Hostile neck anatomy contributes to higher rates of reintervention following endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysm.

INTRODUCTION: Ruptured abdominal aortic aneurysms (AAA) presenting with hostile neck anatomy can represent a challenge in surgical decision-making. We hypothesized that, patients who require reinterventions have higher rates of compromised neck anatomy at initial presentation and may indicate a need for altered surveillance paradigm. METHODS: Patients presenting with ruptured AAA to a single tertiary care institution from 2014 to 2021 were retrospectively reviewed. Those treated with infrarenal EVAR, with no prior aortic surgeries, and with available pre-operative computed tomography (CT) scans were included. Demographics, timing and type of reintervention, follow-up, and survival were collected. CT scans were assessed for hostile neck anatomy via measurements of diameter, length, angle, taper, bulge, calcification, and thrombus. Demographics, comorbidities, and neck anatomy of those with and without reintervention were compared using Fischer's Exact and Student's T-test. Survival was analyzed via Kaplan-Meier and log-rank test. RESULTS: Eighty-nine patients were available for analysis, 37 of which met inclusion criteria. Intraoperative death occurred in 3 patients (8.1%) and 1 patient (2.7%) was intraoperatively converted to an open repair. Thirty-day and 1-year survival were 97% and 91%, respectively. The reintervention rate was 30% (n = 10), occurring at a median of 200 days (18-2053 days) after the index operation. All patients requiring reintervention met hostile neck criteria (p = .002) and had a statistically higher number of hostile neck criteria (1.80 vs 0.87, p = .03). Thirty percent (n = 3) of patients that received a reintervention had neck diameter greater than 3 cm, compared to zero patients in the non-reintervention group (p = .022). Proximal reinterventions (n = 5) had statistically higher neck diameters and neck angle compared to the non-reintervention group. CONCLUSION: Infrarenal rEVAR is effective at preventing acute mortality despite specific anatomic considerations that may contribute to the higher reintervention rates, and therefore those parameters ought to be considered when following patients in the post-intervention period.

Pioneer re-entry into covered stent graft to recanalize occluded, jailed external iliac artery.

Aortoiliac occlusive disease in patients who are poor surgical candidates requires innovative strategies in endovascular surgery. We present a case of a 59-year-old gentleman with significant medical comorbidities and chronic limb-threatening ischemia secondary to a chronically occluded left-to-right cross-femoral bypass, as well as an occluded right iliac system owing to a jailed right external iliac artery from a prior common-to-internal iliac covered stent, originally done for buttock claudication. He was treated successfully from an endovascular approach with kissing stents in the right internal and external iliac arteries after gaining access to the old right common iliac stent via an ipsilateral access and use of a Pioneer intravascular ultrasound-guided re-entry catheter. Use of this strategy to treat complex aortoiliac occlusions in patients that are not suitable surgical candidates can be achieved effectively, even in the setting of existing prior ipsilateral stent grafts.

Thoracic Aortic Aneurysms and Arch Disease.

Aortic arch and descending thoracic pathology have historically remained in the realm of open surgical repair. Technology is quickly pushing to bring these under the endovascular umbrella, with lower morbidity repairs proving safe in their early experience. Much work remains particularly for acute aortic syndromes, however, to understand who is best treated medically, surgically, endovascularly, or with hybrid approaches.

Successful endovascular salvage of a maldeployed iliac limb extension during complex aortic reconstruction.

PURPOSE: The worst complication during cannulation of the contralateral gate during complex endovascular aortic repair is deployment of the limb extension behind the main graft body. CASE REPORT: A patient with a 5.7 cm juxtarenal abdominal aortic aneurysm was taken to the operating room for fenestrated endovascular aortic repair and iliac branch device. Percutaneous femoral access was used to deploy a Gore Iliac Branch Endoprosthesis, followed by a physician modified Cook Alpha thoracic stent graft with four fenestrations. Next a Gore Excluder was deployed to bridge the fenestrated component to the iliac branch and native left common iliac artery creating distal seal. Due to the severe tortuosity, a buddy wire technique, using a stiff lunderquist wire, was used to cannulate the contralateral gate. Unfortunately, after cannulation, the limb was advanced over the buddy lunderquist wire instead of the luminal wire. We used a backtable modified guide catheter to provide the necessary pushability to navigate wires between the aberrantly deployed limb extension and the iliac branch device. Using through-and-through access, we then successfully deployed a parallel flared limb in the correct plane. CONCLUSION: Careful communication, wire marking, and attention to intraoperative flow can minimize risks of complication, but knowledge of bail out techniques remains imperative.

Percutaneous, Antegrade Access of the Superficial Femoral Artery can be Safely Used in Procedures for the Treatment of Lower Extremity Limb Ischemia.

