Impact of gap distance between fenestration and aortic wall on target artery instability following fenestrated-branched endovascular aortic repair.

OBJECTIVE: Target artery (TA) instability has been the most frequent indication for secondary intervention after fenestrated and branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms (TAAAs). The aim of the present study was to evaluate the effect of the gap distance between the endograft reinforced fenestration and TA origin at the aortic wall (fenestration gap [FG]) on target-related outcomes after FB-EVAR. METHODS: The clinical data and imaging studies of 430 patients enrolled in a prospective, nonrandomized study to evaluate FB-EVAR using manufactured stent grafts were reviewed. Of the 430 patients, 340 (79%) had had more than one vessel incorporated by fenestration. The FG was retrospectively measured on postoperative imaging studies and classified into three groups: no gap (FG, 0 mm), FG 1 to 4 mm, and FG ≥5 mm. The primary outcome was freedom from TA instability. The secondary end points included TA-related endoleak, TA secondary intervention, and TA patency. RESULTS: A total of 1558 renal-mesenteric TAs were incorporated by 1104 reinforced fenestrations and 454 directional branches (DBs), with a mean of 3.9 ± 0.5 vessels per patient. The mean FG was 2.8 ± 4.5 mm, with an FG of 0 mm for 646 TAs, 1 to 4 mm for 209 TAs, and ≥5 mm for 249 TAs. An FG of ≥5 mm was associated with significantly lower (P < .001) freedom from TA instability, type Ic or IIIc endoleak, and secondary interventions at 5 years. Compared with DBs, fenestrations with an FG of ≥5 mm had similar primary patency and freedom from TA instability but significantly lower freedom from type Ic or IIIc endoleak (91% ± 2% vs 95% ± 1%; log rank, P = .02) and secondary interventions (87% ± 3% vs 93% ± 2%; log-rank, P = .02) at 5 years. The independent predictors of TA instability included postdissection TAAAs (hazard ratio, 2.5; 95% confidence interval, 1.2-5.4) and FG ≥5 mm (hazard ratio, 1.6; 95% confidence interval, 1.2-1.8). TAs incorporated by reinforced fenestrations had higher primary (99% ± 0.8% vs 97% ± 1.0%; P = .039) and secondary (100% vs 98% ± 1.0%; P = .012) patency rates at 5 years compared with DBs, with the lowest primary patency observed for renal DBs (80% ± 6% vs 92% ± 2%; P = .008). CONCLUSIONS: An FG of ≥5 mm was independently associated with an increased risk of TA instability, type Ic or IIIc endoleaks, and secondary interventions for patients treated by FB-EVAR using fenestrated designs. TAs incorporated by DBs had lower 5-year primary and secondary patency compared with those with reinforced fenestrations, with the lowest 5-year patency of 80% for renal branches. Compared with DBs, fenestrations with an FG of ≥5 mm carried a greater risk of type Ic or IIIc endoleak and secondary interventions. Independent predictors of TA instability included postdissection TAAAs and a greater FG. In contrast, dual antiplatelet therapy and larger TA diameters were protective.

Proximal fixation of endovascular aortic device may not be associated with renal function decline after abdominal aortic aneurysm repair.

OBJECTIVE: Significant debate exists among providers who perform endovascular abdominal aortic aneurysm repair (EVAR) regarding the renal function change between suprarenal (SuF) and infrarenal (InF) fixation devices. The purpose of this study is to review our institution's experience using these devices in terms of renal function. METHODS: This is a retrospective review of all elective EVARs performed within a three-site health system (Florida, Minnesota, and Arizona) during the period of 2000 to 2018. The primary outcome was renal function decline on long-term follow-up depending on the anatomical fixation of the device (SuF vs InF). Secondary outcomes were length of hospitalization (LOH) and progression to hemodialysis. Multivariable regression analysis was performed to test for associations affecting LOH. RESULTS: There were 1130 elective EVARs included in our review. Of those, 670 (59.3%) had SuF and 460 (40.7%) InF. Long-term follow-up was 4.8 ± 3.7 years, and the rate of change in creatinine and estimated glomerular filtration rate (eGFR) were not statistically significant among groups (SuF vs InF). LOH was higher in those individuals with a SuF device (3.4 ± 2.2 vs 2.3 ± 1.0 days; P < .001). Ten patients with chronic kidney disease progressed to hemodialysis at 6.7 ± 3.8 years from EVAR. On Kaplan-Meier analysis, patients with chronic kidney disease with SuF were more likely to progress to hemodialysis (P = .039). On multivariable regression, female sex (Coef, 2.4; 95% confidence interval [CI], 0.17-0.41; P = .02), SuF (Coef, 9.5; 95% CI, 0.11-1.11; P < .0001), and intraoperative blood loss of greater than 150 mL (Coef, 15.4; 95% CI, 0.11-1.76; P < .0001) were predictors of prolonged LOH. CONCLUSIONS: Our three-site, single-institution data indicate that, although the starting eGFR was statistically lower in those individuals undergoing elective EVAR with InF, device fixation type did not affect the creatinine and eGFR on long-term follow-up. However, caution should be exercised at the time of abdominal aortic aneurysm repair in those individuals who already presented with renal dysfunction.

