Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning.

OBJECTIVE: Critical thinking and accurate case analysis is difficult to quantify even within the context of routine morbidity and mortality reporting. We designed and implemented a HIPAA-compliant adverse outcome reporting system that collects weekly resident assessments of clinical care across multiple domains (case summary, complications, error analysis, Clavien-Dindo Harm, cognitive bias, standard of care, and ACGME core competencies). We hypothesized that incorporation of this system into the residency program's core curriculum would allow for identification of areas of cognitive weakness or strength and provide a longitudinal evaluation of critical thinking development. DESIGN: A validated, password-protected electronic platform linked to our electronic medical record was used to collect cases weekly in which surgical adverse events occurred. General surgery residents critiqued 1932 cases over a 4-year period from 3 major medical centers within our system. These data were reviewed by teaching faculty, corrected for accuracy and graded utilizing the software's critique algorithm. Grades were emailed to the residents at the time of the review, collected prospectively, stratified, and analyzed by post-graduate year (PGY). Evaluation of the resident scores for each domain and the resultant composite scores allowed for comparison of critical thinking skills across post-graduate year (PGY) over time. SETTING: Data was collected from 3 independently ACGME-accredited surgery residency programs over 3 tertiary hospitals within our health system. PARTICIPANTS: General surgery residents in clinical PGY 1-5. RESULTS: Residents scored highest in properly identifying ACGME core competencies and determining Clavien-Dindo scores (p < 0.006) with no improvement in providing accurate and concise clinical summaries. However, residents improved in recording data sufficient to identify error (p < 0.00001). A positive linear trend in median scores for all remaining domains except for cognitive bias was demonstrated (p < 0.001). Senior residents scored significantly higher than junior residents in all domains. Scores > 90% were never achieved. CONCLUSIONS: The use of an electronic standardized critique algorithm in the evaluation and assessment of adverse surgical case outcomes enabled the measure of residents' critical thinking skills. Feedback in the form of teaching faculty-facilitated discussion and emailed grades enhanced adult learning with a steady improvement in performance over PGY. Although residents improved with PGY, the data suggest that further improvement in all categories is possible. Implementing this standardized critique algorithm across PGY allows for evaluation of areas of individual resident weakness vs. strength, progression over time, and comparisons to peers. These data suggest that routine complication reporting may be enhanced as a critical thinking assessment tool and that improvement in critical thinking can be quantified. Incorporation of this platform into M&M conference has the potential to augment executive function and professional identity development.

Contemporary outcomes of initial treatment strategy of endovascular intervention or bypass in patients with critical limb ischemia.

OBJECTIVE: The optimal management for revascularization after critical limb ischemia (CLI) is controversial due to limited studies comparing long-term results of endovascular and open techniques. This study compares long-term outcomes after initial management of CLI via lower extremity bypass (LEB) and percutaneous vascular intervention (PVI). METHODS: This retrospective cohort study investigates outcomes of patients who underwent endovascular or open surgical management for CLI at a single institution from 2013-2018. All patients with diagnosis of CLI were included and separated based on initial therapy of PVI or LEB. Demographic, procedural, and follow-up data were assessed. Primary endpoints included major adverse limb events (MALE), specifically the need for major amputation and reintervention. Secondary endpoints included mortality at 30 days and one year. A multivariable Cox Proportional Hazard regression model was used to assess the relationship between Surgery group and time to MALE/death while controlling for confounding variables. RESULTS: This study identified 338 patients with an initial diagnosis of CLI who underwent either LEB (n = 108, 32%) or PVI (n = 230, 68%). The average age was 71.4, 54.4% were male, 30% were African American, 53.6% were diabetic, and 93.2% had hypertension. Patients who underwent LEB were more predominantly smokers (p = .003) and less predominantly on dialysis at time of surgery (p = .01). Re-intervention rates in the bypass group (11%) were not significantly different than the PVI group (9%; p = .95). In the bypass group, 20 (19%) patients had a major amputation with a median time of 189.5 days compared to 23 (10%) patients at a median time of 113 days in the PVI group; however, this difference was not significant (p = .16). There was no significant difference in 1-year mortality between the LEB (2%) and PVI group (4%; p = .2). The cumulative incidence of MALE/death at 30 days was 4.0% in the bypass group and 3.7% in the PVI group (p = .2). Incidences of MALE/death were 21.1% and 48.5% in the bypass group and 19.7 and 45.9% in the PVI group at one and 2 years, respectively. Intervention type was not found to be significantly associated with MALE/death after controlling for possible confounders (HR = 0.82, p = .43). CONCLUSIONS: In the initial management of CLI, there is no significant difference in long-term outcomes in terms of major amputation, need for reintervention, limb-salvage, and 1-year mortality.

Effect of access site choice on inferior vena cava filter angulation and outcomes.

