Temporary mesenteric venous shunting for portal vein reconstruction: A novel technical adjunct.

Pancreatic resection not infrequently requires portal vein (PV) repair or replacement. PV reconstruction often requires bypass grafting or patch venoplasty, and these grafts and patches require time to thaw or harvest. Mesenteric ischemia and congestion with associated bowel edema may result from prolonged venous occlusion during thawing, harvesting, and reconstructing. Temporary shunting of the mesenteric venous circulation may mitigate these adverse effects. Twenty-one patients were shunted using Argyle shunts during PV reconstruction from 2010 to 2020. Reconstructions in this series consisted of aortic homograft interposition grafts (52%), bovine pericardial patches (38%), internal jugular vein interposition grafts (5%), and internal jugular patches (5%). No intraoperative complications resulted from shunt placement; technical success of PV reconstruction was 100%. Temporary venous shunting during PV reconstruction is safe, technically straightforward, and may serve to decrease the duration of venous mesenteric occlusion.

Long-term outcomes in the smoking claudicant after peripheral vascular interventions.

OBJECTIVE: Emphasis on tobacco cessation, given the urgent and emergent nature of vascular surgery, is less prevalent than standard elective cases such as hernia repairs, cosmetic surgery, and bariatric procedures. The goal of this study is to determine the effect of active smoking on claudicating individuals undergoing peripheral vascular interventions (PVIs). Our goal is to determine if a greater emphasis on education should be placed on smoking cessation in nonurgent cases scheduled through clinic visits and not the Emergency Department. METHODS: This study was performed using the multi-institution de-identified Vascular Quality Initiative/Medicare-linked database (Vascular Implant Surveillance and Interventional Outcomes Network [VISION]). Claudicants who underwent PVI for peripheral arterial occlusive disease between 2004 and 2019 were included in our study. Our final sample consisted of a total of 18,726 patients: 3617 nonsmokers (19.3%) (NSs), 9975 former smokers (53.3%) (FSs), and 5134 current smokers (27.4%) (CSs). We performed propensity score matching on 29 variables (age, gender, race, ethnicity, treatment setting [outpatient or inpatient], obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, prior bypass or PVI, preoperative medications, level of treatment, concomitant endarterectomy, and treatment type [atherectomy, angioplasty, stent]) between NS vs FS and FS vs CS. Outcomes were long-term (5-year) overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS). RESULTS: Propensity score matching resulted in 3160 well-matched pairs of NS and FS and 3750 well-matched pairs of FS and CS. There was no difference between FS and NS in terms of OS (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.82-1.09; P = .43), FR (HR, 0.96; 95% CI, 0.89-1.04; P = .35), or AFS (HR, 0.90; 95% CI, 0.79-1.03; P = .12). However, when compared with CS, we found FS to have a higher OS (HR, 1.18; 95% CI, 1.04-1.33; P = .01), less FR (HR, 0.89; 95% CI, 0.83-0.96; P = .003), and greater AFS (HR, 1.16; 95% CI, 1.03-1.31; P = .01). CONCLUSIONS: This multi-institutional Medicare-linked study looking at elective PVI cases in patients with peripheral artery disease presenting with claudication found that FSs have similar 5-year outcomes in comparison to NSs in terms of OS, FR, and AFS. Additionally, CSs have lower OS and AFS when compared with FSs. Overall, this suggests that smoking claudicants should be highly encouraged and referred to structured smoking cessation programs or even required to stop smoking prior to elective PVI due to the perceived 5-year benefit.

Patients with Prior Exposure to a Combination of Statins & Angiotensin-Converting Enzyme Inhibitors (ACE-Is)/Angiotensin Receptor Blockers (ARBs) Have Better Outcomes after Carotid Revascularization than Patients with Prior Exposure to Statins Alone: A MultiCenter Analysis.