Deep vein thrombosis and pulmonary embolism among hospitalized coronavirus disease 2019-positive patients predicted for higher mortality and prolonged intensive care unit and hospital stays in a multisite healthcare system.

OBJECTIVE: We assessed the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hospitalized patients with coronavirus disease 2019 (COVID-19) compared with that in a matched cohort with similar cardiovascular risk factors and the effects of DVT and PE on the hospital course. METHODS: We performed a retrospective review of prospectively collected data from COVID-19 patients who had been hospitalized from March 11, 2020 to September 4, 2020. The patients were randomly matched in a 1:1 ratio by age, sex, hospital of admission, smoking history, diabetes mellitus, and coronary artery disease with a cohort of patients without COVID-19. The primary end point was the incidence of DVT/PE and the odds of developing DVT/PE using a conditional logistic regression model. The secondary end point was the hospitalization outcomes for COVID-19 patients with and without DVT/PE, including mortality, intensive care unit (ICU) admission, ICU stay, and length of hospitalization (LOH). Multivariable regression analysis was performed to identify the variables associated with mortality, ICU admission, discharge disposition, ICU duration, and LOH. RESULTS: A total of 13,310 patients had tested positive for COVID-19, 915 of whom (6.9%) had been hospitalized across our multisite health care system. The mean age of the hospitalized patients was 60.8 ± 17.0 years, and 396 (43.3%) were women. Of the 915 patients, 82 (9.0%) had had a diagnosis of DVT/PE confirmed by ultrasound examination of the extremities and/or computed tomography angiography of the chest. The odds of presenting with DVT/PE in the setting of COVID-19 infection was greater than that without COVID-19 infection (0.6% [5 of 915] vs 9.0% [82 of 915]; odds ratio [OR], 18; 95% confidence interval [CI], 8.0-51.2; P < .001). The vascular risk factors were not different between the COVID-19 patients with and without DVT/PE. Mortality (P = .02), the need for ICU stay (P < .001), duration of ICU stay (P < .001), and LOH (P < .001) were greater in the DVT/PE cohort than in the cohort without DVT/PE. On multivariable logistic regression analysis, the hemoglobin (OR, 0.71; 95% CI, 0.46-0.95; P = .04) and D-dimer (OR, 1.0; 95% CI, 0.33-1.56; P = .03) levels were associated with higher mortality. Higher activated partial thromboplastin times (OR, 1.1; 95% CI, 1.00-1.12; P = .03) and higher interleukin-6 (IL-6) levels (OR, 1.0; 95% CI, 1.01-1.07; P = .05) were associated with a greater risk of ICU admission. IL-6 (OR, 1.0; 95% CI, 1.00-1.02; P = .05) was associated with a greater risk of rehabilitation placement after discharge. On multivariable gamma regression analysis, hemoglobin (coefficient, -3.0; 95% CI, 0.03-0.08; P = .005) was associated with a prolonged ICU stay, and the activated partial thromboplastin time (coefficient, 2.0; 95% CI, 0.003-0.006; P = .05), international normalized ratio (coefficient, -3.2; 95% CI, 0.06-0.19; P = .002) and IL-6 (coefficient, 2.4; 95% CI, 0.0011-0.0027; P = .02) were associated with a prolonged LOH. CONCLUSIONS: A significantly greater incidence of DVT/PE occurred in hospitalized COVID-19-positive patients compared with a non-COVID-19 cohort matched for cardiovascular risk factors. Patients affected by DVT/PE were more likely to experience greater mortality, to require ICU admission, and experience prolonged ICU stays and LOH compared with COVID-19-positive patients without DVT/PE. Advancements in DVT/PE prevention are needed for patients hospitalized for COVID-19 infection.

