Faculty Bibliography

OBJECTIVE:Open thoracoabdominal aortic aneurysm (TAAA) repair has been associated with high morbidity and mortality before the endovascular era, when repair options were limited. Our institution developed a multidisciplinary protocol to standardize patient selection, operative technique, and postoperative care to improve outcomes for open repairs. This study aimed to evaluate the protocol's preliminary benefits by comparing the outcomes of open TAAA repair on the protocol vs off the protocol. METHODS:A retrospective review of consecutive patients who underwent TAAA repair at a single institution from 2013 to 2023 was completed. Patients who underwent open repair were included and stratified by use of the protocol. The primary outcome was a composite of TAAA life-altering events, including in-hospital mortality, spinal cord ischemia with paraplegia, new onset of dialysis, or stroke. Secondary outcomes included each individual component, length of stay, and nonhome discharge. RESULTS:During the study period, 220 patients underwent TAAA repair at our institution, 190 endovascular and 30 open. There were 14 in the protocol group and 16 in the nonprotocol group. Patient demographics were similar between groups with an overall mean age of 46 years. A connective tissue disorder was present in 64% and 50% (P = .431) of protocol and nonprotocol patients, respectively. The majority of the patients in both groups presented with extent II TAAA (64% vs 75%). The composite end point occurred in 0% of the protocol group vs 38% of the nonprotocol group (P = .010). Secondary outcomes were dialysis (0% vs 19%; P = .23), paraplegia (0% vs 19%; P = .232), stroke (0% vs 0%), in-hospital mortality (0% vs 13%; P = .171), and nonhome discharge (7% vs 50%; P = .012). The median postoperative length of stay was 8 days vs 15 days (P = .038). CONCLUSIONS:In the endovascular era, open TAAA repair can be performed with encouraging outcomes when particular attention is given to patient selection, surgical technique, and postoperative care, with rates of mortality, paraplegia, renal failure, and length of stay that rival endovascular repair.

BACKGROUND:While anemia in patients undergoing endovascular aortic repair (EVAR) has been associated with negative outcomes, the impact of transfusion remains unclear and controversial. This study evaluates the impact of postoperative anemia and red blood cell transfusion in patients undergoing complex EVAR (CEVAR) including fenestrated-branched and chimney EVAR. METHODS:The Society for Vascular Surgery Vascular Quality Initiative was queried for patients undergoing CEVAR with incorporation of 1 or more viscerorenal vessels from 2014 to 2020. Patients were grouped by postoperative nadir hemoglobin (Hgb) level (<7, 7-8, 8-9, 9-10, >10 g/dL), then stratified by transfusion status. The primary endpoint was major adverse cardiac events (MACE), including myocardial infarction, heart failure, dysrhythmia, and stroke. Secondary endpoints included in-hospital mortality and 1-year survival. RESULTS:In total, 4,966 patients met criteria for analysis including 9% with Hgb <7, 14% with Hgb 7-8, 16% with Hgb 8-9, 17% with Hgb 9-10, and 43% with Hgb >10. The rate of transfusion correlated inversely by lowest Hgb level: 89%, 74%, 40%, 21%, 6%, respectively. MACE, in-hospital mortality and 1-year survival correlated with Hgb level, with the worst outcomes in the lowest level. MACE was significantly higher for patients that received transfusion across all Hgb groups: 33.42% vs. 15.63%, P = 0.048; 23.38% vs. 14.04%, P = 0.008; 18.69% vs. 5.97%, P < 0.0001; 14.44% vs. 6.55%, P = 0.0006, and 13.08% vs. 3.43%, P < 0.0001, respectively. In-hospital mortality was significantly higher for patients that received transfusion in all groups except Hgb <7. On multivariable analysis transfusion remained an independent predictor for MACE and in-hospital mortality. CONCLUSION/CONCLUSIONS:Postoperative anemia in patients undergoing CEVAR is associated with worse outcomes. However, rather than attenuating the negative impact of anemia, transfusion is independently associated with increased MACE and in-hospital mortality. These findings suggest potential harm of liberal transfusion and support the practice of using a hemoglobin level of 7 g/dL as the threshold for transfusion in stable patients that are not actively bleeding. Further study is necessary to determine the optimal transfusion threshold for patients undergoing CEVAR.