BACKGROUND: Statin use has been studied and confirmed to have a beneficial impact on perioperative carotid endarterectomy (CEA) and carotid artery stenting (CAS) outcomes. The benefits of Angiotensin-converting enzyme inhibitors (ACE-I) in hypertension, ischemic heart disease, heart failure, diabetes mellitus, and renal disease are well-known; however, the impact of continuing or withholding ACE-Is/angiotensin receptor blockers (ARBs) on CEA and CAS outcomes is not addressed well in the literature. This study aimed to evaluate the impact of preoperative statin use combined with ACE-Is/ARBs in patients undergoing CEA or CAS on mortality and morbidity using a multi-institutional database. METHODS: Using the data of all patients who underwent carotid artery revascularization, including CEA, transcarotid artery revascularization, and transfemoral carotid artery stenting from 2016 to 2021 in the Vascular Quality Initiative data, we determined as our primary outcome 30-day mortality/stroke after carotid revascularization based on periop exposure to statins alone, or the combination of statins and ACE-Is/ARBs. Secondary outcomes were postop myocardial infarction and postop congestive heart failure. Poisson regression with robust variance was used to determine postop outcomes comparing the combination of statin and ACE-Is/ARBs group with statins alone group. RESULTS: A total of 131,285 patients were included in the study, with 59,860 (46%) patients receiving statin only, and 71,425 (54%) receiving both statin and ACE-Is/ARBs preoperatively. Both patient groups differed significantly in preop clinical and demographic characteristics. After adjusting for potential confounders, the statins plus ACE-I/ARB group had a 12% lower risk of postop mortality/stroke (Incident Rate Ratio comparing Statin/ACE group to Statins Only group [IRR] 0.88, 95% confidence interval 0.81-0.95, P = 0.001), 18% lower risk of postop congestive heart failure (IRR 0.82, 95% CI 0.68-0.98, P = 0.029), and similar risk of postop myocardial infarction (IRR 1.05 95% confidence interval 0.91-1.20, P = 0.54) compared to the statin-only group. CONCLUSION: Statins combined with ACE-Is/ARBs perioperatively offer better protection compared to statins alone in patients undergoing carotid revascularization surgery. We recommend the continuation of ACE-Is/ARBs use in patients undergoing carotid revascularization, especially if they have concurrent hypertension. Further prospective studies are needed to evaluate the benefit of adding ACE-Is/ARBs.

Perioperative Blood Transfusion Is Associated with Worse 30-Day Mortality and Complications After Thoracic Endovascular Aortic Repair.

BACKGROUND: It is not uncommon for patients requiring vascular surgery, and in particular aortic surgery, to have increased requirements for blood transfusion. However, studies examining the effects of perioperative transfusion for thoracic endovascular aortic repair (TEVAR) are limited. Using large multicenter data, we aimed to study the impact of perioperative blood transfusion on 30-day mortality and complications after TEVAR. METHODS: A total of 9,263 patients who underwent TEVAR were included in this retrospective study from the multicenter Vascular Quality Initiative cohort spanning 2010-2022. We excluded patients who were post-traumatic, anemic (World Health Organization criteria: hemoglobin < 12 g/dl and < 13 g/dl for females and males respectively), who underwent open conversions or presented with ruptured aneurysms. Primary outcomes were 30-day mortality and stroke. Secondary outcomes were postop congestive heart failure (CHF), respiratory complications, spinal cord ischemia (SCI), myocardial infarction (MI) and any postop complications (composite variable). Poisson regression with robust variance was performed to determine the risk of post op outcomes comparing patients who received red blood cells (RBCs) to those who did not. RESULTS: Comparing patients without any transfusion (n = 8,223), perioperative transfusion of 1-3 units (n = 735) was associated with 3-fold increased risk of 30-day mortality (adjusted relative risk [aRR] 3.30, 95% confidence interval [CI] 2.39,4.57, P < 0.001), almost 2-fold increased risk of stroke (aRR 1.98, 95% CI 1.24,3.15, P = 0.004), 2.7-fold increased risk of SCI (aRR 2.66, 95% CI 1.87-3.77, P < 0.001), 3-fold increased risk of MI (aRR 3.40, 95% CI 2.30, 5.03, P < 0.001), 2-fold increased risk of CHF (aRR 2.04, 95% CI 1.09, 3.83, P = 0.03), 3.5-fold increased risk of respiratory complications (aRR 3.49, 95% CI 2.67, 4.56, P < 0.001), and 2-fold increased risk of any postop complication (aRR 2.36, 95% CI 2.04, 2.73, P < 0.001). These effects were even higher in patients transfused 4 or more units (n = 305) than seen in the effects seen in those transfused 1-3 units; comparing each group to patients who received none. CONCLUSIONS: In hemodynamically stable patients undergoing TEVAR for nonemergent/emergent and nontraumatic indications, transfusion of any amount perioperatively is associated with worse 30-day mortality, stroke, SCI, MI, CHF, and respiratory complications. A conservative transfusion approach and multidisciplinary care to identify complications and rescue TEVAR patients who receive any amount of RBCs perioperatively might help improve outcomes. Future studies to understand the mechanisms of outcomes for transfused patients are needed.