BACKGROUND: In the present study, we compared the outcomes of inferior vena cava (IVC) filter placement between the femoral vein (FV) and internal jugular (IJ) vein access sites. METHODS: We performed a retrospective study using the Vascular Quality Initiative database to assess patients who had undergone IVC filter placement from 2013 to 2019. The patients were placed into two groups according to the access site location: FV and IJ vein. The FV group included patients with access via the right and left FVs and other leg veins, and the IJ group included patients with access via the right or left IJ vein. The primary outcome was the rate of filter angulation. The secondary outcomes included access site complications such as deep vein thrombosis, hematoma, and bleeding requiring transfusion. RESULTS: Of 13,221 patients, 8214 (63%) had undergone IVC filter placement via FV access and 4789 (37%) via IJ access. The remaining 218 patients had had an unknown access site or were excluded. Within the IJ group, 4696 (98.0%) had undergone access via the right IJ and 93 (2%) via the left IJ. Within the FV (common femoral, femoral, or other infrainguinal veins) group, 7007 (85.3%) had undergone access via the right FV and 1207 (14.6%) via the left FV. The mean patient age was 63 ± 15.9 years, the mean body mass index was 30.9 ± 9.60 kg/m2, and 6788 of the patients were men (52.0%). The most common indication for filter placement was a contraindication to anticoagulation because of a recent or active bleeding episode (30%), followed by planned surgery (22%), new deep vein thrombosis/pulmonary embolism (7%), fall risk (5%), and trauma (4%). Infrarenal filters had been placed in 97.9% of the patients. Univariate analysis identified body mass index and suprarenal placement as independent risk factors for angulation. The final multivariate analysis showed a significant increase in angulation (0.9% vs 0.34%; odds ratio, 1.46; 95% confidence interval, 1.02-2.11; P = .04) and increased access site complications (0.25% vs 0.07%; odds ratio, 2.068; 95% confidence interval, 1.01-4.23; P = .048) in the FV access group. No significant correlation between the access site and retrieval rate was found (P = .9270). CONCLUSIONS: Placement of IVC filters via IJ access showed a lower rate of filter angulation in the IVC and fewer access site complications compared with FV access.

Does Surgeon Experience Correlate with Crowd-Sourced Skill Assessment in Robotic Bariatric Surgery?

BACKGROUND: The Global Evaluative Assessment of Robotic Skills (GEARS) rubric provides a measure of skill in robotic surgery. We hypothesize surgery performed by more experienced operators will be associated with higher GEARS scores. METHOD: Patients undergoing sleeve gastrectomy from 2016 to 2020 were analyzed. Three groups were defined by time in practice: less than 5, between 5 and 15, and more than 15 years. Continuous variables were compared with ANOVA and multivariable regression was performed. RESULTS: Fourteen operators performing 154 cases were included. More experienced surgeons had higher GEARS scores and shorter operative times. On multivariable regression, operative time (P = 0.027), efficiency (P = .022), depth perception (P = 0.033), and bimanual dexterity (P = 0.047) were associated with experience. CONCLUSIONS: In our video-based assessment (VBA) model, operative time and several GEARS subcomponent scores were associated with surgical experience. Further studies should determine the association between these metrics and surgical outcomes.

Spinal Cord Ischemia following Simultaneous EVAR and TEVAR for Concomitant Thoracic and Abdominal Aortic Aneurysms.

BACKGROUND: In patients with abdominal aortic aneurysms, 10-20% has concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms. METHODS: A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia. RESULTS: Simultaneous EVAR and TEVAR were performed in 25 patients. Median age was 75.0 (interquartile range [IQR], 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and 4 (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR, 52.0-65.0). Infrarenal aortic neck length was 15.0 mm (IQR, 10.0-25.0), and diameter was 27.0 mm (IQR, 24.5-30.0). Median procedure time was 185.0 min (IQR, 117.8-251.3), fluoroscopy time 32.7 min (IQR, 21.8-63.1), and contrast volume 165 mL (IQR, 115.0-207.0). There were 3 (12.0%) Type Ia endoleaks and 3 (12.0%) Type II endoleaks in EVAR's, with 1 (4.0%) Type Ia and 1 (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in 3 (12.0%) patients (1 elective, 2 ruptures). Spinal cord ischemia occurred in 1 (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was 1 (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR, 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35 mm (IQR, -11.5 to 2.5) and 8.0 (IQR, -10.5 to 12.0), respectively. CONCLUSIONS: Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.

External iliac artery extension causes greater aneurysm sac regression than the bell-bottom technique or iliac branch endoprosthesis for repair of concomitant infrarenal aortic and iliac artery aneurysm.