Women have similar mortality but higher morbidity than men after elective endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Sex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes. METHODS: All elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications. RESULTS: There were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P < .001), had a lower body mass index (median, 26.1 kg/m2 [IQR, 22.1-31.0 kg/m2] vs 28.3 kg/m2 [IQR, 25.3-31.6 kg/m2]; P < .001 and hematocrit (median, 37.6% [IQR, 33.4%-40.6%] vs 39.4% [IQR, 35.6%-42.6%]; P < .001) and had higher glomerular filtration rate (median, 84.4 mL/min per 1.73m2 [IQR, 62.3-103 mL/min/1.73 m2] vs 51.1 mL/min/1.73 m2 [IQR, 41.8-60.8 mL/min/1.73 m2]; P < .001. Female patients were also more likely to be active smokers (15.3% vs 13.1%; P < .001) and have chronic obstructive pulmonary disease (24.7% vs 15.3%; P = .001). They were less likely to have coronary artery disease (31.6% vs 45.6%; P < .001). Aneurysms in women were slightly smaller in size (median, 54 mm [IQR, 50.0-58.0 mm] vs 55 mm [IQR, 51.0-60.0 mm]; P = .004). In-hospital mortality and mortality at the 3-year follow-up was not significant between female and male patients (0.86% vs 0.17%; P = .11 and 38.4% vs 36.2%; P = .57). However, female patients returned to the operating room with a greater frequency than male patients (3.9% vs 1.4%; P = .011). LOH (mean, 3.4 ± 3.8 days vs 2.5 ± 2.4 days; P < .001) and ICU days (mean, 0.3 ± 2.0 days vs 0.1 ± 0.5 days; P < .001) were longer for female patients. After hospitalization, female patients were discharged to rehabilitation facilities in greater proportion (12.7% vs 3.1%; P < .001) than their male counterparts. On multivariable analysis, female sex was associated with a return to the operating room (odds ratio, 6.4; 95% confidence interval [CI], 1.4-3.5; P = .02), longer LOH (Coef 4.0; 95% CI, 1.0-2.5; P = .00007), more ICU days (Coef 2.8; 95% CI, 1.1-3.0; P = .005), and a greater likelihood of posthospitalization rehabilitation facility placement (odds ratio, 5.8; 95% CI, 1.5-2.4; P = .0001). CONCLUSIONS: Our three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.

Effect of aortic angulation on the outcomes of fenestrated-branched endovascular aortic repair.

OBJECTIVE: To investigate the effect of aortic angulation on the early and midterm outcomes of fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms (PRAA). METHODS: We retrospectively reviewed the data of consecutive patients enrolled in a prospective nonrandomized physician-sponsored investigational device exemption study (2013-2018). The infrarenal, suprarenal, and supraceliac aortic angles were measured on three-dimensional reconstructions of the preoperative computed tomography angiogram; a 45° cutoff was used for the analysis. End points were technical success, freedom from endograft-related complications (defined by type IA/IB/IIIA/IIIB/IIID endoleaks, and limb thrombosis); and freedom from target vessel instability (defined by branch-related death, occlusion, rupture or reintervention for stenosis, endoleak, or disconnection). Cox proportional hazard multivariable regression analyses were preformed to assess impact of covariates. RESULTS: There were 298 patients treated for 102 PRAAs (34%) and 196 TAAAs (66%) (78 extent IV, 118 extent I-III) with 1156 renal-mesenteric vessels incorporated. An angulation of >45° was present in the infrarenal aortic axis in 94 patients (32%), suprarenal axis in 39 (13%), and supraceliac axis in 93 (31%). A supraceliac angle of >45° was more common with extent I-III TAAAs (P = .01). Technical success was 97% and was not significantly related to aortic angulation; the total operating time and fluoroscopy time were significantly longer in patients with any aortic angulation of >45°. Freedom from endograft-related complications was 93% (95% confidence interval [CI], 90%-97%) at 42 months, and was not associated with infrarenal (HR, 1.0; 95% CI, 0.4-2.9; P = .976), suprarenal (HR, 1.7; 95% CI, 0.5-1.8; P = .428), or supraceliac (HR, 0.9; 95% CI, 0.3-2.6; P = .886) aortic angles of >45°. Overall freedom from target vessel instability was 92% (95% CI, 90%-94%) at 42 months. By multivariable analysis, target vessel instability was not affected by an infrarenal angle of >45° (HR, 1.5; 95% CI, 0.9-2.4; P = .135) and a supraceliac angle of >45° (HR, 0.9; 95% CI, 0.5-1.5; P = .627), but was associated with a suprarenal angle of >45° (HR, 5.6; 95% CI, 3.5-9.1; P < .001), even after adjustment for aneurysm extent and type of bridging stent. In this subgroup of patients, the use of directional branch vs fenestration (P = .10) and the type of bridging stent (P = .10) did not significantly impact target vessel instability. CONCLUSIONS: Fenestrated-branched endovascular aneurysm repair can achieve excellent early and midterm results among patients with an aortic angulation of >45°, with no increase in rates of graft-related complications. However, increased aortic angulation was associated with longer operative and fluoroscopy times. The suprarenal aortic angle was the most important determinant of more target vessel events, independent of stent design or which bridging stent was selected.

Telemedicine in vascular surgery during the coronavirus disease-2019 pandemic: A multisite healthcare system experience.

