those who develop an ulcer will experience recurrent...
Of the roughly 38 million people diagnosed with type 2 diabetes mellitus in the United States, up to 34% will develop a diabetic foot ulcer at some point, up to 75% of those who develop an ulcer will experience recurrent ulcers, and approximately 18% of patients with a diabetic foot ulcer will undergo lower-limb amputation. The aim of this study was to determine whether depressive symptoms change after a minor, nontraumatic amputation. We conducted a multimethod study consisting of semi-structured interviews (n = 12) and a retrospective cohort (n = 20) of patients with type 2 diabetes mellitus who underwent a nontraumatic, minor amputation of a single toe (partial or total) or partial ray resection. Patient Health Questionnaire-9 (PHQ-9) scores were noted before and after surgery within 30 days of each other. The Wilcoxon matched pairs signed rank test was used to determine differences in the PHQ-9 scores before amputation and after amputation. Of the 20 patients in the retrospective cohort, 90% (18 of 20) had higher PHQ-9 scores within 30 days of amputation. Mean PHQ-9 scores were 3.65 and 12.35 before and after amputation, respectively (a difference of 8.7; P = .0001). Diabetes-related extremity amputation depression and distress is a potentially dangerous complication of diabetes mellitus. Nontraumatic amputations can be a traumatic experience for patients. Surgeons should screen their patients with type 2 diabetes mellitus before and after any (minor or major) nontraumatic amputation and make the appropriate referral, if necessary. Sufficient evidence exists in the literature to warrant the inclusion of psychiatrists and other mental health clinicians in multidisciplinary limb preservation teams.
Diabetic foot infections: Questions for an infectious disease consultant.
Nauriyal V, Byers K
Semin Vasc Surg · 2025 Mar · PMID 40086926 · Publisher ↗
Diabetic foot infection can lead to limb amputation in approximately 17% of affected patients. Given the complex pathophysiology associated with diabetic foot infection, the goal of limb preservation is best achieved wit...
Diabetic foot infection can lead to limb amputation in approximately 17% of affected patients. Given the complex pathophysiology associated with diabetic foot infection, the goal of limb preservation is best achieved with a multidisciplinary approach and a team of providers including infectious disease consultants. However, these infections often affect populations living in nonmetropolitan areas, where access to an infectious disease physician may be limited. It may fall on the surgeons and primary care providers to not only diagnose infections early, including osteomyelitis, but also facilitate prompt, appropriate antibiotic management. The decision to treat with antibiotics alone versus surgery, choice of antibiotic, route of administration, and duration of treatment are complicated concepts that require a patient-specific approach. In addition, use of oral antibiotics and long-acting lipoglycopeptides has gained prominence and offers an alternate solution to the tedious, resource-intense process of outpatient intravenous antibiotic treatment. The goal of this article is to outline and address diagnostic and management questions that would be posed to an infectious disease consultant. The responses would include a literature review of current management concepts and highlights from the 2023 Infectious Disease Society of America and International Working Group on the Diabetic Foot guidelines.
Charcot neuroarthropathy: Surgical and conservative treatment approaches.
Hurst M, Shin L
Semin Vasc Surg · 2025 Mar · PMID 40086925 · Publisher ↗
Charcot neuroarthropathy (CN) is an inflammatory condition affecting the joints of patients with peripheral neuropathy; its prevalence is as high as 7.5%. It is commonly seen in patients with diabetes and poses a signifi...
Charcot neuroarthropathy (CN) is an inflammatory condition affecting the joints of patients with peripheral neuropathy; its prevalence is as high as 7.5%. It is commonly seen in patients with diabetes and poses a significant public health burden. CN often leads to severe morbidity, with complications including ulcerations, infections, and lower extremity amputations, and a 5-year mortality rate of 29.0%. The etiology of this condition is a combination of inflammation, neurotrauma, and altered bone metabolism, necessitating early identification and accurate diagnosis through clinical evaluation and imaging studies. Conservative management, particularly total contact casting, plays a pivotal role in managing midfoot ulcers, demonstrating success in reducing plantar pressure and promoting ulcer healing. Surgical interventions are aimed to stabilize affected joints through techniques like arthrodesis and osteotomy and creating a plantigrade foot. Reconstructive options, including external and internal fixation, play a crucial role in the healing process. Postoperative management, including rehabilitation, is vital for successful outcomes, with surgical success rates varying based on procedures. CN is often misdiagnosed as gout, deep vein thrombosis, cellulitis, or infection, and diagnosis is often delayed in the acute care setting. Early diagnosis and intervention can significantly improve outcomes for these patients.