BACKGROUND: Recent studies have shown that antegrade access for treatment of infrainguinal peripheral vascular disease is associated with decreased radiation exposure and contrast use without a significant increase in access complication, although data are limited on antegrade superficial femoral artery (SFA) access for larger sheath sizes. We aim to describe a single institution's contemporary experience with percutaneous antegrade SFA access. METHODS: A retrospective review of percutaneous, infrainguinal endovascular interventions for arterial occlusive disease at a major academic institution was conducted between 2018 and 2020. Antegrade, percutaneous, SFA access cases were included. Information on demographics, indication, sheath size, arteries treated, type of intervention, concurrent pedal access, closure devices, and complications was collected and analyzed. RESULTS: A total of 45 patients with an average body mass index of 25.25 were identified. Indications for intervention included tissue loss (64.4%), rest pain (6.7%), claudication (13.3%), and acute limb ischemia (11.1%). Of which, 80.0% of patients had multilevel interventions. Angioplasty was performed in 68.8% of patients, stenting in 8.3%, atherectomy in 15.6%, and thrombectomy in 7.3%. Nearly a quarter of cases involved concurrent pedal access. Maximum sheath size was 4F for 4.4% of patients, 5F for 28.9%, 6F for 46.7%, 7F for 11.1%, and 8F for 8.9%. The closure device was utilized in 75.6% of cases, with no closure device failures. In the entire cohort, there were no demonstrated access site complications. CONCLUSIONS: This study demonstrates percutaneous, antegrade SFA access for complex endovascular interventions for infrainguinal occlusive disease can be effectively utilized, even with larger sheath size. Moreover, routine use of closure devices is safe, improving patient comfort and expediting time to ambulation.

Plaque contact surface area and lumen volume predict stroke risk in extracranial carotid artery stenosis.

BACKGROUND: The standard indication for intervention in asymptomatic disease is currently percent stenosis in the internal carotid artery as measured by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method, which remains limited in discriminating power. Computed tomography angiography (CTA) is widely used to calculate NASCET stenosis, but also offers the opportunity to analyze carotid artery plaques from a morphological perspective that has not been widely used. We aim to improve stroke risk stratification of patients with carotid artery stenosis using plaque three-dimensional (3D) modeling and image analysis. METHODS: Patients with computed tomography angiographies appropriate for 3D reconstruction were identified from a National Institutes of Health-designated stroke center database, and carotid arteries were segmented and analyzed using software algorithms to calculate contact surface area (CSA) between the plaque and blood flow, and volume of the flow lumen within the region of the plaque (lumen volume [LV]). These novel parameters factor in the 3D morphometry inherent to each carotid plaque and were compared between stroke and nonstroke groups. RESULTS: A total of 134 carotid arteries were analyzed, 33 of which were associated with an ipsilateral stroke. Plaques associated with stroke demonstrated statistically significant increases in average CSA (541.52 mm2) and LV (394.64 mm3) when compared with those not associated with stroke (371.18 mm2 and 245.92 mm3, respectively). When comparing area under the receiver operating characteristics curve between NASCET (0.65) percent stenosis, CSA (0.74), and LV (0.77), both CSA and LV demonstrated more favorable values in predicting stroke risk in patients with carotid stenosis. CONCLUSIONS: The data presented here demonstrate morphological features of carotid plaques that are independent of NASCET criteria stratification and may present an improved method in assessing stroke risk in patients with carotid artery stenosis.

Does etiology of gastroparesis determine clinical outcomes in gastric electrical stimulation treatment of gastroparesis?

BACKGROUND: Gastroparesis is a condition characterized by impaired gastric motility that may result in weight loss and malnutrition. There have been promising studies demonstrating improvement in symptoms after gastric electrical stimulation (GES) implantation for medically refractory gastroparetics [1-10]. With the heterogeneous population of gastroparetics, the aim of this study was to assess if etiology correlated with response to GES. METHODS: A retrospective review and analysis was performed on patients who underwent GES over a 10-year period at a single institution. Each patient was stratified into an etiological subset (diabetes, idiopathic, post-surgical). Patients were compared by demographics, medical and surgical history, subsequent GES explantation vs continued therapy, need for supplemental nutrition postoperatively, weight gain, weight loss or weight maintenance, and readmission rates. RESULTS: 183 patients underwent GES from 2005 to 2015. 50% were diabetic (n = 91), 42% idiopathic (n = 76), and 9% post-surgical (n = 16). Diabetic patients (DM) demonstrated the highest likelihood of continued therapy compared to post-surgical (PS) and idiopathic patients (ID) (54.7% vs 9.5% vs 35.8%, respectively, p < 0.05). DM patients saw a greater incidence of weight gain > 4 kg, compared to PS and IS patients (67.6% vs 8.1% vs. 24.3%, respectively, p < 0.05). ID patients were most likely to have it removed compared to DM and PS patients (65.7% vs 28.6% vs 5.7%, respectively, p = < 0.05). PS patients were least likely to have their GES removed. They were also least likely to utilize supplemental nutrition compared to DM and ID (9.4% vs 49.1% vs 41.51%, respectively, p < 0.05). CONCLUSIONS: Patients with gastroparesis had different clinical outcomes after GES therapy based on underlying etiology. By gaining a better understanding of the effects of GES, it can be offered to the appropriate patient.