OBJECTIVE: Aneurysmal extension of abdominal aortic aneurysms (AAAs) to the common iliac artery (CIA) presents a technical challenge to successful endovascular abdominal aortic aneurysm repair (EVAR). In the present study, we compared sac shrinkage and perioperative outcomes after the bell-bottom technique (BBT), internal iliac artery embolization and external iliac artery extension (EIE), and iliac branch endoprosthesis (IBE). METHODS: Using the Vascular Quality Initiative database, a retrospective analysis was conducted for patients who had undergone EVAR from 2013 to 2019. The demographic, anatomic, and perioperative data were analyzed. All patients with a proximal aortic neck length <10 mm and aortic graft diameter >32 mm were excluded from the analysis. The patients were subdivided into four groups according to the distal limb strategy: group 1, control group with a bilateral common iliac artery limb <20 mm; group 2, BBT with either a unilateral or bilateral limb >20 mm; group 3, EIE technique; and group 4, IBE. The primary endpoint was the maximal change in the aortic diameter during follow-up. The secondary endpoints included postoperative complications and the rate of endoleak. RESULTS: The records for 14,455 patients who had undergone EVAR were queried and 5788 met the anatomic criteria. The average age was 73 years, and 86.3% were men. The maximal change in the aortic diameter in the control, BBT, IBE, and EIE groups was -7.2 mm, -6.1 mm, -4.6 mm, and -6.8 mm, respectively (P = .06). The differences were not statistically significant on univariate analysis at an average follow-up of 405 days. However, on multivariable analysis (P = .01), compared with the control group, the BBT and IBE groups were 18.4% (odds ratio [OR], 0.816; 95% confidence interval [CI], 0.68-0.98) and 48.0% (OR, 0.52; 95% CI, 0.33-0.82) less likely to experience aneurysmal shrinkage, respectively. In contrast, the EIE group showed no significant difference in shrinkage compared with that in the control group. Multivariable analysis of the groups also revealed that compared directly with the BBT group, the EIE group was 69.5% more likely to have experienced shrinkage in the aortic aneurysmal diameter (OR, 1.70; 95% CI, 1.05-2.75). The BBT and IBE groups had a significantly higher rate of type II endoleaks (17.63% and 16.95%, respectively; P = .03). The EIE group had a higher rate of type Ib endoleaks (1.9%) compared with the BBT (1.1%), IBE (1.7%), and control (0.3%) groups (P = .01). No differences were found between the groups in terms of postoperative myocardial infarction (P = .47) or respiratory (P = .61) or intestinal (P = .71) complications. However, the rates of limb complications and reoperation were higher in the EIE group. CONCLUSIONS: The present study revealed that the EIE technique was more likely to demonstrate shrinkage in the aortic aneurysmal diameter than were the BBT and IBE groups compared with the control group on multivariable analysis. The EIE technique was also more likely to result in aneurysmal sac shrinkage than was the BBT group, albeit with greater rates of limb-related complications.

Hospitalist Co-Management of a Vascular Surgery Service Improves Quality Outcomes and Reduces Cost.

BACKGROUND: Hospitalists can be instrumental in management of inpatients with multiple comorbidities requiring complex medical care such as vascular surgery patients, as well as an expertise in health care delivery. We instituted a unique hospitalist co-management program and assessed length of stay, 30-day readmission rates and mortality, and performed an overall cost-analysis. METHODS: Hospitalist co-management of vascular surgery inpatients was implemented beginning April 2019, and data was studied until March 2020. We compared this data to an eight-month period prior to implementing co-management (7/2018 - 3/2019). Patient-related outcomes that were assessed include length of stay, re-admission index, mortality index, case-mix index. Cost-analysis was performed to look at indirect and direct cost of care. RESULTS: A total of 1,062 patients were included in the study 520 pre co-management and 542 patients were post-comanagement. Baseline case-mix index was 2.47, and post-comanagement was 2.46 (P >0.05). In terms of average length of stay (aLOS), the baseline aLOS was 5.16 days per patient, while after co-management it was significantly decreased by 1.25 days to 3.91 days (P <0.05). This improvement in length of stay opened an average of 2.4 telemetry beds per day. Similarly, excess days per patient which reflects the expected length of stay based on comorbidities, improved from -0.59 to -1.65, an improvement of -1.46. CONCLUSIONS: Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings. The overall average variable direct cost decreased by $1,732 per patient.

Laser-assisted "Scissor" Technique to Facilitate Thoracic Endovascular Aortic Repair for Chronic Type B Aortic Dissection.