The role of flaps in preventing lower extremity amputations.
Felder JM, Nageeb E, Rocha I … +3 more , Qasawa R, Moltaji S, Fuse Y
Semin Vasc Surg · 2025 Mar · PMID 40086924 · Publisher ↗
The increasing prevalence of chronic limb-threatening ischemia and diabetes mellitus has led to a surge in lower extremity amputations, driven by the combination of peripheral arterial disease and extensive wounds. Altho...
The increasing prevalence of chronic limb-threatening ischemia and diabetes mellitus has led to a surge in lower extremity amputations, driven by the combination of peripheral arterial disease and extensive wounds. Although revascularization often addresses ischemia, severe wounds pose a significant risk of amputation. Flaps, which involve the transfer of vascularized tissue, can provide immediate closure of complex wounds, particularly those involving bone or tendon exposure, where skin grafts are insufficient. Flap reconstruction of wounds can prevent amputation in cases when revascularization alone would not, but these complex efforts require close collaboration between vascular and plastic surgeons. Despite their potential to prevent amputations, flaps are underused in vascular surgery due to limited availability and expertise, particularly in complex cases involving diabetes and peripheral vascular disease. There are also socioeconomic and reimbursement challenges that limit interest on the part of plastic surgeons. This article explores the principles, techniques, and challenges of flap reconstruction in lower extremity limb salvage, emphasizing the need for multidisciplinary care.
Fundamentals of wound care for amputation prevention.
Moschiar Almeida B, Evans R, Kayssi A
Semin Vasc Surg · 2025 Mar · PMID 40086923 · Publisher ↗
The initial skin breakdown and subsequent healing processes are complex and influenced by various parameters, including systemic factors, infectious bioburden, and perfusion. Vascular wounds comprise inadequate inflow (d...
The initial skin breakdown and subsequent healing processes are complex and influenced by various parameters, including systemic factors, infectious bioburden, and perfusion. Vascular wounds comprise inadequate inflow (due to peripheral artery disease), microvascular damage (result of diabetes mellitus), or vasoconstriction. Normal healing of acute wounds occurs in a sequence of defined stages; however, if a dysregulated inflammatory state ensues, it is classified as chronic. Both chronic and vascular wounds carry an increased risk of amputation. Therefore, holistic wound care is crucial in preventing limb loss. This review outlines a systematic approach to wound assessment and examines the latest recommendations for managing vascular wounds, focusing on strategies for preventing amputations.
Percutaneous approach to deep vein arterialization for the "no-option" chronic limb-threatening ischemia patient.
Rice JR, Chatman BC, Genovese EA
Semin Vasc Surg · 2025 Mar · PMID 40086922 · Publisher ↗
Chronic limb-threatening ischemia is an advanced stage of peripheral artery disease characterized by rest pain or tissue loss. Treatment of patients classified as ``no-option'' CLTI remains particularly challenging, as h...
Chronic limb-threatening ischemia is an advanced stage of peripheral artery disease characterized by rest pain or tissue loss. Treatment of patients classified as ``no-option'' CLTI remains particularly challenging, as historically their primary treatment has been limited to major amputation. Venous arterialization has emerged as a promising alternative in this difficult-to-treat population. Advances in optimized technology and endovascular techniques, particularly deep venous arterialization, have had encouraging outcomes for long-term limb salvage. Successful limb preservation relies on proper patient selection, a compliant patient, and a robust multidisciplinary clinical team to support the complex processes of deep venous arterialization maturation and wound healing. This review will discuss the historical background of venous arterialization, patient selection criteria, and surgical techniques for percutaneous deep venous arterialization, and postoperative management after the index procedure, including wound care, surveillance, and reintervention strategies for successful limb salvage.