BACKGROUND:This study assessed the association between chronic obstructive pulmonary disease (COPD) severity and postoperative mortality among patients undergoing thoracic endovascular aortic repair (TEVAR) and complex endovascular aortic repair (CEVAR). METHODS:A retrospective review of the Vascular Quality Initiative database identified elective TEVAR and CEVAR cases from 2013 to 2022, with endograft proximal landing zone ≥2 for thoracic or complex abdominal aortic disease. Symptomatic diseases, ruptures, and urgent or emergent surgeries were excluded. Patients were stratified by COPD severity. The primary outcome was in-hospital mortality. Secondary outcomes included respiratory complications and 1-year mortality. Multivariable logistic regression was used for in-hospital mortality, respiratory complications, and 1-year mortality. RESULTS:Among 11,336 patients with TEVAR and CEVAR, 66% did not have COPD, 9% had COPD not on medications, 20% had COPD on medications, and 6% had COPD on home supplemental oxygen. In-hospital mortality was 2.3%, 3.7%, 3.2%, and 4.5% (P = 0.0004) respectively, and was not associated with increased odds of mortality. Respiratory complications occurred in 4.3%, 4.5%, 6.4%, and 7.3% (P < 0.0001) and were associated with increased odds for COPD on medications (OR 1.3) and COPD on home supplemental oxygen (OR 1.7). 1-year survival was 91%, 87%, 86%, and 80% and associated with increased risk for each COPD group (HR 1.4, HR 1.4, HR 1.9). CONCLUSION/CONCLUSIONS:Patients with COPD undergoing TEVAR and CEVAR have increased rates of in-hospital mortality, respiratory complications, and 1-year mortality. COPD severity is independently associated with increased respiratory complications and 1-year mortality, which should be factored into preoperative decision-making.

BACKGROUND:Treatment of iliac artery aneurysms (IAAs) with the iliac branch endoprosthesis (IBE) during endovascular repair of infrarenal abdominal aortic aneurysm (endovascular aortic repair (EVAR)) has been well-documented as effective. However, limited data exist evaluating the safety and efficacy of treating complex abdominal (cAAAs) and thoracoabdominal aortic aneurysms (TAAAs) with associated IAA with combined physician-modified fenestrated-branched EVAR (PM-FBEVAR) and IBE. Moreover, limited studies exist assessing the impact of adding IBE on the outcomes following PM-FBEVAR. Therefore, we compared the clinical outcomes of patients who underwent PM-FBEVAR with and without IBE for the treatment of cAAA and TAAA. METHODS:A single-institution retrospective review of consecutive patients who underwent PM-FBEVAR between September 2015 and February 2021 was conducted. Patients with both unilateral and bilateral IBE implantation were included. Infected aneurysms and pseudoaneurysms were excluded. Demographics, technical success, and operative factors were analyzed. Primary outcomes were incidence of pelvic ischemia including buttock and thigh claudication, bowel and spinal cord ischemia, patency of internal and external limbs of IBE, and target vessel instability. Secondary outcomes included technical success, 30-day major adverse events, 30-day and all-cause mortality, and endoleaks. RESULTS:Among 183 patients identified who underwent PM-FBEVAR, 22 patients underwent PM-FBEVAR and IBE with 3 patients treated with bilateral IBEs. There was no pelvic ischemia in the PM-FBEVAR and IBE group. Technical success, fluoroscopy time, and procedure time were comparable between the 2 groups. Contrast usage was higher in the PM-FBEVAR and IBE group (P = 0.01). Thirty-day major adverse event and mortality were not statistically different between the 2 groups. At a mean follow-up of 23 months, all-cause mortality was similar for both groups (21% vs. 27%; P = 0.47). Patency of internal iliac artery limb and external iliac artery limb of the IBE were 96% (24 of 25) and 100%, respectively, during mean follow-up of 23 months. The patient with occlusion of internal iliac limb was asymptomatic and received no reintervention. CONCLUSIONS:Treatment of cAAA and TAAA associated with IAA using combined PM-FBEVAR and IBE is feasible with high efficacy and safety, and without adverse effect on outcomes. Long-term follow-up is planned to assess durability of repair with PM-FBEVAR and IBE.