OBJECTIVE: To assess the introduction of telemedicine as an alternative to the traditional face-to-face encounters with vascular surgery patients in the era of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A retrospective review of prospectively collected data on face-to-face and telemedicine interactions was conducted at a multisite health care system from January to August 2020 in vascular surgery patients during the COVID-19 pandemic. The end point is direct patient satisfaction comparison between face-to-face and telemedicine encounters/interactions prior and during the pandemic. RESULTS: There were 6262 patient encounters from January 1, 2020, to August 6, 2020. Of the total encounters, 790 (12.6%) were via telemedicine, which were initiated on March 11, 2020, after the World Health Organization's declaration of the COVID-19 pandemic. These telemedicine encounters were readily adopted and embraced by both the providers and patients and remain popular as an option to patients for all types of visits. Of these patients, 78.7% rated their overall health care experience during face-to-face encounters as very good and 80.6% of patients rated their health care experience during telemedicine encounters as very good (P = .78). CONCLUSIONS: Although the COVID-19 pandemic has produced unprecedented consequences to the practice of medicine and specifically of vascular surgery, our multisite health care system has been able to swiftly adapt and adopt telemedicine technologies for the care of our complex patients. Most important, the high quality of patient-reported satisfaction and health care experience has remained unchanged.

A multi-institutional review of endovenous thermal ablation of the saphenous vein finds male sex and use of anticoagulation are predictors of long-term failure.

BACKGROUND: To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. METHODS: A review of our EVA database (1998-2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. RESULTS: 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46-018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69-0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. CONCLUSION: Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Management of abdominal aortic prosthetic graft and endograft infections. A multidisciplinary update.

Abdominal aortic graft infections (AGIs) occur in 1-5% of aortic prosthetic placements. It can result in limb amputation, pseudo-aneurysm formation, septic emboli, aorto-enteric fistulae, septic shock and death. The most frequently involved pathogens are methicillin-susceptible Staphylococcus aureus, methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococci, followed by Enterobacteriaceae and uncommon bacteria. In case of gut involvement the presence of fungi has to be considered. Computed tomography angiography is actually the gold standard diagnostic imaging but magnetic resonance is a valid alternative. Nuclear medicine imaging is commonly used to improve sensitivity and specificity. Signs and symptoms are often aspecific and blood cultures can be negative, requiring alternative ways to detect the microorganism responsible for infection, such as 16S rRNA gene sequencing and molecular rapid diagnostic tests. Curative surgical intervention is the first choice approach, with in-situ reconstruction providing by far the best outcome and xenopericardial bovine patch as a promising option. For patients unable to undergo major surgery, the outcome of conservative approach remains uncertain but usually provides for life-long suppressive therapy. However, in selected cases an attempt of stopping antibiotic treatment after 3-6 months can be done. Given the difficulty in their management, we performed a review of AGIs, in order to raise awareness on clinical presentation, current available diagnostic tools, prophylaxis, surgical and anti-infective treatment of AGIs.

Underutilization of antiplatelet and statin therapy after postoperative myocardial infarction following vascular surgery.

OBJECTIVE: The objective of this study was to investigate adherence to practice guidelines for antiplatelet and statin use after postoperative myocardial infarction (POMI) and its effect on late mortality following vascular surgery in a multicenter registry. METHODS: Antiplatelet and statin use was examined in 1749 vascular surgery procedures with POMI within the Vascular Quality Initiative (VQI) from 2005 to 2015. Our primary aim was to assess cardiac medication (CM) use at discharge, defined as (1) single antiplatelet therapy (SAPT; aspirin or P2Y12 inhibitor) or dual antiplatelet therapy (DAPT; aspirin and P2Y12 inhibitor) and (2) statin therapy. Long-term mortality in patients with POMI was analyzed on the basis of discharge CM. A proportional hazards model was developed to control for factors associated with mortality. Regional differences in CM use at discharge after POMI were compared. RESULTS: Overall discharge CM use after POMI included aspirin (81%), P2Y12 inhibitor (38%), statin therapy (76%), and combined antiplatelet and statin (74%). At discharge, 26% of patients were not receiving combined antiplatelet and statin therapy. SAPT (50%) was more common than DAPT (35%; P < .001). Patients with POMI undergoing carotid endarterectomy were more likely to be discharged on CM (80%) compared with patients undergoing infrainguinal bypass (78%), suprainguinal bypass (72%), endovascular aneurysm repair (71%), and open abdominal aortic aneurysm repair (59%; P < .001). Patients receiving SAPT or DAPT plus statin therapy had improved survival (79%) compared with those receiving noncombination or no therapy (69%) with mean follow-up of 5.5 years and 4.9 years, respectively (log-rank, P = .001). After adjustment for covariates including preoperative medications, treatment with SAPT or DAPT plus statin at discharge was associated with lower late mortality compared with noncombination or no therapy (hazard ratio, 0.72; 95% confidence interval, 0.56-0.93; P = .01). Regional variation in CM at discharge following POMI was also observed with a range of 33% to 100% (P = .05). CONCLUSIONS: Within the VQI, regional and procedure-specific variation exists in CM regimen after POMI following vascular surgery. Absence of combined antiplatelet and statin therapy at discharge after POMI was associated with higher late mortality and represents an area for quality improvement in the care of these patients.

The natural history of type II endoleaks after endovascular aneurysm repair for ruptured abdominal aortic aneurysm.