Renin-Angiotensin-Aldosterone System Inhibitors Are Associated With Favorable Outcomes Compared to Beta Blockers in Reducing Mortality Following Abdominal Aneurysm Repair.

Background The best medical therapy to control hypertension following abdominal aortic aneurysm repair is yet to be determined. We therefore examined whether treatment with renin-angiotensin-aldosterone system inhibitors (RAASIs) versus beta blockers influenced postoperative and 1-year clinical end points following abdominal aortic aneurysm repair in a Medicare-linked database. Methods and Results All patients with hypertension undergoing endovascular aneurysm repair and open aneurysm repair in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database between 2003 and 2018 were included. Patients were divided into 2 groups based on their preoperative and discharge medications, either RAASIs or beta blockers. Our cohort included 8789 patients, of whom 3523 (40.1%) were on RAASIs, and 5266 (59.9%) were on beta blockers. After propensity score matching, there were 3053 matched pairs of patients in each group. After matching, RAASI use was associated with lower risk of postoperative mortality (odds ratio [OR], 0.3 [95% CI, 0.1-0.6]), myocardial infarction (OR, 0.1 [95% CI, 0.03-0.6]), and nonhome discharge (OR, 0.6 [95% CI, 0.5-0.7]). Before propensity score matching, RAASI use was associated with lower 1-year mortality (hazard ratio [HR], 0.4 [95% CI, 0.4-0.5]) and lower risk of aneurysmal rupture (HR, 0.7 [95% CI, 0.5-0.9]). These results persisted after propensity score matching for mortality (HR, 0.4 [95% CI, 0.4-0.5]) and aneurysmal rupture (HR, 0.7 [95% CI, 0.5-0.9]). Conclusions In this large contemporary retrospective cohort study, RAASI use was associated with favorable postoperative outcomes compared with beta blockers. It was also associated with lower mortality and aneurysmal rupture at 1 year of follow-up.

Vascular Surgery in Low-Income and Middle-Income Countries: A State-of-the-Art Review.

BACKGROUND: Cardiovascular disease (CVD) represents 32% of all global deaths. Studies have shown an increase in CVD prevalence and mortality with the most substantial increase in low-income and middle-income countries (LMICs). Within LMICs, we sought to 1) measure the burden of CVD with respect to aortic aneurysm (AA), ischemic stroke (IS), and peripheral arterial disease (PAD); 2) quantify surgical access to vascular surgery services; and 3) identify challenges and solutions to addressing disparities. METHODS: The Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool was used to assess the global burden of CVD (AA, PAD, IS). Population data were extracted from the World Bank & Workforce data. A literature review was completed through PubMed. RESULTS: The number of deaths attributable to AA, PAD, and IS in LMICs increased by up to 102% between 1990 and 2019. Disability-adjusted life-years (DALYs) lost to AA, PAD, and IS in LMICs also increased by up to 67%. High-income countries (HIC) had a less considerable increase in deaths and DALYs during this time period. There are 101 and 72.7 vascular surgeons per 10 million people in the United States and United Kingdom, respectively. LMICs, such as Morocco, Iran, and South Africa have 10 times less this number. Ethiopia has 0.25 vascular surgeons per 10 million people, 400 times less than the United States. Interventions addressing these global disparities should address infrastructure and financing, data collection and sharing, patient knowledge and beliefs, and workforce development. CONCLUSIONS: Extreme regional discrepancies are evidence at a global scale. Identifying mechanisms to expand the vascular surgical workforce to meet the increasing need for vascular surgical access is imminent.