BACKGROUND: There has been an increase in utilization of thoracic endovascular aortic repair (TEVAR) to treat aneurysms with chronic dissection. Despite significant progress, TEVAR is hindered by persistent perfusion of the false lumen and aneurysm growth. Various techniques to address false lumen perfusion exist. We preset our experience of laser fenestration with disruption of the dissection flap to facilitate TEVAR and avoid persistent retrograde false lumen perfusion. METHODS: Review a technique to treat patients with thoracic aortic aneurysm complicated by chronic dissection. This is an adjunct to a TEVAR procedure with final goal to treat the aneurysm and avoid retrograde false lumen perfusion. Under IVUS guidance, we performed a Phillips/Spectranetics laser fenestration of the intimal flap followed by a scissoring technique to obliterate the dissection flap and create a distal seal zone. Stent-grafts placed following flap obliteration allow graft expansion and apposition to the entire outer aortic and avoid retrograde perfusion of the false lumen. RESULTS: Two patients underwent TEVAR in conjunction with laser obliteration of the dissection flap, including 1 undergoing primary repair of a chronic Type B dissection with aneurysm, and 1 as a completion second stage elephant trunk procedure. Technical success was achieved in both cases, with successful implantation of the endograft, and freedom from type I and III endoleaks. Absence of false lumen flow, and patency of the visceral vessels was confirmed on completion angiography. True lumen patency and obliteration of the intimal flap were confirmed by IVUS. Early follow up confirms exclusion of the aneurysm, with no evidence of retrograde perfusion of the false lumen. CONCLUSIONS: Thoracic aortic aneurysms in the context of chronic dissections can be successfully treated with TEVAR and laser obliteration of the chronic dissection flap to fully exclude the aneurysm and avoid retrograde false lumen perfusion.

Periprocedural Outcomes of Popliteal vs Upper Extremity Access in the Treatment of Superficial Femoral Artery Occlusive Disease.

PURPOSE: Percutaneous lower extremity revascularization is being performed via upper extremity, pedal, or popliteal access with increasing frequency. This study aimed to compare periprocedural outcomes of popliteal (POA) and upper extremity (UEA) access for the treatment of isolated superficial femoral artery (SFA) occlusive disease. MATERIALS AND METHODS: A retrospective cohort study compared the outcomes of patients undergoing primary percutaneous intervention of SFA occlusive disease with POA or UEA using the Vascular Quality Initiative database from December 2010 to June 2019. Our primary endpoint was technical success. Secondary endpoints included factors associated with perioperative complications. RESULTS: A total of 349 patients underwent isolated SFA intervention through the popliteal, radial, or brachial artery. UEA was performed in 188 (53.9%) patients and POA in 161 (46.1%). Technical success with TASC A lesions was 95.8% and with TASC D lesions, 65.0%. POA had a higher proportion of TASC D lesions (24.8% vs 10.6%, p<0.001), and larger (≥7 Fr) sheath size (14.3% vs 2.7%, p<0.001). UEA had a higher proportion of no calcification (27.1% vs 11.2%, p<0.001), and smaller (4-5 Fr) sheath size (46.8% vs 34.8%, p=0.023). There was no difference in technical success between UEA and POA (88.8% vs 84.5%, p=0.230), which was also seen on multivariable analysis (p=0.985). Univariate analysis revealed technical failure was associated with TASC D lesions (45.7% vs 12.9%, p<0.001) and the presence of severe calcifications (39.1% vs 17.5%, p=0.002). Multivariable analysis confirmed technical failure was associated with degree of calcification (OR, 2.4; 95% CI, 1.18 to 4.89; p=0.016) and TASC D lesions (OR, 5.01; 95% CI, 2.45 to 10.24; p<0.001). Postoperative complications were associated with UEA on univariate (p=0.041) and multivariate analysis (OR, 2.08; 95% CI, 0.80 to 5.37; p=0.016). Access site complications were also associated with UEA compared to POA (4.3% vs 0.0%, p=0.027). CONCLUSIONS: There is no difference in technical success between UEA and POA when treating isolated SFA occlusive disease, and UEA is associated with a higher complication rate. Technical success is dependent on calcification and TASC II classification. Based on similar technical success rates and low complication rates, POA should be considered as a viable alternative to UEA when planning endovascular interventions.

Outcomes of chimney/snorkel endovascular repair for symptomatic and ruptured abdominal aortic aneurysms.