A scoping review of limb preservation interventions with primary care providers caring for US Indigenous patients with diabetes and peripheral artery disease.
Homco J, Gehring T, Jackson WL … +6 more , Nsa W, Whitekiller M, Clifton S, Nelson PR, Lesselroth B, Kempe K
Semin Vasc Surg · 2025 Mar · PMID 40086921 · Publisher ↗
Amputation disparities due to diabetes and peripheral artery disease occur among vulnerable and historically mistreated populations. In Oklahoma, some of the highest amputation rates occur in Indigenous residents. Knowin...
Amputation disparities due to diabetes and peripheral artery disease occur among vulnerable and historically mistreated populations. In Oklahoma, some of the highest amputation rates occur in Indigenous residents. Knowing that primary care providers are often the first to tackle prevention and assess at-risk limbs, we sought to understand the historical efforts made by primary care providers in this high-risk population. This scoping review evaluates the literature to summarize prior amputation prevention interventions and their characteristics, including the outcome metrics used among Indigenous populations in the United States. We searched MEDLINE using a combination of Medical Subject Headings and keywords related to amputation, limb preservation, limb salvage, and American Indian and Indigenous health inequities or disparities and ethnicity. We conducted our final search on October 4, 2024, including articles in English and those that focused on primary care practice-based interventions. We excluded case reports, trauma- or oncologic-related amputations, or articles describing interventions not conducted in the United States. We identified 404 articles and 3 fit the review criteria. All interventions were analyses of programs to improve diabetes care. All interventions occurred between 1986 and 2001 and were multilevel in structure. Intervention strategies used included expanded infrastructure, provider and patient education, implementation of clinical workflow and provider metrics, community awareness projects, foot-care expertise and footwear, and field visits. No interventions specifically targeted peripheral artery disease. This scoping review identifies a significant contemporary gap in amputation reduction interventions among Indigenous populations in the United States and highlights multiple areas where interventions may be needed to combat ongoing amputation disparities for a high-risk population.
Institutional toe & flow programs: How and why the teams work.
Naiem AA, Callahan RT, Reyzelman AM … +1 more , Conte MS
Semin Vasc Surg · 2025 Mar · PMID 40086920 · Publisher ↗
Diabetic foot ulcers with or without concomitant chronic limb-threatening ischemia put patients at exceedingly high risk of limb loss and death. The toe & flow model is a multidisciplinary team-based model captained by a...
Diabetic foot ulcers with or without concomitant chronic limb-threatening ischemia put patients at exceedingly high risk of limb loss and death. The toe & flow model is a multidisciplinary team-based model captained by a podiatrist or orthopedic foot and ankle specialist and a vascular specialist, which streamlines treatment for patients with diabetic foot ulcer and chronic limb-threatening ischemia. This model creates a functional ecosystem around it by integrating other medical professionals and community partners. It provides a high standard of care first via community education and engagement. It eliminates barriers to access between it and the community by establishing clear referral pathways. This model uses the best available evidence to create treatment pathways governing the patient trajectory through different stage of disease. Once acute treatment is provided, it aims to consolidate success and disease remission through aggressive surveillance and collaboration with the community. An important aspect of this model is that it collects and reports its outcomes and serves as an educational hub within its region. It ultimately aims to develop national policies and allocate resources to continue to improve. This review sheds light on successes associated with institutional toe & flow programs.
Diabetic foot in primary and tertiary (DEFINITE) care: An efficacious, synergistic and cost-effective multidisciplinary team model for diabetic foot care in Singapore.