Long-term outcomes after lower extremity bypass in the actively smoking claudicant.

OBJECTIVE: Smoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is for elective general surgery procedures. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. METHODS: We queried the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 36 clinical variables (age, gender, race, ethnicity, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS). RESULTS: Propensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (HR, 0.93; 95% CI, 0.70-1.24; P = .61), LS (HR, 1.07; 95% CI, 0.63-1.82; P = .80), FR (HR, 0.9; 95% CI,0.71-1.21; P = .59), or AFS (HR, 0.93; 95% CI,0.71-1.22; P = .62). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI,0.94-1.97; P = .11) or FR (HR, 1.02; 95% CI,0.88-1.19; P = .76). However, we did find a significant increase in OS (HR, 1.37; 95% CI,1.15-1.64, P <.001) and AFS (HR, 1.38; 95% CI,1.18-1.62; P < .001) in FS compared with CS. CONCLUSIONS: Claudicants represent a unique nonemergent vascular patient population that may require LEB. Our study found that FS have better OS and AFS when compared with CS. Additionally, FS mimic nonsmokers at 5-year outcomes for OS, LS, FR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before elective LEB procedures in claudicants.

Carotid lesion length independently predicts stroke and death after transcarotid artery revascularization and transfemoral carotid artery stenting.

OBJECTIVES: Prior data from the Carotid Revascularization Endarterectomy vs Stenting Trial suggested that the higher perioperative stroke or death event rate among patients treated with transfemoral carotid artery stenting (TFCAS) appears to be strongly related to the lesion length. Nonetheless, data regarding the impact of lesion length on outcomes of transcarotid artery revascularization (TCAR) with flow reversal are lacking. Herein, we aimed to compare the outcomes of TCAR vs TFCAS stratified by the length of the carotid lesion. METHODS: Our cohort was derived from the Vascular Quality Initiative database for carotid artery stenting between 2016 and 2021. Restricted cubic spline analysis was used to describe the relationship between the primary outcome (in-hospital stroke/death) and the exposure variable (lesion length) in the overall cohort. This relationship was not linear, and knots were identified where significant changes in the slope of the curve occurred. We therefore divided patients based on knot with the most significant inflection into two groups: lesion length <25 mm (short) and lesion length ≥25 mm. Clinically relevant and statistically significant variables on univariable analysis were added to the final logistic regression model clustered by center identifier to study the association between lesion length and in-hospital outcomes stratified by the stent approach. RESULTS: The study cohort included 17,931 TCAR (52.6% with long lesions) and 12,036 TFCAS (53.2% with long lesions) patients. Patients with long lesions had higher rates of being symptomatic among both TCAR (27.2% vs 24.3%, P < .001) and TFCAS (43.5% vs 38.5%, P < .001) and were more likely to undergo general anesthesia in TCAR (84.7% vs 81.9%, P < .001) and TFCAS (21.6% vs 15.8%, P < .001). After adjusting for potential confounders, long carotid lesions were associated with higher odds of stroke, stroke/transient ischemic attack (TIA), and stroke/death compared with short lesions among patients who underwent TCAR or TFCAS. However, when comparing TCAR vs TFCAS outcomes in patients with long lesions, TCAR was found to be associated with a 30% reduction in stroke/TIA (adjusted odds ratio [aOR]: 0.7, 95% confidence interval [CI]: 0.6-0.9, P = .015), stroke (aOR: 0.7, 95% CI: 0.5-0.9, P = .009), and extended length of stay (ELOS) (aOR: 0.7, 95% CI: 0.6-0.8, P < .001). There was also a 40% reduction in the odds of in-hospital stroke/death (aOR: 0.6, 95% CI: 0.5-0.8, P < .001) and a 70% reduction in mortality (aOR: 0.3, 95% CI: 0.2-0.4, P < .001) in TCAR compared with TFCAS. CONCLUSIONS: In this large contemporary retrospective national study, carotid lesion length appears to negatively impact in-hospital outcomes for TCAR and TFCAS. In the presence of lesions longer than 25 mm, TCAR appears to be safer than TFCAS with regard to the risk of in-hospital stroke, stroke/TIA, death, stroke/death, and ELOS. These favorable outcomes seem to confirm the relative advantage of flow reversal compared with distal embolic protection devices in terms of neuroprotection.