OBJECTIVE: Symptomatic and ruptured abdominal aortic aneurysms (AAAs) are increasingly being managed with endovascular aneurysm repair (EVAR). We aimed to identify the outcomes of symptomatic and ruptured AAAs that had undergone EVAR with a chimney or snorkel technique (ChEVAR). METHODS: A retrospective cohort study was performed using the Vascular Quality Initiative registry from March 2013 to July 2019. All patients with symptomatic and ruptured AAAs with a proximal aortic zone of disease from 6 to 9 who had undergone ChEVAR were included. The outcomes were analyzed in accordance with the Society for Vascular Surgery reporting standards for EVAR. RESULTS: ChEVAR was performed in 77 patients (ruptured, 35 [45.5%]; symptomatic, 42 [54.5%]). The median age was 73.0 years (interquartile range [IQR], 67.0-81.0 years), and 54 patients (70.1%) were men. The median maximum aneurysm diameter was 67.5 mm (IQR, 54.5-83.3 mm). All patients had American Society of Anesthesiologists class ≥III. For the patients with ruptured AAAs, the mean lowest preoperative systolic blood pressure was 95.3 ± 29.3 mm Hg. The fluoroscopy time was 57.4 minutes (IQR, 41.2-79.0 minutes). The proximal aortic zone of disease was zone 6 in 9 (11.7%), zone 7 in 21 (27.3%), zone 8 in 36 (46.8%), and zone 9 in 11 (14.3%) patients. ChEVAR involved more than one vessel in 55 patients (71.4%). No significant difference was found in 30-day mortality between the patients with ruptured vs symptomatic AAAs (11.4% vs 7.1%; P = .695). Reintervention was required for 10 patients (13.0%) at a median of 9 postoperative days, 2 (20.0%) of whom died. Postoperatively, 31 patients (40.3%) had experienced a major complication. A type I endoleak had occurred in nine patients (11.7%), two (22.2%) of whom died. Long-term follow-up data were available for 38 patients (49.4%) at a median of 406.5 days (IQR, 326.8-602.0 days) postoperatively. Of the 18 patients with long-term radiographic data, sac growth was detected in 4 (22.2%). A total of 14 patients had died at a median of 26.5 days (IQR, 3.0-468.5 days). CONCLUSIONS: ChEVAR for symptomatic and ruptured AAAs can be performed with acceptable rates of morbidity and mortality. Long-term data are needed to determine the durability.

Preoperative Stress Test and Postoperative MI in Patients Requiring Lower Extremity Bypass for Critical Limb Ischemia.

BACKGROUND: Patients with critical limb ischemia (CLI) often require lower extremity bypass surgery for limb salvage. A myocardial infarction (MI) is a major postoperative risk. Our objective is to assess the utility of preoperative stress test in determining patient outcomes. METHODS: This is a retrospective study utilizing the national Vascular Quality Initiative database. We collected data from 2013-2018 on all patients undergoing lower extremity bypass for CLI and assessed whether or not they had a preoperative stress test. Rates of an MI were then compared between groups of patients who either did not receive a stress test, had a normal stress test or a positive stress test. An MI was distinguished as troponin only and electrocardiogram (EKG)/clinical. Our secondary end point was in-hospital mortality. Univariate and multivariate analysis with the stress test as a covariate was used to determine significance. RESULTS: During this time period, 29,937 bypasses were performed on 27,219 patients. The average age was 67.5 years (±11.09), 66.3% were men, and 17.3% were African American. Risk factors included hypertension (89.5%), diabetes (55.9%), congestive heart failure (20%), coronary artery disease (32.5%), coronary artery bypass graft (22.2%), and percutaneous coronary intervention (21%). 19,108 patients (64.1%) did not undergo the stress test before bypass, 6,830 (22.9%) had a normal stress test, and 2,898 (9.7%) had a positive stress test. Overall rate of an MI was 4%, with 2% being troponin only and 2% EKG/clinical. The positive stress test had a higher rate of troponin only (2.85%) as well as EKG/clinical (3.37%) MI. For every 10 year increase in age, the odds of having a postoperative MI increased by 27% (P < 0.0001). Overall in-hospital mortality was 1.4%. Patients with positive stress tests had a 2.6% mortality compared with normal/not performed at 1.3%. Of the patients who died, 21.5% had an EKG/clinical MI. Of those patients, 50% did not have a stress test, 12% had normal stress tests, and 23% had positive stress tests. When comparing rates of patients who died or had an MI, there was no difference between patients who had no or a normal stress test (7.29%) versus those who had a positive stress test (7.58%), (P = 0.11). CONCLUSIONS: A positive stress test before lower extremity bypass is a significant predictor of a postoperative MI. However, mortality increase was minimal in patients with a positive stress test. Therefore, the stress test result should not delay care for patients needing urgent revascularization.

Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

Outcomes of Endovascular Management of Isolated Profunda Femoris Artery Occlusive Disease.

BACKGROUND: Endovascular management of isolated profunda femoris artery occlusive disease has not been well studied. Our aim is to analyze the outcomes of endovascular management of profunda artery occlusive disease. METHODS: This is a retrospective analysis using data from the Vascular Quality Initiative. All patients from 2013 to 2018 treated percutaneously for isolated profunda artery occlusive disease were included. Endovascular treatment included plain balloon alone, stent, stent graft, atherectomy, and drug-coated balloon without any concomitant endovascular or surgical treatment. Demographic, procedural, and follow-up data were obtained. Primary end points were primary patency, improvement of symptoms, and need for reintervention. Univariate and multivariable analysis was used to assess for significant variables. RESULTS: Of the 105,568 lower extremity endovascular interventions performed during this time period, there were 361 procedures (0.3%) performed on 341 patients for isolated profunda artery occlusive disease. The average age of these patients was 67.8 years (+/- 11.8), with 59.8% being men. The most common indication for treatment of the profunda artery was claudication (44.8%), followed by tissue loss (28.5%) and rest pain (26.0%). The most common treatment modality was plain balloon (58.5%), followed by stent (18.6%), drug-coated balloon (10.0%), atherectomy (9.4%), and stent graft (3.6%). At a mean follow-up of 13 months (+/-4.6), data were available for 238 patients (69.7%). Overall primary patency at 13 months was 92.9%. There was no significant difference in terms of patency for each treatment modality (Table I). Preoperative ambulatory status, aspirin, and statin were significantly associated with patency. At most recent follow-up, 67% of patients had improvement of their symptoms, whereas 29% were unchanged. Reintervention data were available for 247 patients, with a reintervention rate of 15.8% (n = 39) and a mean reintervention time of 226 days (+/- 173), with the majority of reinterventions (62%) occurring in the plain balloon group. Reinterventions were primarily endovascular (64%) with 9 patients (23%) undergoing surgical reintervention. CONCLUSIONS: Endovascular management of profunda femoris artery occlusive disease has acceptable one-year patency rates with low reintervention rates. Endovascular treatment may be an acceptable alternative to selected patients who are high-risk for surgery.

