Faculty Bibliography

BACKGROUND:Duplex-derived velocity measurements are often used to determine the need for carotid revascularization. There is evidence that severe ipsilateral carotid stenosis can cause artificially elevated velocities in the contralateral carotid artery, which may decrease following ipsilateral revascularization. The objective of this study was to determine if contralateral carotid artery duplex velocities decrease following ipsilateral carotid endarterectomy or stenting procedures. METHODS:This is a single institutional retrospective study of prospectively collected data on all patients who underwent carotid revascularization from 2013 to 2021. Patients with immediate preoperative and first postoperative Duplex scan within 4 months of carotid revascularization at our vascular laboratory were included for analysis. Patients with contralateral occlusion were excluded. Duplex criteria used to define moderate (50-69%) and severe (>70%) stenosis were systolic velocity ≥125 cm/sec and ≥230 cm/sec, respectively. RESULTS:Between 2013 and 2021, 129 patients with bilateral carotid stenosis underwent either carotid endarterectomy (98) or a stenting procedure (31). The majority of patients (90%) underwent intervention for severe stenosis. Preoperatively, the contralateral artery was categorized as severe in 30.4% patients. After ipsilateral carotid revascularization, 86 patients (67.2%) saw a decrease in the contralateral artery peak systolic velocity (PSV), while the remaining remained stable or increased. Fifty-four patients had a change in designated stenosis severity in the contralateral artery. Between the carotid endarterectomy and stenting cohorts, there was no significant difference in the proportion of patients whose contralateral velocity decreased (69.4% vs. 61.3%, P = 0.402). Patients with coronary artery disease and diabetes were significantly less likely to experience a decrease in the contralateral artery PSV after ipsilateral intervention (P = 0.018 and P = 0.033). CONCLUSIONS:In patients with bilateral carotid disease, ipsilateral revascularization can change the contralateral artery velocity and perceived disease severity. Most patients were noted to have a decrease in the contralateral artery PSV, although almost one-third either stayed stable or increased. On multivariable analysis, patients with coronary artery disease and diabetes were less likely to see a decrease in the contralateral artery PSV after intervention. Patients who are at risk for artificial elevation of the contralateral artery may warrant a re-evaluation of the contralateral artery after ipsilateral intervention. These patients are potentially better assessed with axial imaging, although further research is needed.

BACKGROUND:While prior studies have confirmed the protective effect of diabetes on abdominal aortic aneurysm (AAA) development, much less is known about the effect of diabetes, and in particular insulin dependence, on outcomes following AAA repair. In this study, we aim to evaluate the role of insulin-dependent diabetes on short-term and long-term outcomes following open and endovascular AAA repair. METHODS:The Vascular Implant Surveillance and Interventional Outcomes Network (VISION), a registry linking the Vascular Quality Initiative (VQI) data with Medicare claims, was queried for patients who underwent open or endovascular AAA repair from 2011 to the present. Exclusion criteria were unknown diabetes status, prior aortic intervention, maximum aneurysm diameter <45 mm at presentation, and Medicare Advantage coverage due to inconsistent follow-up. Patients were stratified based on diabetes status (no diabetes versus diabetes) and insulin dependence (no diabetes or non-insulin-dependent diabetes versus insulin-dependent diabetes). RESULTS:Of the 38,437 cases in the VISION endovascular aortic aneurysm (EVAR) and open aortic aneurysm repair (OAR) databases, 21,943 met inclusion criteria. Perioperative outcomes after OAR were comparable between diabetic and nondiabetic patients. However, diabetic patients undergoing EVAR were significantly more likely to have a postoperative myocardial infarction (1.0% vs 0.6%, P = 0.04) and have a 30-day readmission (10.9% vs 8.8%, P < 0.001). Insulin-dependent diabetic patients were more likely to require a 30-day readmission after OAR (24.5% vs 13.5%, P = 0.02) and EVAR (15.1% vs 9.0%, P < 0.001); however, only insulin-dependent diabetes mellitus (IDDM) patients undergoing EVAR experienced higher rates of postoperative myocardial infarction (1.9% vs 0.7%, P < 0.01). After propensity score matching, patients with IDDM undergoing EVAR were additionally at increased risk of mortality at 1-year, 3-year, and 5-year follow-up with the highest risk occurring at the 1-year mark (hazard ratio 1.79, P < 0.0001), while IDDM patients undergoing OAR were only at a significantly increased risk of mortality at 5-year follow-up (hazard ratio 1.90, P = 0.01). CONCLUSIONS:Patients with insulin-dependent diabetes have greater than 14% one-year mortality following open or endovascular aneurysm repair, compared to 8% for all others. Our findings raise questions about whether insulin-dependent diabetics should have a higher size threshold for prophylactic repair, although further studies are needed to address this question and consider the influence of glycemic control on these outcomes.