Portalvein reconstruction with a cadaveric descending thoracic aortic homograft.

Improvements in chemoradiotherapy have rendered complex pancreatic cancers involving the portal vein (PV) amenable to resection. PV reconstruction (PVR) is an essential component. Various conduits have been proposed; however, the optimal choice remains unknown. Fourteen patients underwent PVR with a cadaveric descending thoracic aortic homograft from 2014 to 2020. The primary diagnosis was pancreatic cancer. The splenic vein was ligated in seven patients (50%). The 30-day and 3-, 12-, and 24-month primary patency rates were 100%, 86%, 76%, and 76%, respectively. We found a cadaveric descending thoracic aortic homograft is an excellent conduit for PVR, given the optimal size, rapidly availability, favorable risk profile, and absence of harvest site complications.

Vascular trainee perceptions of diversity, equity, and inclusion within United States vascular surgery training programs.

OBJECTIVES: Vascular surgery training programs face multiple pressures, including attracting and retaining trainees. Current knowledge of trainees' views with respect to diversity and equity in vascular training programs is limited. We sought to understand United States vascular surgery trainees' perceptions and expectations regarding diversity, equity, and inclusion (DEI). METHODS: The Association of Program Directors in Vascular Surgery designed and administered the Annual Training Survey to specifically address DEI and administered it to all trainees (Integrated Residents/Fellows; n = 637) at 122 institutions in August 2020. RESULTS: Of the 637 vascular trainees, 227 (35%) responded. The respondents included 115 male and 62 female trainees, with 50 not disclosing or not answering the question. The majority of respondents (96.9%) believed their programs incorporated a diverse background of trainees. Of the trainees, 89.8% felt that the faculty were similarly comprised of a diverse background. The majority of respondents (63.6%) felt that their training program was both more diverse and focused on inclusion compared with other training programs at their institution. However, 20% of respondents had experienced discrimination. Seventy-three percent (n = 143) of trainees felt empowered to disagree or engage in a discussion should they observe a faculty member make a disparaging remark about a patient's background/race/gender, although 27% (n = 35) trainees expressed fear of retaliation as a reason to not engage. Trainees view their program director (82.6%), faculty mentor (60.9%), and Graduate Medical Education office (52.7%) as potential resources for support. Overall, 83.7% (n = 160) of trainees believe that their program has been open to discussion of race relations within the medical community. CONCLUSIONS: Trainees are committed to multifaceted diversity and inclusion. The perception of trainees regarding DEI issues within vascular surgery training programs appears to be positive; however, trainees did describe discrimination and gender biases in their institutions. This data has the potential to improve institutional education of faculty and trainees about the multidimensional levels of diversity and increased awareness and incorporation of this philosophy can assist in the recruitment of diverse vascular surgeons.

Effect of routine intracerebral completion angiography on outcomes after transcarotid artery revascularization.