OBJECTIVE: The natural history of type II endoleak (T2EL) after endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) remains elusive; as such, treatment guidelines are ill defined. The purpose of this study was to better delineate the natural history of T2EL after EVAR for rAAA in an effort to determine the need for reintervention and optimal surveillance. METHODS: A retrospective record review was conducted of all patients undergoing EVAR for rAAA in two large tertiary care academic vascular centers. Patient demographics, comorbidities, anatomic variables, and operative details were analyzed. Primary outcomes included the presence of T2EL, reintervention, delayed rupture, and aneurysm-related death. RESULTS: EVAR was used to treat rAAA in 56 patients between 2000 and 2013. Mean follow-up of this cohort was 634 days. Completion arteriogram demonstrated T2ELs in 12 patients (21%), and an additional four T2ELs (7%) were found by postoperative computed tomography angiogram that were not identified on the completion angiogram. Body mass index was the only statistically significant variable associated with the development of T2EL (P = .03). Preoperative warfarin use, aortic thrombus burden, and device type did not correlate with T2EL development. Iliolumbar vessels supplied 75% (n = 12) of T2ELs. Of the 14 patients with T2ELs who underwent serial imaging postoperatively, six (43%) sealed spontaneously. Five patients (36%) underwent reintervention for T2EL by way of coil embolization-four in which treatment was initiated by attending preference. One patient was treated for ongoing anemia in the immediate postoperative period. There was no sac expansion, delayed rupture, or graft explantation. CONCLUSIONS: T2ELs after EVAR for rAAA are common and appear to be associated with a benign natural history if left untreated. Although many will spontaneously seal early in the postoperative period, those that remain patent do not appear to increase the risk for sac expansion or delayed rupture or affect patient survival. As such, a conservative approach to treatment of T2ELs in rAAA may be warranted.

Impact of femoropopliteal endovascular interventions on subsequent open bypass.

OBJECTIVE: An endovascular-first approach has been widely adopted as an alternative to surgical bypass in patients who need lower extremity revascularization for femoropopliteal disease. This study evaluated anatomic changes in the extent of bypass and outcomes of open bypass (OBP) surgery after failed endovascular treatment (EVT). METHODS: We reviewed consecutive patients treated by endovascular femoropopliteal revascularization from 2002 to 2012. Patients requiring OBP after failed EVT were analyzed. Blinded investigators reviewed preoperative and postintervention angiographies. The location of the intended distal anastomosis before the endovascular intervention was compared with the open procedure after failed EVT, and results were analyzed for amputation and patency rates. RESULTS: There were 566 patients (322 men [57%]) who underwent 836 endovascular femoropopliteal revascularizations in 665 limbs. Patients were a mean age of 72 ± 11 years. Mean follow-up was 20 months. Indication for revascularization was critical limb ischemia in 33% of patients before the index endovascular procedure. Interventions were performed for de novo lesions in 604 procedures (72%) or restenosis in 232 (28%). TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease A and B lesions were treated in 547 patients (65%). Balloon angioplasty was used in 822 interventions (98%), with primary or secondary stenting using self-expandable stents performed in 367 (44%). Thirty OBPs were required in 566 patients (5.3%) at an average of 15 months after the index EVT. OBP consisted of 6 above-knee, 14 below-knee, and 10 tibial bypasses. Vein and prosthetic conduits were used equally. Location of the distal anastomosis changed to a more distal target in 13 (5 below-knee and 8 tibial) of 30 patients (43%). Median follow-up was 36 months (range, 0.5-104 months), with a primary patency of 66% at 1 year and 46% at 3 years. Of the 30 bypasses, seven patients required reintervention with percutaneous angioplasty (n = 4) and patch angioplasty (n = 3). Five patients required redo bypass after failed endovascular salvage (lysis or angioplasty, or both), and redo bypass was not attempted in two. Eight patients (27%) progressed to major amputation, for an amputation-free survival of 79% at 1 year and 67% at 3 years. CONCLUSIONS: OBP after failed EVT was needed in a minority of patients. A change in the bypass target to a more distal site was identified in nearly half of patients. Although an endovascular-first approach to treating claudication and critical limb ischemia is safe and resulted in few progressing to OBP, poor outcomes of open interventions after EVT can be expected if EVT fails.

Preoperative antiplatelet and statin treatment was not associated with reduced myocardial infarction after high-risk vascular operations in the Vascular Quality Initiative.