Single versus Multiple Vessel Endovascular Tibial Artery Revascularization for Critical Limb Ischemia: A Review of the Literature.

Vascular interventionalists have long debated on whether one or multiple patent tibial arteries (run-off) are necessary to treat critical limb ischemia, including ischemic rest pain and tissue loss. This review article seeks to clarify data surrounding this topic by including literature from retrospective studies, prospective studies, meta-analyses, and randomized controlled trials. Our conclusion is that revascularizing a single tibial artery to the foot is adequate for wound healing.

Management of the Left Subclavian Artery in TEVAR for Chronic Type B Aortic Dissection.

OBJECTIVES: Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD. METHODS: The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards. RESULTS: Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident (P = .16), spinal cord ischemia (P = 1.00), or death (P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04). CONCLUSIONS: Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.

Outcomes of Thoracic Endovascular Aneurysm Repair (TEVAR) in Patients With Connective Tissue Disorders.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) remains controversial in patients with connective tissue disorders given the concern for durability. We report on the largest series to date on outcomes of patients with thoracic aortic disease and connective tissue disorders treated with TEVAR. METHODS: The Vascular Quality Initiative registry identified 12 207 patients treated with TEVAR from January 2010 to December 2018, including 102 with Marfans, Ehlers-Danlos, or Loey-Dietz syndrome. Outcomes were analyzed per the Society for Vascular Surgery reporting standards. RESULTS: Median age was 50.6 years (interquartile range: 57.0-75.0), and 62 (60.7%) were male. Eighty-eight (86.3%) patients had Marfan, 9 (8.8%) had Ehlers-Danlos, and 5 (4.9%) had Loey-Dietz syndrome. Twenty-six (25.5%) patients were treated for degenerative aneurysmal disease and 76 (74.5%) patients for type B dissections (33 acute, 31 chronic). Most common indications for interventions in patients with type B dissection were pain (n = 41), aneurysmal degeneration (n = 16), and malperfusion (n = 8), with 3 patients who presented ruptured. There was no significant difference in perioperative complications between acute/chronic dissections and aneurysms (P = .14). Percutaneous access was utilized in 61.7% of patients, with a 2.9% rate of arterial injury requiring reintervention. Follow-up data were available for 75 (73.3%) patients at a mean follow-up of 15.6 months. Overall mortality was 5.3%. There were 30 patients with follow-up endoleak data, and 8 (26.7%) endoleaks were identified. All endoleaks were in patients treated for acute type B dissection, and all resolved after a mean of 2.1 reinterventions. Three patients treated for acute Type B Aortic Dissection (TBAD) had retrograde dissections requiring intervention. DISCUSSION: Thoracic endovascular aortic repair for patients with connective tissue disorders can be performed with low perioperative mortality, spinal cord ischemia, or Cerebrovascular Accident (CVA). On follow-up, acute type B aortic dissections represent a higher risk subgroup with increased rates of endoleak and retrograde dissection. Closer follow-up for these patients and early reintervention may be beneficial.

Embolization Techniques for Arteriovenous Malformations in Parkes-Weber Syndrome.