OBJECTIVE: Completion cerebral angiography (CCA) after transcarotid artery revascularization (TCAR) has been used to identify distal embolization after stenting and serve as a measure of intraoperative quality control. Nevertheless, no general evidence has been reported regarding the benefit of performing routine CCA. The aim of the present study was to evaluate the potential risks and benefits of routine CCA. METHODS: We retrospectively reviewed the Vascular Quality Initiative database for TCAR from 2016 to 2021. The patients were divided into two groups: those with no CCA performed and those with CCA performed. The primary outcome was in-hospital stroke or death. The secondary outcomes included stroke, death, myocardial infarction, and a return to the operating room (RTOR). Clinically relevant and statistically significantly variables on univariable analysis were added to a logistic regression model clustered by center identifier. RESULTS: A total of 18,155 patients who had undergone TCAR were identified, of whom 11,607 (63.7%) had undergone routine CCA. The patients with routine CCA were more likely to have contralateral carotid occlusion and to have received general anesthesia. After adjusting for potential confounders, we found no differences in the risk of stroke/death (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.8-1.3; P = .820), stroke/transient ischemic attack (TIA; aOR, 1.00; 95% CI, 0.8-1.3; P = .998), stroke (aOR, 1.1; 95% CI, 0.8-1.4; P = .452), death (aOR, 0.98; 95% CI, 0.6-1.6; P = .953), myocardial infarction (aOR, 0.78; 95% CI, 0.5-1.2; P = .240), or RTOR (aOR, 1.5; 95% CI, 0.6-3.8; P = .412) between patients who had undergone CCA and those who had not. A subanalysis of the patients with new occlusions detected by CCA (69 patients [0.6%]; 19 not treated and 50 treated) indicated a higher risk of stroke/death for the patients with treated new occlusions (aOR, 7.1; 95% CI, 2.9-17.3; P < .001) and stroke/TIA (aOR, 5.8; 95% CI, 2.3-14.7; P < .001) than for the patients who had not undergone CCA. However, no differences were found in stroke/death (aOR, 3.3; 95% CI, 0.37-29.5; P = .283) or stroke/TIA (aOR, 3.1; 95% CI, 0.3-29.4; P = .327) for patients with nontreated new occlusions compared with patients who had not undergone CCA. CONCLUSIONS: In the present retrospective study, routine performance of CCA was not beneficial, with no significant differences in in-hospital stroke or death detected. The detection of new lesions on CCA was rare. Moreover, identifying new occlusions using CCA was associated with higher odds of stroke or death when these new lesions were treated. Further studies are needed to define the etiology of the worse outcomes for patients undergoing intervention for lesions discovered using CCA and delineate the optimal timing for further imaging and intervention.

Endovascular repair of traumatic axillosubclavian artery injuries.

Gun violence reached a 20-year peak in 2020, with the first-line treatment of axillosubclavian vascular injuries (SAVIs) remaining unknown. Traditional open exposure is difficult and exposes patients to iatrogenic venous and brachial plexus injury. The practice of endovascular treatment has been increasing. We performed a retrospective analysis of SAVIs at a level I trauma center. Seven patients were identified. Endovascular repair was performed in five patients. Technical success was 100%. The early results suggest that endovascular treatment of trauma-related SAVIs can be performed safely and effectively. However, complications such as stent thrombosis or occlusion can occur, demonstrating the need for surveillance.

Retrograde Superior Mesenteric Artery Stenting in Case of SMA Shuttering.

This case describes a patient who underwent endovascular repair for an extent V thoracoabdominal aneurysm with planned coverage of the celiac artery. Following deployment of the stent graft, the superior mesenteric artery was shuttered, and the patient subsequently developed signs and symptoms of bowel ischemia. The patient underwent successful retrograde open superior mesenteric artery stenting with resolution of her symptoms. Although retrograde open mesenteric artery stenting (ROMS) has been primarily shown to be effective in acute mesenteric ischemia, this case demonstrates that ROMS can be used as a salvage option for shuttering during endovascular procedures.

Evolution of Late Right Heart Failure With Left Ventricular Assist Devices and Association With Outcomes.

BACKGROUND: A revised definition of right heart failure (RHF) for the Society of Thoracic Surgeons Intermacs database of left ventricular assist devices (LVADs) was introduced in June 2014. OBJECTIVES: The purpose of this study was to determine the prevalence and severity of RHF over time and the association of RHF status at 3 months with 12-month outcomes after LVAD. METHODS: All patients in Society of Thoracic Surgeons Intermacs with follow-up and supported at least 3 months with a continuous flow LVAD implanted between June 2, 2014 and March 31, 2017 without a simultaneous RVAD. RHF was defined as both documentation and manifestations of elevated central venous pressures. RESULTS: There were 6,118 patients included with an incidence of RHF at 3, 6, and 12 months postimplant categorized as mild in 5%, 6%, and 6% and moderate in 5%, 3%, and 3%, respectively. For those with no RHF at 3 months, there was a low incidence of subsequent RHF at 6 and 12 months. The lack of RHF at 3 months, compared with mild and moderate RHF, was associated with a lower 12-month cumulative incidence of mortality (6.9% vs 16.7% vs 28.1%; P < 0.0001) and a lower 12-month cumulative incidence of stroke (7.4% vs 9.5% vs 11.0%; P = 0.0095), gastrointestinal bleeding (14.8% vs 24.2% vs 23.6%; P < 0.0001), and rehospitalization (65.2% vs 73.2% vs 71.2%; P < 0.0001). CONCLUSIONS: In patients surviving 3 months with LVAD support alone, mild or moderate RHF occurred in nearly 1 of 10 patients at 12 months. Patients with late RHF had worse survival and a higher cumulative incidence of major adverse events.