Leo WZ, Ge L, Chandrasekar S … +16 more , Tan E, Loh YB, Zhu X, Liew H, Yong E, Chew T, Hoe J, Law C, Lin J, Lim JA, Lingam P, Molina J, Ang G, Sun Y, Lo ZJ, DEFINITE (Diabetic Foot in Primary and Tertiary) Care Team
Semin Vasc Surg · 2025 Mar · PMID 40086919 · Publisher ↗
Diabetic foot ulcers (DFUs) and lower extremity amputations (LEAs) threaten survival and quality of life (QoL) of patients, contributing to healthcare and economic burden. Guidelines advocate for a multidisciplinary team...
Diabetic foot ulcers (DFUs) and lower extremity amputations (LEAs) threaten survival and quality of life (QoL) of patients, contributing to healthcare and economic burden. Guidelines advocate for a multidisciplinary team (MDT) approach, but limited literature exists on cost-effectiveness and collaboration with primary care. We present the outcomes of the Diabetic Foot in Primary and Tertiary (DEFINITE) Care program, an MDT initiative in Singapore across primary and tertiary care. Patients with DFU from June 2020 to 2022 were enrolled. Clinical outcomes encompassed one-year minor and major LEAs, mortality and LEA-free survival rates. Healthcare utilization outcomes included number of admissions, length of stay, and primary care and hospital visits. QoL and Patient Reported Outcome Measures (PROMs) were respectively assessed using the EuroQol Five-Dimensional Questionnaire and Diabetic Foot Ulcer Scale-Short Form. Results from DEFINITE were propensity-score matched against a retrospective cohort. Cost-effectiveness analysis was performed using Markov simulation. Subgroup analyses focused on at-risk populations, including patients without access to MDT clinics or podiatry, appointment defaulters, octogenarians, patients with end-stage renal failure and different primary care locations. Total of 2,798 patients, with a mean age of 65.7 years and majority males (61.4%), were included for analysis. DEFINITE Care patients had higher minor LEA and improved LEA-free survival rates, fewer and shorter hospital admissions, and enhanced QoL and PROMs. DEFINITE Care demonstrated greater cost-effectiveness when compared to traditional care. Outcomes varied among subgroups. DEFINITE Care is an efficacious and cost-effective MDT model which fosters collaboration between primary and tertiary care for diabetic limb salvage.
Best practice offloading treatments for diabetic foot ulcer healing, remission, and better plans for the healing-remission transition.
Lazzarini PA, van Netten JJ
Semin Vasc Surg · 2025 Mar · PMID 40086918 · Publisher ↗
Diabetes-related foot disease is arguably the world's least known major health problem and causes a disease burden larger than most well-known diseases, such as stroke and breast cancer. This burden is driven by people d...
Diabetes-related foot disease is arguably the world's least known major health problem and causes a disease burden larger than most well-known diseases, such as stroke and breast cancer. This burden is driven by people developing more severe stages of foot disease, such as foot ulcers and infections, and with that worsening quality of life. To reduce this burden, we need treatments that prevent more severe stages of foot disease and improve quality of life. Best practice offloading treatments have been found to be arguably the most effective existing treatments to heal and prevent diabetes-related foot ulcers and infections, but can worsen quality of life. Furthermore, high re-ulceration rates still occur with best practice offloading treatments after healing. This may be because of the gap in guideline recommendations on the transition from ulcer healing to ulcer remission when it comes to offloading treatments. In this paper, we review why we need offloading treatments and what are the best offloading treatments recommended by the latest international guidelines for healing and remission. Further, we propose plans for future best practice offloading treatments for the transition from healing-to-remission to help reduce re-ulceration rates and improve longer-term ulcer remission. These plans could be the catalyst for better transitioning patients from first ulcer presentation through healing and into long-term remission, and in turn delivering better quality of life, and lower diabetes-related foot disease burdens on patients, nations, and the globe in future.
On the go with Toe & Flow: Private Clinic Design and Flow.
Li B, Montero-Baker M, Lepow BD
Semin Vasc Surg · 2025 Mar · PMID 40086917 · Publisher ↗
Lower extremity amputation secondary to diabetes and/or peripheral artery disease is a significant health issue globally. Many amputation prevention programs exist in academic settings; however, given the increasing admi...
