Initial experience with the ambulatory management of acute iliofemoral deep vein thrombosis with May-Thurner syndrome with percutaneous mechanical thrombectomy, angioplasty and stenting.

OBJECTIVE: Patients undergoing intervention for acute iliofemoral deep vein thrombosis (IFDVT) with May-Thurner syndrome (MTS) typically require inpatient (IP) hospitalization for initial treatment with anticoagulation and management with pharmacomechanical thrombectomy. Direct oral anticoagulants and percutaneous mechanical thrombectomy (PMT) devices offer the opportunity for outpatient (OP) management. We describe our approach with these patients. METHODS: Patients receiving intervention for acute IFDVT from January 2020 through October 2022 were retrospectively reviewed. Patients undergoing unilateral thrombectomy, venous angioplasty, and stenting for IFDVT with MTS comprised the study population and were divided into two groups: (1) patients admitted to the hospital and treated as IPs and (2) patients who underwent therapy as OPs. The two groups were compared regarding demographics, risk factors, procedural success, complications, and follow-up. RESULTS: A total of 92 patients were treated for IFDVT with thrombectomy, angioplasty, and stenting of whom 58 comprised the IP group and 34 the OP group. All 92 patients underwent PMT using the Inari ClotTriever (Inari Medical), intravascular ultrasound, angioplasty, and stenting with 100% technical success. Three patients in the IP group required adjuvant thrombolysis. There was no difference in primary patency of the treated IFDVT segment at 12 months between the two groups (IP, 73.5%; OP, 86.7%; P = .21, log-rank test). CONCLUSIONS: Patients with acute IFDVT and MTS deemed appropriate for thrombectomy and iliac revascularization can be managed with initiation of ambulatory direct oral anticoagulant therapy and subsequent return for ambulatory PMT, angioplasty, and stenting. This approach avoids the expense of IP care and allows for effective use of resources at a time when staffing and supply chain shortages have led to inefficiencies in the provision of IP care for nonemergent conditions.

Innovative use of iliac branch device for repair of a type V thoracoabdominal aortic aneurysm.

In this innovative technique case report, we describe the off-label use of an iliac branch endoprosthesis and a main body endovascular aneurysm repair component for total endovascular repair of a thoracoabdominal aortic aneurysm in a patient unsuitable for open repair. In the present report, we describe case planning and measurement techniques for this type of repair and postoperative considerations. The take-home lessons include the importance of advanced planning and the overall feasibility of this technique compared with other approaches, including the snorkel technique, in select patients.

Patient risk factors associated with embolic stroke volumes after revascularization.

OBJECTIVE: Previous research has shown that subclinical, microembolic infarcts result in long-term cognitive changes. Whereas both carotid endarterectomy (CEA) and carotid artery stenting (CAS) have potential for microembolic events, CAS has been shown to have a larger volume of infarct. We have previously shown that large-volume infarction is associated with long-term memory deterioration. The purpose of this study was to identify independent risk factors that trend toward higher embolic volumes in both procedures. METHODS: A total of 162 patients who underwent carotid revascularization procedures were prospectively recruited at two separate institutions. Preoperative and postoperative brain magnetic resonance images were compared to identify procedure-related microinfarcts. A novel semiautomated approach was used to define volumes of infarcts for each patient. Patient-related factors including comorbidities, symptomatic status, and medications were analyzed. Tweedie regression analysis was used to identify risk factors associated with procedure-related infarct volume. Variables with an unadjusted P value of ≤ .05 were included in the multivariate analysis. RESULTS: There were 80 CAS and 82 CEA procedures performed and analyzed for the data set; 81% of CAS patients had procedure-related new infarcts with a mean volume of 388.15 ± 927.90 mm3 compared with 30% of CEA patients with a mean volume of 74.80 ± 225.52 mm3. In the CAS cohort, increasing age (adjusted coefficient ± standard error, 0.06 ± 0.02; P < .01) and obesity (1.14 ± 0.35; P < .01) were positively correlated with infarct volume, whereas antiplatelet use (-1.11 ± 0.33; P < .001) was negatively correlated with infarct volume. For the CEA group, diabetes (adjusted coefficient ± standard error, 1.69 ± 0.65; P < .01) was identified as the only risk factor positively correlated with infarct volume, whereas increasing age (-0.10 ± 0.05; P = .03) was negatively correlated with infarct volume. CONCLUSIONS: Risk factors for CAS- or CEA-related infarct volumes are identified in our study. Although the result warrants further validation, this study showed that advanced age, obesity, and diabetes independently predicted volume of microinfarcts related to CAS and CEA. These data provide valuable information for patient factor-based risk stratification and preoperative consultation for each procedure.

Carotid Aneurysm Review.

Aneurysms of the carotid artery are rare with multiple underlying etiologies. Treatment is largely open surgery but medical and endovascular therapies have been used based on presentation, anatomy, and etiology. There is a moderate amount of retrospective case series data on surgical results but no prospective data or data comparing open versus endovascular therapy exists. Much research is still needed but difficult to obtain in this rare disease process.