BACKGROUND:Despite the expanded application of thoracic endovascular aortic repair (TEVAR) in patients with significant cardiac comorbidities, the effect of decreased left ventricular ejection fraction (EF) on outcomes remains unknown. The aim of this study was to compare outcomes in patients with normal and abnormal EFs undergoing TEVAR for type-B aortic dissection (TBAD). METHODS:The Vascular Quality Initiative database was reviewed from 2012 to 2020. Patients were categorized into severely reduced (EF ≤ 30%), reduced (EF 30-50%) and normal EF (EF>50%). Baseline characteristics, procedural details and 18-month outcomes were compared. Multivariable logistic regression identified factors associated with mortality, major adverse cardiac events (MACEs), and aortic-related reintervention. RESULTS:Of 1,993 patients, 38 (2%) and 208 (10%) patients had severely reduced ejection fraction (SREF) and reduced ejection fraction (REF). Patients with abnormal EF were more likely to have cardiac comorbidities and be prescribed angiotensin-converting enzyme inhibitors and anticoagulants. Perioperatively, patients with SREF were more likely to experience mortality (13.2% vs. 6.7% vs. 4.4%, P = 0.018), MACE (26.3% vs. 11.5% vs. 8%, P < 0.001), hemodialysis (13.5% vs. 5% vs. 2.9%, P = 0.001) and aortic related reintervention (21.1% vs. 13% vs. 10%, P = 0.041), compared to REF and normal ejection fraction (NEF) patients. However, these associations were not present on multivariable analysis. At 18 months, mortality was significantly higher in patients with SREF, which was confirmed on multivariable analysis, but depressed EF was not associated with increased aortic reintervention compared to NEF. CONCLUSIONS:SREF was not independently associated with perioperative mortality or MACE compared to NEF. REF had similar risk of morbidity and mortality compared to NEF in both the perioperative and early postoperative periods. TEVAR-related complications were similar among the cohorts. As such, TEVAR may be offered to appropriately selected patients regardless of EF.

OBJECTIVE:The outcomes of patients with premature cerebrovascular disease (age ≤55 years) who undergo carotid artery stenting are not well-defined. Our study objective was to analyze the outcomes of younger patients undergoing carotid stenting. METHODS:The Society for Vascular Surgery Vascular Quality Initiative was queried for transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) procedures between 2016 and 2020. Patients were stratified based on age ≤55 or >55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction (MI), and composite outcomes. Secondary endpoints included procedural failure (defined as ipsilateral restenosis ≥80% or occlusion) and reintervention rates. RESULTS:Of the 35,802 patients who underwent either TF-CAS or TCAR, 2912 (6.1%) were ≤55 years. Younger patients were less likely than older patients to have coronary disease (30.5% vs 50.2%; P < .001), diabetes (31.5% vs 37.9%; P < .001), and hypertension (71.8% vs 89.8%; P < .001), but were more likely to be female (45% vs 35.4%; P < .001) and active smokers (50.9% vs 24.0%; P < .001) Younger patients were also more likely to have had a prior transient ischemic attack or stroke than older patients (70.7% vs 56.9%; P < .001). TF-CAS was more frequently performed in younger patients (79.7% vs 55.4%; P < .001). In the periprocedural period, younger patients were less likely to have a MI than older patients (0.3% vs 0.7%; P < .001), but there was no significant difference in the rates of periprocedural stroke (1.5% vs 2.0%; P = .173) and composite outcomes of stroke/death (2.6% vs 2.7%; P = .686) and stroke/death/MI (2.9% vs 3.2%; P = .353) between our two cohorts. The mean follow-up was 12 months regardless of age. During follow-up, younger patients were significantly more likely to experience significant (≥80%) restenosis or occlusion (4.7% vs 2.3%; P = .001) and to undergo reintervention (3.3% vs 1.7%; P < .001). However, there was no statistical difference in the frequency of late strokes