BACKGROUND: Multiple high-flow arteriovenous malformations (AVMs) are the hallmark of Parkes-Weber syndrome (PWS). Surgical resection has historically shown poor outcomes with PWS. The aim of this study was to assess the management of PWS in the current era. METHODS: A retrospective review was performed from 2004 to 2017 on all patients presenting to a single institution for the management of PWS. Presentation, techniques, complications, and outcomes were reviewed. RESULTS: Fourteen patients (50% male) with PWS were seen at our institution, and mean age was 19.9 years (range, 4.7-68.8). The lower extremity was affected in 12 (86%) and the upper extremity in 2 (14%) patients. All patients presented with pain and swelling in the affected limb. Seven (50%) patients presented with ulcers, of which 3 (43%) had extensive wounds. Five (36%) patients had echocardiographic evidence of high-output cardiac failure. All patients underwent angiography with the intention to treat. Three (21%) patients were found to have diffuse arteriovenous communication with no discrete AVM nidus and thus did not undergo intervention. The remaining 11 (79%) patients underwent transcatheter embolization of the AVM's arterial inflow. Six (55%) patients required multiple or staged inflow embolization procedures, with a mean of 3.3 (range, 1-10) interventions. Thirty-two arterial embolization procedures were performed in total. n-Butyl-2-cyanoacrylate (nBCA) adhesive was used in 22 (69%), microspheres in 8 (25%), and a combination of coils and nBCA adhesive in 2 (6%) cases. Technical angiographic success was seen in all patients. Six (55%) patients also had interventions to treat the venous component of the malformation, either concomitantly or during a separate procedure. This included radiofrequency ablation in 1 (17%), coil embolization in 1 (17%), sodium tetradecyl sulfate (STS) sclerotherapy in 2 (33%), and a combination of STS, coil embolization, and vein stripping in 2 (33%) patients. Ten (91%) patients experienced a partial response and 1 (9%) patient experienced no response to treatment. No patients had a complete response, as expected with the diffuse nature of this disease. There were no periprocedural complications. Two of 3 patients with complex wounds required major amputations for gangrene, including one above-knee and one below-knee amputation at 128 months and 66 months after the index procedure, respectively. CONCLUSIONS: AVMs in PWS can be successfully treated by a transcatheter approach. Multiple interventions are usually required. Patients with extensive wounds remain at risk for loss of limb.

Risk Factors for Postoperative Hypotension and Hypertension following Carotid Endarterectomy.

BACKGROUND: Patients undergoing carotid endarterectomy (CEA) often experience postoperative hemodynamic changes that require intravenous medications for hypo- and hypertension. Prior studies have found these changes to be associated with increased risks of 30-day mortality, stroke, myocardial infarction (MI), and length of stay (LOS). Our aim is to investigate preoperative risk factors associated with the need for postoperative intravenous medications for blood pressure control. METHODS: A retrospective review of an internally maintained prospective database of patients undergoing carotid interventions between January 2014 and March 2019 was performed. Demographic data, clinical history, and perioperative data were recorded. Carotid artery stents and reinterventions were excluded. Our primary end points were the need to intervene with intravenous medication for either postoperative hypotension [systolic blood pressure (SBP) <100 mm Hg] or postoperative hypertension (SBP >160 mm Hg). RESULTS: A total of 221 patients were included in the study after excluding those with a prior ipsilateral CEA or carotid artery stent. The mean age was 72.3 (±8.9) years, 157 (71%) patients were male, and 78 (35.3%) were Caucasian. Following CEA, 151 (68.3%) patients were normotensive, while 33 (14.9%) and 37 (16.7%) required medication for hypotension and hypertension, respectively. A univariate logistic regression identified 5 variables as being associated with postoperative blood pressure including race, history of MI, prior percutaneous transluminal coronary angioplasty (PTCA), statin use, and angiotensin-converting enzyme-inhibitor/angiotensin-receptor blocker (ARB) use. A stepwise regression selection found race, prior MI, and statin use to be associated with our primary end points. The hypertensive group was more likely to have a history of MI compared to the hypotensive and normotensive groups (40.5% vs. 27.3% vs. 18.5%, P = 0.02), PTCA (43.2% vs. 39.4% vs. 23.8%, P = 0.03), and statin use (94.6% vs. 93.9% vs. 78.8%, P = 0.01). Mean LOS was also the highest for the hypertensive group, followed by hypotensive and normotensive patients [2.0 (±1.6) vs. 1.8 (±2.4) vs. 1.3 (±0.8), P = 0.002]. Multivariable logistic regression demonstrated that non-Caucasian patients [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.26-5.86, P = 0.01] and those with a history of MI (OR 2.98, 95% CI 1.33-6.67) were more likely to have postoperative hypertension compared to patients who were Caucasian or had no history of MI. CONCLUSIONS: Postoperative hypertension is associated with non-Caucasian race and a history of MI. Given the potential implications for adverse perioperative outcomes including MI, mortality, and LOS, it is important to continue to elucidate potential risk factors in order to further tailor the perioperative management of patients undergoing CEA.

Major Limb Amputations in Patients with Congenital Vascular Malformations.