OBJECTIVE: Medical management with antiplatelet (AP) and statin therapy is recommended for nearly all patients undergoing vascular surgery to reduce cardiovascular events. We assessed the association between preoperative use of AP and statin medications and postoperative in-hospital myocardial infarction (MI) in patients undergoing high-risk open surgery. METHODS: We studied patients who underwent elective suprainguinal (n = 3039) and infrainguinal (n = 8323) bypass and open infrarenal abdominal aortic aneurysm repair (n = 3007) in the Vascular Quality Initiative (VQI, 2005-2014). We assessed the association between AP or statin use and in-hospital postoperative MI and MI/death. Multivariable logistic analyses were performed to identify the patient, procedure, and preoperative medication factors associated with postoperative MI and MI/death across procedures and patient cardiac risk strata. Secondary end points included bleeding, transfusion, and thrombotic complications. RESULTS: Most patients were taking both AP and statin preoperatively (56% both agents vs 19% AP only, 13% statin only, and 12% neither agent). Use of both agents was more common for patients in the highest cardiac risk stratum (low, 54%; intermediate, 59%; high, 61%; P < .01). Increased cardiac risk was associated with higher MI rates (1.8% vs 3.8% vs 6.5% for low, intermediate, and high risk; P < .01). By univariate analysis, MI rate was paradoxically higher for patients taking both agents (3.7%, vs statin only 2.8%, AP only 2.6%, or neither AP nor statin 2.4%; P = .003). After multivariable adjustment, rates of MI in patients taking preoperative AP only (odds ratio [OR], 0.9; 95% confidence interval [CI], 0.7-1.2) and statin only (OR, 0.8; 95% CI, 0.6-1.2) were not different from those in patients taking either or neither medication (neither agent compared with taking both agents: OR, 1.0; 95% CI, 0.7-1.4; P > .05 for all). Similarly, rates of MI/death were not associated with medication status after multivariable adjustment. Estimated blood loss >1 liter (OR, 2.4; 95% CI, 1.6-3.7; P < .01) and transfusions of 1 or 2 units (OR, 2.5; 95% CI, 2.0-3.3; P < .01) and ≥3 units (OR, 4.0; 95% CI, 3.1-5.3; P < .01) were highly associated with MI, with similar findings related to composite MI/death in multivariable analysis. Rates of blood loss were slightly higher with AP use for all procedures; however, increased transfusions occurred only for infrainguinal bypass with AP use. Rates of reoperation for bleeding, graft thrombosis, or graft revision did not differ by preoperative AP use. CONCLUSIONS: Preoperative AP and statin medications as used in VQI were not associated with the rate of in-hospital MI/death after major open vascular operations. Rather, predicted cardiac risk and operative blood loss were significantly associated with in-hospital MI or MI/death. AP and statin medications appear to be more useful in reducing late mortality than early postoperative MI/death in VQI. However, they were not harmful, so their long-term benefit argues for continued use.

Endograft as Bridge to Open Repair for Ruptured Thoracic Aneurysm in a Pregnant Marfan Patient.

Women with Marfan syndrome are at increased risk of aortic events during pregnancy. We present the case of a ruptured descending thoracic aortic aneurysm in a woman with Marfan syndrome who was 25 weeks pregnant. Emergent intervention was performed using an endovascular repair as a bridge to allow continuation of pregnancy, decreasing fetal morbidity, and allow subsequent later definitive open aortic repair.

Operative management of hepatic artery aneurysms.

OBJECTIVE: Degenerative hepatic artery aneurysms (HAAs) are an uncommon pathologic process. The aim of this study was to evaluate the approach to and outcomes of operative management of HAA with open techniques (OTs) and endovascular techniques (ETs). METHODS: Twenty-one patients who underwent intervention for HAA from January 1, 1992, to January 30, 2015, at a single institution were retrospectively reviewed. Patient presentation, risk factors, and operative approach were reviewed. The primary outcome was operative morbidity and mortality. Secondary outcomes included long-term survival, patency, and need for reintervention. RESULTS: Of the 21 patients, 14 (67%) were men. The mean age of all patients was 66 years (range, 30-85 years), with a mean HAA size of 45 ± 28 mm (12 common hepatic, 5 common and proper hepatic, 3 right hepatic, and 1 accessory left hepatic). Nine patients (43%) had connective tissue disorders. More than half of the patients (63%) had synchronous aneurysms (29% in the aorta, 24% in the splenic and iliac arteries, and 10% in the celiac arteries). Ten patients (48%) were asymptomatic. Right upper quadrant pain was the most common symptom at presentation (43%), followed by transaminitis (5%) and obstructive jaundice (5%). Five patients (24%) presented with rupture (size, 15-40 mm). OT was performed in 17 patients; 4 patients had ET. Fourteen patients (67%) underwent open reconstruction of the common hepatic (n = 10), the common and proper hepatic (n = 2), and the right and left accessory hepatic arteries (n = 1 each). Seven bypasses were performed with saphenous vein, six with Dacron, and one with polytetrafluoroethylene. Endoaneurysmorrhaphy alone, patch, and ligation were performed in one instance each. Postoperative complications occurred in six patients (29%), including hemorrhage, graft thrombosis, common bile duct stricture that required reoperation, duodenal perforation, and enterocutaneous fistula. ET was attempted in five patients; coil embolization was performed in four patients (two of the common and two of the right hepatic arteries). Overall mortality was 14% (6% after elective OT, 40% for emergency OT, 0% for ET). Mean follow-up was 32 ± 46 months. Overall survival was 86% at 5 years. Primary and secondary graft patency was 86% at 5 years. One patient underwent reintervention because of occlusion of saphenous vein graft. CONCLUSIONS: Open repair remains the mainstay treatment for degenerative HAA repairs to preserve arterial flow to the liver, with notable morbidity and mortality, particularly in the setting of rupture. However, coil embolization may be applied safely in select patients with aneurysms not involving the proper hepatic artery if adequate collateral circulation ensures hepatic perfusion.