between younger and older patients (3.8% vs 3.2%; P = .129). CONCLUSIONS:Patients with premature cerebrovascular disease undergoing carotid artery stenting are more likely to be African American, female, and active smokers than their older counterparts. Young patients are also more likely to present symptomatically. Although periprocedural outcomes are similar, younger patients have higher rates of procedural failure (significant restenosis or occlusion) and reintervention at 1-year follow-up. However, the clinical implication of late procedural failure is unknown, given that we found no significant difference in the rate of stroke at follow-up. Until further longitudinal studies are completed, clinicians should carefully consider the indications for carotid stenting in patients with premature cerebrovascular disease, and those who do undergo stenting may require close follow-up.

OBJECTIVES/OBJECTIVE:There is a paucity of data regarding outcomes of patients with premature cerebrovascular disease (age ≤ 55 years) who undergo carotid endarterectomy (CEA). The objective of this study was to analyze the demographics, presentation, perioperative and later outcomes of younger patients undergoing CEA. METHODS:The Society for Vascular Surgery Vascular Quality Initiative was queried for CEA cases between 2012-2022. Patients were stratified based on age ≤ 55 or age > 55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction and composite outcomes. Secondary endpoints included restenosis (≥80%) or occlusion, late neurologic events and re-intervention. RESULTS:Of 120,549 patients undergoing CEA, 7,009 (5.5%) were ≤ 55 years old (mean age of 51.3 years). Younger patients were more likely to be African American (7.7% vs 4.5%, p < .001), female (45.2% vs 38.9%, p < .001) and active smokers (57.3% vs 24.1%, p < .001). They were less likely than older patients to have hypertension (82.5% vs 89.7%, p < .001), coronary artery disease (25% vs 27.3%, p < .001) and CHF (7.8% vs 11.4%, p<.001). Younger patients were significantly less likely than older patients to be on aspirin, anti-coagulation, statins, or beta-blockers but were more likely to be taking P2Y12 inhibitors (37.2 vs 33.7%, p <.001). Younger patients were more likely to present with symptomatic disease (35.1% vs 27.6%, p<.001) and were more likely to undergo non-elective CEA (19.2% vs 12.8%; P < .001). Younger and older patients had similar rates of perioperative stroke/death (2% vs 2%, p= NS) and post-operative neurologic events (1.9% vs 1.8%, p = NS). However, younger patients had lower rates of overall postoperative complications compared to their older counterparts (3.7% vs 4.7%, p<.001). 72.6% of patients had recorded follow-up (mean 13 months). During follow-up, younger patients were significantly more likely than older patients to experience a late failure, defined as significant (≥80%) restenosis or complete occlusion of the operated artery (2.4% vs 1.5%, p <.001) and were more likely to experience any neurologic event (3.1% vs 2.3%, p<.001). Re-intervention rates did not significantly differ between the two cohorts. After controlling for co-variates using a logistic regression model, age ≤ 55 years was independently associated with increased odds of late re-stenosis/occlusion (OR 1.591, 95% CI 1.221-2.073, p<.001) as well as late neurologic events (OR 1.304, 95% CI 1.079-1.576, p = 0.006). CONCLUSIONS:Young patients undergoing CEA are more likely to be African American, female, and active smokers. They are more likely to present symptomatically and undergo non-elective CEA. Although perioperative outcomes are similar, younger patients are more likely to experience carotid occlusion or restenosis as well as subsequent neurological events, during relatively short follow-up. These data suggest that younger CEA patients may require more diligent follow-up, and a continued aggressive approach to medical management of atherosclerosis to prevent future events related to the operated artery, given the particularly aggressive nature of premature atherosclerosis.