BACKGROUND: The need for major amputations in patients with vascular malformations is rare. This study reviews our contemporary experience with major amputations in patients with vascular malformations. METHODS: A retrospective review from April 2014 to November 2018 identified 993 patients undergoing management of a vascular malformation involving the upper or lower extremity at a tertiary center. This population was analyzed to identify those requiring either a transfemoral or transhumeral amputation. This cohort was investigated for clinical course, surgical procedures, and outcomes. RESULTS: Five patients (0.5%) underwent major amputation, including 3 transhumeral and 2 above-knee amputations. The median age was 37.8 years (interquartile range (IQR): 25.4-40.2), and 2 (40%) were male. Four (80%) patients had high-flow arteriovenous malformations, including 1 (20%) with Parkes-Weber syndrome. One (20%) patient had a low-flow venous malformation associated with Klippel-Trénaunay syndrome. All patients had malformation extending into the chest or pelvis, with the amputation being at the level of residual malformation. As such, amputation had been initially felt to be high risk because of the proximal extent of the lesions. Before amputation, a median of 11 procedures (IQR: 4-39) were performed per patient. This included 29 transarterial embolizations, 4 transvenous embolizations, 20 direct stick embolizations, 3 debulking procedures, 38 debridements, 6 skin grafts or muscle flaps, and 4 minor amputations. The median time course of treatment before amputation was 117 months (IQR: 44-171). Indications for major amputation included chronic pain and recurrent bleeding in all 5 (100%) patients, loss of function in 2 (40%), nonhealing wounds in 2 (40%), and sepsis in 1 (20%) patient. There were no perioperative deaths. The median blood loss was 1,000 mL (IQR: 650-2,750). All patients required transfusion of packed red blood cells with a mean of 1.6 units (standard deviation: 0.54). Transhumeral amputation was facilitated by transcatheter embolization in 1 (33%) and an occlusion balloon within the subclavian artery in 2 (66%) patients. The median length of stay was 6 days (IQR: 5-13). The median length of follow-up was 132 months (IQR: 68-186) from initial intervention and 12 months (IQR: 8-31) from amputation. Two patients (40%) who had undergone transhumeral amputation required revision of the amputation site for recurrent ulceration at 2 and 38 months. Of these, 1 patient underwent 3 transcatheter embolization procedures before revision and 1 underwent 1 embolization after revision. CONCLUSIONS: Although rare, successful amputation at the level of residual malformation can be performed in select patients with refractory complications of vascular malformations including intractable pain, bleeding, or nonhealing wounds. Specific preoperative and intraoperative measures may be critical to achieve satisfactory outcomes, and endovascular techniques continue to play a role after amputation.

Complexity of Aortic Arch Anatomy Affects the Outcomes of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting.

BACKGROUND: Transcarotid artery revascularization (TCAR) has been shown to have half the rates of transient ischemic attack (TIA), stroke, and death compared with transfemoral carotid artery stenting (TFCAS). Successful outcomes of TFCAS require careful patient selection. The aim of this study was to determine the outcomes of TFCAS versus TCAR in both simple (type I) and complex (type II and III) aortic arches. METHODS: A retrospective cohort study was performed comparing the outcomes of patients undergoing TFCAS versus TCAR with simple and complex aortic arches using the Vascular Quality Initiative registry from August 2011 to May 2019. The primary outcome was a composite of in-hospital TIA/stroke/death. RESULTS: About 6,108 carotid artery interventions were analyzed, including 3,536 (57.9%) patients with type I, 2,013 (33.0%) with type II, and 559 (9.2%) with type III aortic arch. In 3,535 patients with a simple arch, 1,917 underwent TFCAS and 1,619 had TCAR. Mean age was 70.6 (±9.5) years, and 2,382 (67.4%) patients were males. The primary outcome of postoperative TIA/stroke/death was seen significantly less frequently in those undergoing TCAR compared with TFCAS in simple arches (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.43-0.94; P = 0.0236). Although the individual outcome of death occurred less often in TCAR (P = 0.0025), there was no difference in the occurrence of in-hospital stroke (P = 0.8836) or TIA (P = 0.4608). On multivariable analysis, TCAR was associated with improved outcomes (P = 0.0062). A worse outcome was associated with increasing age (P < 0.001), a prior stroke (P < 0.0001), and increasing number of stents (P = 0.0483). In 2,572 patients with a complex arch, 1,416 underwent TFCAS and 1,156 had TCAR. Mean age was 73.0 (±9.1) years, and 1,655 (64.4%) were males. In complex arch anatomy, the primary outcome of in-hospital TIA/stroke/death was seen significantly less frequently in TCAR compared with TFCAS (OR, 0.49; 95% CI, 0.31-0.77; P = 0.0022). Again noted was a significant difference in death, with better outcomes in TCAR (P = 0.0133). Although the occurrence of in-hospital TIA was no different between the 2 approaches (P = 0.6158), there were significantly fewer strokes in those treated with TCAR (P = 0.0132). TCAR (P = 0.0146) was associated with improved outcomes. A worse outcome was seen with advancing age (P = 0.0003), prior strokes (P = 0.01), and a left-sided lesion (P = 0.0176). CONCLUSIONS: TCAR has improved outcomes of TIA/stroke/death compared with TFCAS in both simple and complex aortic arch anatomy. In simple aortic arches, there is no difference in neurologic outcomes between both approaches. In complex arch anatomy, TCAR has fewer strokes.