Lower extremity amputation secondary to diabetes and/or peripheral artery disease is a significant health issue globally. Many amputation prevention programs exist in academic settings; however, given the increasing administrative burdens associated with large institutions, it can be challenging to develop and maintain such programs in the modern era. Private amputation prevention clinics may be a viable alternative, allowing for greater control over services provided and better ability to meet patient needs. HOPE Vascular and Podiatry (https://hcic.io/), a private amputation prevention clinic established in 2023 in Houston, Texas, has successfully integrated a clinical, research, and educational program focused on amputation prevention. Key aspects of this program include a multidisciplinary team consisting of vascular/podiatric surgeons, clinical/administrative staff, and interdisciplinary collaborators. Notable advantages include decentralization of care, improvements in clinician satisfaction, and fewer administrative barriers to providing high-quality care. By identifying and quantifying the need for amputation prevention care in the community, establishing a clear mission, building a minimum viable program, and growing responsibly, there is potential to establish private amputation prevention clinics that provide high-quality, accessible, and personalized care for patients with diabetes and/or peripheral artery disease to improve limb outcomes. In this article, we describe the design and flow of HOPE Vascular and Podiatry, including how the clinic was developed, its mission and values, and ongoing clinical, research, and educational activities. We also share logistical, financial, and operational considerations, and provide lessons learned on how to effectively develop, maintain, and run a successful private amputation prevention clinic.
The role of physical therapy in managing peripheral artery disease and diabetes.
Woelfel SL, Wendland DM
Semin Vasc Surg · 2025 Mar · PMID 40086916 · Publisher ↗
Peripheral artery disease and diabetes mellitus impact millions of adults in the United States and their combined effects are severe, resulting in loss of limb and loss of life. A strong multidisciplinary team is require...
Peripheral artery disease and diabetes mellitus impact millions of adults in the United States and their combined effects are severe, resulting in loss of limb and loss of life. A strong multidisciplinary team is required to comprehensively care for this complicated patient population. As movement specialists, physical therapists are essential members of this team. Many of these patients will benefit from an individualized exercise and mobility prescription for not only disease and wound management but also for safe return to activity once any associated wounds have closed. Specialized care and loading guidance are necessary, especially for the closed but still healing skin. The purpose of this review is to highlight the role of physical therapists as team members in caring for patients with vascular compromise and/or diabetes mellitus. Furthermore, the value added for patient care and outcomes will be emphasized.
In the know with toe and flow.
Kayssi A, Minc S, Armstrong DG
Semin Vasc Surg · 2025 Mar · PMID 40086915 · Full text
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Management of carotid disease in the end-stage renal disease patient.
AbuRahma A, AbuRahma Z
Semin Vasc Surg · 2024 Dec · PMID 39675852 · Publisher ↗
Chronic kidney disease (CKD) has been increasing in incidence as a result of the growing prevalence of diabetes and other risk factors for cardiovascular disease. This study highlights reports related to management of ca...
Chronic kidney disease (CKD) has been increasing in incidence as a result of the growing prevalence of diabetes and other risk factors for cardiovascular disease. This study highlights reports related to management of carotid disease in patients with CKD, with a special emphasis on end-stage renal disease (ESRD). Several earlier studies found that patients with CKD are more likely to die from cardiovascular causes than progress to ESRD requiring dialysis. Data derived from the US Renal Data System showed that the 30-day stroke/death rate was 10% after carotid endarterectomy and 11% after carotid artery stenting in patients on dialysis, with a median postoperative survival of 2.5 years. However, these data were representative of a patient cohort from 2005 to 2008. In the past 2 decades, significant life expectancy gains have been noted for patients with ESRD. Recent studies reported adjusted mortality has decreased by 20% in patients on hemodialysis and 29% in patients who underwent transplantation. In addition, recent studies have found that among patients with CKD, carotid endarterectomy and transcarotid artery revascularization had stroke/death rates of <2% for asymptomatic patients and <3% for symptomatic patients. Based on studies published to date, the risk of carotid intervention, whether carotid endarterectomy or stenting, specifically transcarotid artery revascularization, can be justified for carefully selected symptomatic patients with severe CKD with acceptable operative risk and good long-term life expectancy. However, patients with asymptomatic carotid disease and severe CKD, specifically ESRD, should be offered best optimal medical therapy unless life expectancy exceeds what has been recommended by recent Society for Vascular Surgery carotid guidelines.