OBJECTIVE:Much attention has been given to the influence of anatomic and technical factors, such as maximum abdominal aortic aneurysm diameter and proximal clamp position, in open abdominal aortic aneurysm repair (OSR). However, no studies have rigorously examined the correlation between site of distal anastomosis and OSR outcomes despite conventional wisdom that more proximal sites of anastomosis are preferrable when technically feasible. This study aimed to test the association between sites of distal anastomosis and clinical outcomes for patients undergoing primary elective OSR. METHODS:Our study included 5683 patients undergoing primary elective OSR at 233 centers from 2014 to 2020. Using a variety of statistical methods to account for potential confounders, including multivariable logistic regression and Cox proportional hazards modeling, as well as subgroup analysis, we examined the association between site of distal anastomosis and clinical outcomes in elective OSR. Primary outcomes were major in-hospital complication rate, 30-day mortality, and long-term survival. RESULTS:Patients undergoing elective aortobifemoral reconstruction (n = 672) exhibited significantly increased rates of smoking, chronic obstructive pulmonary disease, and peripheral artery disease in comparison to patients undergoing elective OSR with distal anastomosis to the aorta (n = 2298), common iliac artery (n = 2163), or external iliac artery (n = 550). Patients undergoing aorto-aortic tube grafting were significantly less likely to exhibit iliac aneurysmal disease and significantly more likely to be undergoing elective OSR with a suprarenal or supraceliac proximal clamp position. Using multivariable logistic regression and Cox proportional hazards analysis to control for important confounders, such as age, smoking status, and medical history, we found that distal anastomosis to the common femoral artery was associated with increased odds of major in-hospital complications (adjusted odds ratio, 1.79; 95% confidence interval, 1.46-2.18; P < .001) and reduced long-term survival (adjusted hazard ratio, 1.44; 95% confidence interval, 1.09-1.89; P = .010). We observed no significant differences in 30-day mortality across sites of distal anastomosis in our study population. CONCLUSIONS:It is generally accepted that more proximal sites of distal anastomosis should be selected in OSR when technically feasible. Our findings support this hypothesis by demonstrating that distal anastomosis to the common femoral artery is associated with increased perioperative morbidity and reduced long-term survival. Careful diligence regarding optimization of preoperative health status, perioperative care, and long-term follow-up should be applied to mitigate major complications in this patient population.

Objectives: This study compared outcomes in patients with and without preoperative cardiac stress testing undergoing carotid endarterectomy (CEA).
Method(s): Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database who underwent elective carotid revascularization between 2016 and 2019 were included. Patients were analyzed by group based upon whether they underwent cardiac stress testing within two years preceding revascularization without subsequent coronary intervention. Subset analysis was performed comparing outcomes between those with negative and positive results, defined as evidence of ischemia or myocardial infarction (MI). Outcomes of interest were periprocedural MI/stroke, 90-day readmission rates, as well as late-term mortality.
Result(s): We analyzed 14,470 patients who underwent elective CEA. Of these, 5411 (37.4%) underwent preoperative stress testing and 1231 (29.4%) were positive. Comorbidities were significantly higher among patients undergoing CEA with preoperative stress test compared to those without stress testing. For patients with positive stress test undergoing CEA, there was a significant increase in postoperative MI (1.7% vs 0.6%; P <.001) and 90-day readmission rates (19.6% vs 15.8%; P =.003), but no significant change in postoperative stroke or congestive heart failure incidence. In 3-year follow-up after CEA, those with a positive stress test were more likely to undergo coronary artery bypass graft/percutaneous coronary intervention (adjusted hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.42-2.27; P <.0001) and also exhibited a 28% increase in mortality (adjusted HR, 1.28; 95% CI, 1.03-1.58; P =.03) in follow-up compared to those patients with a negative preoperative stress test (Figure). Conversely, those patients with a negative stress test compared to no stress test undergoing CEA experienced a 14% reduction in follow-up mortality (adjusted HR, 0.86; 95% CI, 0.76-0.98; P =.02) despite no difference in in-hospital MI/stroke or follow-up coronary artery bypass graft/percutaneous coronary intervention (adjusted HR, 0.94; 95% CI, 0.78-1.14; P =.53).