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

OBJECTIVE: Management of type II endoleaks after endovascular aneurysm repair can be problematic. This study reports our experience with a relatively novel strategy to treat this complication, transcaval coil embolization (TCCE) of the aneurysm sac. METHODS: We reviewed 29 consecutive patients undergoing TCCE from 2010 to 2013. Demographics, operative details, and outcomes were assessed. RESULTS: Since 2006, 29 TCCEs have been performed at our institution in 26 patients for sac expansion from type II endoleaks. Patients were male (83%) and former or current smokers (88%), with an average age of 78 ± 7.1 years. TCCE was performed a mean of 4.2 ± 4 years after initial endovascular aneurysm repair. Endoleaks resulted in a mean sac growth of 1.2 ± 1 cm in diameter and 37% ± 32% by volume. Forty-six percent had prior procedures (5 translumbar, 3 transarterial, 3 transcaval, 1 aortic cuff, and 1 iliac limb extension). Two patients had no flow identified in the aneurysm sac after puncture was successful, and one was found to have a hygroma rather than arterial flow. An additional two patients had ultimate embolization from sac access between the endograft iliac limb and arterial wall after transcaval puncture failed, for a 90% procedural success (83% for transcaval technical success). Mean fluoroscopy time was 27 ± 13 minutes with 29 ± 21 mL of contrast material used and a median of 10 coils per case. Additional adjuncts included thrombin injection (17%), intravascular ultrasound (14%), sac pressure measurements (28%), and on-table integrated computed tomography (17%). Median length of stay was 1 day (range, 0-5 days). There were no procedural adverse events. Reintervention was required in five cases (three repeated TCCEs, two graft relinings). One-year freedom from reintervention was 95%. At a mean 16.5 months of follow-up, 70% experienced no further endoleak and had stable or decreasing sac diameters. There have been no ruptures during follow-up. CONCLUSIONS: In this series, TCCE for treatment of aneurysm enlargement due to type II endoleaks was safe and relatively effective despite prior failed interventions in nearly half of the cases. TCCE is a useful alternative in cases in which the anatomy makes other approaches difficult or impossible.

Surgical treatment of popliteal venous aneurysms.

BACKGROUND: Popliteal venous aneurysms (PVAs) are rare; however, they can lead to pulmonary emboli (PEs) and death. The purpose of this study was to review our institutional management of PVA. METHODS: All patients with PVA undergoing intervention in our institution were identified over a 15-year period (1998-2013). A retrospective review including clinical presentation, modality of diagnosis, surgical treatment, 30-day morbidity and mortality, and follow-up are reported. RESULTS: Five male and 3 female patients with PVA were identified. Mean age was 38.6 years (range, 14-65). Five patients presented with PE; 1 developed PE while on anticoagulation. Two presented with lower extremity pain. Two patients had PVA found incidentally. Diagnosis of PVA was made by duplex ultrasound (US) in 6 patients, physical examination confirmed with duplex US in 1 patient, and magnetic resonance imaging in 1 patient. Mean aneurysm size was 26 mm (range, 20-37). Four were saccular and 4 fusiform. Three PVAs contained thrombus, including 2 patients presenting with PE and 1 with calf pain. Five patients underwent aneurysmectomy with lateral venorrhaphy, and 3 patients had resection of the aneurysm with interposition vein graft. There were no operative or 30-day mortalities. Two patients with vein grafts had early postoperative complications; one developed a hematoma that required operative evacuation and one had thrombosis of the vein graft requiring thrombolysis. Mean follow-up was 26 months with 87.5% primary patency, 100% secondary patency, and no recurrences. CONCLUSIONS: PVAs are rare, but can lead to significant morbidity and death. Based on this small group, aneurysmectomy with lateral venorrhaphy appears to have fewer complications compared with those treated with vein grafts. Overall, operative repair of PVA is safe and recommended in select patients with PVA.

Participation in the Vascular Quality Initiative is associated with improved perioperative medication use, which is associated with longer patient survival.