Occlusion of the Celiac Artery during Endovascular Thoracoabdominal Aortic Aneurysm Repair Is associated with Increased Perioperative Morbidity and Mortality.

BACKGROUND: Some studies suggest that celiac artery coverage during elective endovascular thoracoabdominal aortic aneurysm (TAAA) repair is safe given sufficient collateralization of visceral organ perfusion from the superior mesenteric artery. However, there is concern that celiac artery coverage may lead to increased risk of foregut or spinal cord ischemia with an attendant increased risk of mortality. We sought to investigate rates of bowel ischemia, spinal cord ischemia, and 30-day mortality associated with celiac artery coverage during TEVAR and complex EVAR. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was queried for TEVAR and complex EVAR cases from 2012 to 2018. Inclusion criteria included TAAA pathology and endograft extension to aortic zone 6. Patients with aortic rupture, trauma, prior thoracic aortic surgery, known preoperative occlusion of the left subclavian superior mesenteric, or celiac arteries were excluded. Cases with intraoperative celiac artery occlusion (CAO) were compared retrospectively to cases with celiac artery preservation (CAP). Primary outcomes included 30-day mortality and a composite end point of 30-day mortality, spinal cord ischemia (transient or permanent lower extremity neurologic deficit), and bowel ischemia (colonoscopic evidence of ischemia, bloody stools in a patient who dies prior to colonoscopy or laparotomy, or other documented clinical diagnosis). Univariable comparisons were performed using chi-squared tests and Student's t-tests, as appropriate. Multivariable logistic regression analyses were employed to identify independent predictors of outcome. RESULTS: There were 628 cases identified for inclusion in the study. Patients undergoing CAO (n = 44) were more likely to be female or to have higher rates of preoperative spinal drain use, American Society of Anesthesiologists score ≥3, low preop hemoglobin, and/or symptomatic presentation, but fewer mean number of aortic zones covered. CAO was associated with higher 30-day mortality (5 of 44, 11%) compared to CAP (23 of 584, 4%), P = 0.039. The composite end point occurred at a significantly greater proportion for those who had CAO (10 of 44, 23%) compared to CAP (53 of 584, 9%, P = 0.008), driven by higher rates of 30-day mortality and bowel ischemia (9% vs. 2%, P = 0.026). By multivariate analysis, CAO was predictive of 30-day mortality (odds ratio [OR] = 3.9, 95% confidence interval [CI] = 1.1-13.8, P = 0.04) and the composite endpoint (OR = 3.0, 95% CI = 1.1-8.5, P = 0.03). Increasing procedure time was also associated with 30-day mortality (OR = 1.4, 95% CI = 1.1-1.7, P < 0.001) and the composite end point (OR = 1.4, 95% CI = 1.1-1.6, P < 0.001). CONCLUSIONS: For those treated for TAAAs, CAO was independently predictive of increased 30-day mortality and a composite end point of perioperative mortality, spinal cord ischemia, and bowel ischemia. When treating patients with extensive aortic aneurysmal disease, physicians should attempt to preserve the celiac artery, by revascularization or avoiding ostium coverage, whenever feasible.

Identification of Priority Areas for Increased Testing Using Geospatial Mapping of Incident HIV Cases Near Charleston, South Carolina.

Analysis of disease incidence using geospatial mapping techniques can enhance targeted public health efforts in resource-limited settings. While data for HIV incidence are readily available for some metropolitan regions, there is no existing resource that maps HIV incidence geospatially for Charleston, South Carolina and surrounding counties. To facilitate the public health approach to address the HIV epidemic in this region, we used data collected by the South Carolina Department of Health and Environmental Control (SC-DHEC) from 2014 to 2015 to generate local geospatial maps of disease incidence and identify specific areas that may benefit from increased testing and educational efforts. We identified specific zip codes in which there were a high number of cases from patients residing in those areas, but a low number of providers reporting new cases, and we describe ongoing efforts to address this disparity. This analysis identifies a local, collaborative approach to address the HIV epidemic using routinely collected surveillance data.