Conclusion(s): Our study highlights that cardiac stress testing in appropriately selected patients can facilitate risk stratification and identify patients at higher risk of postoperative adverse cardiac events. Furthermore, judicious patient selection for elective CEA is warranted in patients with a positive preoperative stress test given the increased late mortality. [Formula presented]
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OBJECTIVE:Renal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR. METHODS:The Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes. RESULTS:Of 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P < .001), with higher incidence of hypertension (92% vs 84%; P = .004) and diabetes (29% vs 21%; P = .005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P < .001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P < .001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P < .001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P = .039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P < .001), but the need for new RRT was similar (1.1% vs 0.4%; P = .15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P < .001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P = .02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P = .235). CONCLUSIONS:Among patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI.

Objective: Renal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR.
Method(s): The Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes.
Result(s): Of 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P <.001), with higher incidence of hypertension (92% vs 84%; P =.004) and diabetes (29% vs 21%; P =.005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P <.001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P <.001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P <.001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P =.039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P <.001), but the need for new RRT was similar (1.1% vs 0.4%; P =.15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P <.001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P =.02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P =.235).
Conclusion(s): Among patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI. Keywords: End-stage renal disease, Endovascular abdominal aortic aneurysm, Multi-institutional study, Renal transplant, Renal transplant recipient, Vascular Quality Initiative database
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INTRODUCTION/BACKGROUND:Endovascular aneurysm repair (EVAR) has improved outcomes for ruptured abdominal aortic aneurysms (rAAA) compared to open repair. We examined the impact of aorto-uni-iliac (AUI) versus standard bifurcated endograft configuration on outcomes in rAAA. METHODS:Patients 18 years or older in the VQI database who underwent EVAR for rAAA from January 2011 to April 2020 were included. Patient characteristics were analyzed by graft configuration: AUI or standard bifurcated. Primary and secondary outcomes included 30-day mortality, post-operative major adverse events (MAE; myocardial infarction, stroke, heart failure, mesenteric ischemia, lower extremity embolization, dialysis requirement, re-operation, pneumonia or re-intubation) and 1-year mortality. A subset propensity-score matched (PSM) cohort was also analyzed. RESULTS:We included 2717 patients: 151 had AUI and 2566 had standard bifurcated repair. There was no significant difference between groups in terms of age, major medical comorbidities, anatomic aortic neck characteristics, or rates of conversion to open repair. Patients undergoing AUI were more commonly female (30% vs. 22%, p=0.011) and had a history of CHF (19% vs. 12%, p=0.013). Perioperatively, patients undergoing AUI had a significantly higher incidence of cardiac arrest (15% vs. 7%, p<0.001), greater intra-operative blood loss (1.3L vs. 0.6L, p<0.001), longer operative duration (218min vs. 138min, p<0.0001), higher incidence of MAE (46.3% vs. 33.3%, p=0.001), as well as prolonged ICU (7 vs. 4.7 days p=0.0006) and overall hospital length of stay (11.4 vs. 8.1 days, p=0.0003). Kaplan-Meier survival analyses demonstrated significant differences in 30-day (31.1% vs. 20.2%, log-rank p=0.001) and 1-year mortality (41.7% vs. 27.7%, log-rank p=0.001). The PSM cohort demonstrated similar results. CONCLUSION/CONCLUSIONS:The AUI configuration for rAAA appears to be implemented in a sicker cohort of patients and is associated with worse perioperative and 1-year outcomes compared to a bifurcated graft configuration, which was also seen on propensity matched analysis. Standard bifurcated graft configuration may be the preferred approach in the management of rAAA unless AUI configuration is mandated by patient anatomy or other extenuating circumstances.