Hepatorenal bypass resulting in dialysis independence in case of acute renal failure.

In the present case report, we have described a patient with bilateral renal artery occlusion resulting in the acute onset of refractory hypertension and renal failure requiring hemodialysis. Endovascular stenting of the renal arteries was not feasible owing to extensive aortic and renal orifice calcification. After consultation with nephrology and medical optimization, the patient underwent unilateral hepatorenal bypass, with subsequent improvement in renal function and sustained freedom from dialysis. Although percutaneous revascularization has become the preferred option for surgical management of renal artery occlusion, the findings from the present case have demonstrated that hepatorenal bypass remains a viable alternative for more complex cases.

Evolving Concepts, Management, and Treatment of Type 1 Endoleaks after Endovascular Aneurysm Repair.

Over the past 20 years, there has been tremendous progress in endovascular aneurysm repair techniques and devices. The application of new third- and fourth-generation devices (from 2003 onward) has led to changes in the incidence and management of endoleaks. This comprehensive review aims to outline the most recent concepts with respect to pathophysiology/risk factors and management of Type 1 endoleaks.

Delayed delivery of endothelial progenitor cell-derived extracellular vesicles via shear thinning gel improves postinfarct hemodynamics.

BACKGROUND: Extracellular vesicles (EVs) are promising therapeutics for cardiovascular disease, but poorly-timed delivery might hinder efficacy. We characterized the time-dependent response to endothelial progenitor cell (EPC)-EVs within an injectable shear-thinning hydrogel (STG+EV) post-myocardial infarction (MI) to identify when an optimal response is achieved. METHODS: The angiogenic effects of prolonged hypoxia on cell response to EPC-EV therapy and EV uptake affinity were tested in vitro. A rat model of acute MI via left anterior descending artery ligation was created and STG+EV was delivered via intramyocardial injections into the infarct border zone at time points corresponding to phases of post-MI inflammation: 0 hours (immediate), 3 hours (acute inflammation), 4 days (proliferative), and 2 weeks (fibrosis). Hemodynamics 4 weeks post-treatment were compared across treatment and control groups (phosphate buffered saline [PBS], shear-thinning gel). Scar thickness and ventricular diameter were assessed histologically. The primary hemodynamic end point was end systolic elastance. The secondary end point was scar thickness. RESULTS: EPC-EVs incubated with chronically versus acutely hypoxic human umbilical vein endothelial cells resulted in a 2.56 ± 0.53 versus 1.65 ± 0.15-fold increase (P = .05) in a number of vascular meshes and higher uptake of EVs over 14 hours. End systolic elastance improved with STG+EV therapy at 4 days (0.54 ± 0.08) versus PBS or shear-thinning gel (0.26 ± 0.03 [P = .02]; 0.23 ± 0.02 [P = .01]). Preservation of ventricular diameter (6.20 ± 0.73 mm vs 8.58 ± 0.38 mm [P = .04]; 9.13 ± 0.25 mm [P = .01]) and scar thickness (0.89 ± 0.05 mm vs 0.62 ± 0.03 mm [P < .0001] and 0.58 ± 0.05 mm [P < .0001]) was significantly greater at 4 days, compared wit PBS and shear-thinning gel controls. CONCLUSIONS: Delivery of STG+EV 4 days post-MI improved left ventricular contractility and preserved global ventricular geometry, compared with controls and immediate therapy post-MI. These findings suggest other cell-derived therapies can be optimized by strategic timing of therapeutic intervention.

Transplant Volume Is Associated With Graft Acceptance Threshold and Center Resource Availability.