OBJECTIVE: Medical management (MM) with antiplatelet (AP) and statin therapy is recommended for most patients undergoing vascular surgery and has been advocated by the Vascular Quality Initiative (VQI). We analyzed the effect of VQI participation on perioperative (preoperative and postoperative) MM use over time and the effect of discharge MM on patient survival. METHODS: We studied VQI patients treated with MM preoperatively and at discharge from 2005 to 2014, including all elective carotid endarterectomy/carotid stenting (n = 28,092), suprainguinal/infrainguinal bypass (n = 11,362), peripheral vascular interventions (n = 24,476), open/endovascular abdominal aortic aneurysm repair (n = 13,503), and thoracic endovascular aneurysm repair (n = 702). We examined trends of MM use over time, as well as the effect of duration of VQI participation on MM use. Multivariable logistic regression analysis was performed to identify factors associated with MM use. In addition, the Cox proportional hazards model was used to identify factors associated with 5-year survival. RESULTS: MM with AP and statin preoperatively and postoperatively across VQI centers improved from 55% in 2005 to 68% in 2009, with a subsequent overall decline to 62% by 2014, coincident with many new centers with lower MM rates joining VQI in 2010. Longer center participation in VQI was associated with improved perioperative MM overall. This was also noted across all procedure types, with MM increasing from 47% to 82% for aneurysm repairs and 69% to 83% for carotid procedures from 1 to 12 years of participation in VQI. After multivariable adjustment, centers in VQI ≥3 years were 30% more likely to have patients on MM (odds ratio, 1.3, 95% confidence interval [CI], 1.3-1.4). Importantly, discharge on AP and statin therapy was associated with improved 5-year survival, compared with discharge on neither medication (82% [95% CI, 81%-83%] vs 67% [95% CI, 62%-72%]), and an adjusted hazard ratio for death of 0.6 (95% CI, 0.5-0.7; P < .001). Discharge on a single medication was associated with intermediate survival at 5 years (AP only: 77% [95% CI, 75%-79%]; statin only: 73% [95% CI, 68%-77%]). CONCLUSIONS: These data demonstrate that MM is associated with improved survival after a number of vascular procedures. Importantly, VQI participation improves the use of MM, demonstrating that involvement in an organized quality effort can affect patient outcomes.

The role of thrombolytics in acute and chronic occlusion of the hand.

Distal arm and hand ischemia from vessel thrombosis or embolism remains a difficult clinical challenge. The causes of ischemia are variable and include connective tissue disease, embolism, atherosclerosis, and iatrogenic etiology. Although reports are limited, treatment with catheter-directed thrombolysis has favorable results in cases of acute thrombosis, with most patients (80%) demonstrating improvement. Digital amputation rates are less than 10% and the hand is often salvaged. Bleeding and access-site complications remain prevalent in patients undergoing intra-arterial thrombolysis. This review discusses etiology, treatment approaches, outcomes, and complications when thrombolytic therapy is used for distal arm and hand ischemia.

Improving outcomes for diabetic patients undergoing revascularization for critical limb ischemia: does the quality of outpatient diabetic care matter?

BACKGROUND: Diabetic patients who undergo lower extremity surgical revascularization for critical limb ischemia (CLI) are at high risk for amputation or death, even when their inpatient procedures are successful. We hypothesized that postoperative outcomes might be improved in regions where diabetics with CLI receive more frequent high-quality outpatient care. METHODS: A retrospective cohort study was performed among 172,134 patients with CLI (52% male, 15% black, mean age 76 years) who underwent open and endovascular lower extremity revascularization procedures using Medicare claims (2004-2007), which included 84,653 (49%) beneficiaries who were diabetic. Regional utilization of annual serum cholesterol and hemoglobin A1c testing were used to assess the quality of outpatient diabetic care. We examined relationships between frequency of diabetic testing with amputation-free survival (AFS), major adverse limb events (MALE), and rates of readmission across all US hospital referral regions. RESULTS: There was significant regional variation in annual serum cholesterol and hemoglobin A1c testing across the United States (87% highest quartile vs. 59% lowest quartile, P < 0.01). Compared with the lowest quartile of diabetic testing, diabetic patients undergoing lower extremity revascularization in regions with the highest quartile of diabetic testing had significantly improved AFS (hazards ratio [HR]: 0.94, 95% confidence interval [CI]: 0.90-0.97; P < 0.01) and MALE (HR: 0.92, 95% CI: 0.89-0.96; P < 0.01) persisting up to 2 years after lower extremity revascularization, even after adjusting for procedure type, gender, age, race, and comorbidities. Moreover, the risk of 30-day readmission was significantly reduced in regions with the highest versus lowest quartile of diabetic testing (odds ratio: 0.91, 95% CI: 0.85-0.97; P < 0.01). Nondiabetic patients with CLI, in comparison, did not benefit to the same extent from undergoing revascularization in regions with high-quality outpatient diabetic care. CONCLUSIONS: Diabetic patients undergoing lower extremity revascularization in regions with higher utilization of diabetic care quality measures have significantly better long-term limb salvage and readmission outcomes. Our study underscores the importance of providing optimal outpatient care to diabetics following vascular surgery and outlines a potential strategy for quality improvement in these high-risk patients.