The effects of hemodialysis on the cardiovascular system.
Pallister ZS, Chung J
Semin Vasc Surg · 2024 Dec · PMID 39675851 · Publisher ↗
Chronic kidney disease and dialysis-dependent end-stage renal disease are increasing in prevalence in the United States. The costs associated with end-stage renal disease management comprise approximately 1% of the feder...
Chronic kidney disease and dialysis-dependent end-stage renal disease are increasing in prevalence in the United States. The costs associated with end-stage renal disease management comprise approximately 1% of the federal government's annual budget. Chronic kidney disease and end-stage renal disease cause significant derangements of the cardiac and vascular system. Pathophysiologic hallmarks include alterations of the renin-angiotensin system, chronically increased sympathetic tone, calcium and phosphate imbalance, pro-inflammatory cytokine release, and uremic toxin accumulation. This results in several pathologies specific to the cardiac and vascular systems, which will each be reviewed separately herein.
Effects of dialysis on peripheral arterial disease.
Liebscher SC, Bertges DJ
Semin Vasc Surg · 2024 Dec · PMID 39675850 · Publisher ↗
End-stage renal disease is an independent risk factor for the development of peripheral arterial disease, with considerably worse outcomes in patients with concomitant diseases. It is important to realize the widespread,...
End-stage renal disease is an independent risk factor for the development of peripheral arterial disease, with considerably worse outcomes in patients with concomitant diseases. It is important to realize the widespread, yet frequently asymptomatic, nature of peripheral arterial disease in patients with end-stage renal disease due to the presence of other comorbidities that decrease activity levels and sensation to allow for early recognition and timely medical management to try and mitigate otherwise poor outcomes. Despite their high risk, properly selected patients derive benefit from revascularization; both open and endovascular approaches provide similar outcomes in terms of overall survival, amputation-free survival, and limb salvage, with perhaps a slight preference toward open repair. This narrative review of the literature evaluates the epidemiology, pathophysiology, outcomes, and management strategies that provide the best possible outcomes for patients with peripheral arterial disease and end-stage renal disease.
Management of dialysis access in the post-transplantation patient.
Lynch L, Chang K, Stutsrim A … +2 more , Sheehan M, Edwards M
Semin Vasc Surg · 2024 Dec · PMID 39675849 · Publisher ↗
Arteriovenous fistula (AVF) is the preferred access for hemodialysis in patients with end-stage renal disease, and arteriovenous grafts are used when AVF creation is not feasible. Post renal transplantation, hemodialysis...
Arteriovenous fistula (AVF) is the preferred access for hemodialysis in patients with end-stage renal disease, and arteriovenous grafts are used when AVF creation is not feasible. Post renal transplantation, hemodialysis may be needed due to delayed graft function or transplantation failure. This review aimed to summarize current evidence on the impact of maintaining versus ligating AV access on renal function and cardiovascular outcomes post transplantation. A comprehensive review of literature was conducted, analyzing studies on the effects of AVF and AV graft maintenance or ligation on renal and cardiovascular outcomes in patients post transplantation. Evidence indicates that maintaining AVF post transplantation is associated with higher estimated glomerular filtration rate and better renal function retention, but poses risks for cardiovascular complications, such as left ventricular hypertrophy. Ligation of AVF is linked to improved cardiovascular outcomes, including reduced N-terminal pro-B-type natriuretic peptide levels, but may lead to a greater decline in estimated glomerular filtration rate. No significant difference in long-term renal allograft survival was observed between maintaining and ligating AV access. The decision to maintain or ligate AV access in patients post renal transplantation should be individualized, considering both renal function preservation and cardiovascular health. Although maintaining AVF may benefit renal function, it poses cardiovascular risks, whereas ligation can mitigate these risks without significantly affecting allograft survival.
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