BACKGROUND: Heart transplant volume varies significantly among centers. We hypothesized that centers where the transplant team routinely accepts organs previously declined by other centers and where operating room availability is unrestricted have higher transplant volumes. METHODS AND RESULTS: We used the potential transplant recipient sequence number in the United Network for Organ Sharing database as a surrogate for graft acceptance threshold and the number of transplantations occurring on weekends and 8 major holidays as a marker of center resource availability. Centers were classified as low-, medium-, or high-volume if the average annual number of transplants were, respectively, <10, 10-30, or >30 over a 10-year period. From July 12, 2006, to December 31, 2015, 19,054 transplants were performed by 142 centers. There were 59 low-volume centers, 69 medium-volume centers, and 14 high-volume centers with median potential transplant recipient sequence numbers for transplanted candidates of 7 (interquartile range 3-11), 7 (5-10), and 15 (7-40), respectively (P = .002). The median proportion of off-hours transplantations performed by medium-volume centers was 28% (25%-31%) compared with 32% (29%-33%) by high-volume centers (P = .009). Five-year survival was equivalent among all centers (P = .053). CONCLUSIONS: Transplants for candidates with high sequence numbers and unrestricted operating room availability are associated with increased center volume without sacrificing post-transplantation survival.

Better With Time: An Economic Assessment of Long-Term Mechanical Circulatory Support in a Population Surviving at Least 1 Year with a Left Ventricular Assist Device.

This study aims to identify the major components of left ventricular assist device (LVAD)-related costs in a population on long-term mechanical circulatory support to gain insight into opportunities for improvements in quality, safety, and efficiency of care for end-stage heart failure patients. This was a single institution, retrospective cost analysis of patients who received a Heartmate II or HeartWare LVAD between November 2005 and October 2015. Payments for hospitalization for device implantation and subsequent readmissions were represented as the institution's 2015 Medicare reimbursement rate. The incidence, average Medicare reimbursement, and length of stay of readmissions were analyzed for the first year postimplant. A full year of LVAD-related hospitalizations in patients surviving ≥12 months, has a median Medicare reimbursement of $247,208. The most common complications related to ventricular assist devices were gastrointestinal bleeding, driveline infection, stroke, and pump thrombosis. Over 90% of total costs were incurred during the initial hospitalization. Seventy-five percent of first-time readmissions occurred within the first 4 months post discharge. Intensive care unit costs accounted for the single largest cost category during readmissions for all of the 4 most common complications. The trends demonstrated suggest that longer lengths of LVAD support in appropriately selected patients results in progressively decreasing cost-per-month up to 12 months, given the large upfront cost of device implantation and relatively modest additional costs of readmissions. This analysis emphasizes the importance of devices with improved complication profiles and clinical protocols to reduce unnecessary intensive care unit stays to increase the cost effectiveness of long-term ventricular assist device therapy.

Natural History of Nonoperative Management of Grade II Blunt Thoracic Aortic Injury.

BACKGROUND: The morbidity and mortality of thoracic blunt aortic injury (BAI) has been both diminished and revolutionized by the advent of endovascular repair. Nevertheless, the question remains as to what severity of injury requires endovascular repair. We therefore conducted a retrospective analysis of our experience with nonoperative grade II BAI of the thoracic aorta. METHODS: The records of patients with BAI from 2007 to 2017 at a Level I trauma center were retrospectively reviewed. Images were reviewed and graded by a radiologist according to the Society of Vascular Surgery Guidelines (grade I-IV). Demographics, injury severity, and outcomes were recorded. RESULTS: We identified 111 patients with BAI. Of these, 15 were deemed grade II injuries and were managed nonoperatively. Mean patient age was 45 ± 21 years; 60% of patients were male. The mean injury severity scale was 36 ± 13. No patients had progression of BAI to a more severe grade requiring intervention. Until now, the survival rate is 86.7% with a mean follow-up of 69 months (range 7-138). CONCLUSIONS: Within the grade II BAI cohort, injury progression did not occur, nor were any operative interventions performed. We conclude that grade II BAI can be managed nonoperatively. However, given that progression of the BAI is possible, follow-up aortic imaging is encouraged as well as appropriate blood pressure control and exercise restriction.