BACKGROUND:Anemia is highly prevalent in patients with peripheral vascular disease and has been associated with postoperative cardiac events and mortality and adverse limb events after revascularization procedures. Allogenic blood transfusions have also been associated with adverse events including hospital-acquired infections, cardiac morbidity, and reduced survival. The aim of this study was to evaluate the impact of blood transfusion on major adverse cardiac events (MACE) and major adverse limb events (MALE) in patients undergoing infrainguinal lower extremity bypass (LEB) operations. METHODS:We performed a retrospective cohort analysis of patients undergoing infrainguinal LEB in the Society for Vascular Surgery Vascular Quality Initiative database between 2003 and 2020. Patients were first grouped by their preoperative hemoglobin (Hgb) number (severe anemia: Hgb 7-10 g/dL; moderate anemia: 10-12 g/dL; normal Hgb: >12 g/dL) and then stratified by their transfusion status (perioperative transfusion versus no perioperative transfusion). Primary end points were MACE, defined as myocardial infarction, new congestive heart failure, dysrhythmia, or stroke in the postoperative period, and MALE, defined as return to operating room for thrombosis, loss of primary patency on follow-up, and major ipsilateral amputation on follow-up. Secondary outcomes included wound complications, graft infections, 30-day mortality, and 1-year survival. Outcomes were compared between patients who received transfusions and those who did not at every anemic threshold. Multivariable logistic regression was performed to evaluate the impact of blood transfusion on primary outcomes. RESULTS:A total of 55,884 patients were included for analysis, of which 16.3% had severe anemia, 25.9% had moderate anemia, and 57.8% had normal Hgb. Anemia severity was associated with increased rates of MACE (9.8% vs. 8.3% vs. 5.2%, P < 0.0001) and MALE (32.2% vs. 24.8% vs. 18.6%, P < 0.0001). On univariate analysis, transfusion was consistently associated with increased rates of MACE and MALE at every anemic threshold (P < 0.0001 for all). Transfusion was also associated with increased rates of 30-day mortality at all anemic thresholds (P < 0.0001 for all) and reduced 1-year survival at all anemic thresholds (log-rank P < 0.0001 for all). On multivariable analysis for MACE, an interaction factor was observed between preoperative Hgb and transfusion status (P < 0.0001). At every anemic threshold, transfusion was independently associated with MACE (severe: odds ratio [OR] 2.4 [95% confidence interval [CI]: 2.0-2.9]; moderate: OR 2.8 [95% CI: 2.5-3.2]; normal: OR 4.5 [95% CI: 4.0-5.0]). On multivariable analysis for MALE, an interaction factor was also observed between preoperative Hgb and transfusion status (P < 0.0001). At every anemic threshold, transfusion was independently associated with MALE (severe: OR 2.1 [95% CI: 1.9-2.3]; moderate: OR 1.8 [95% CI: 1.7-2.0]; normal: OR 2.6 [95% CI: 2.4-2.8]). CONCLUSIONS:Perioperative blood transfusion in patients undergoing infrainguinal LEB is independently associated with MACE and MALE in all patients with preoperative Hgb >7 g/dL. Despite the morbidities associated with anemia, these findings highlight that transfusion may not be the optimal treatment modality, particularly in patients with higher preoperative Hgb. Future research is needed to define the transfusion threshold in this population.

OBJECTIVE:Fenestrated-branched endovascular aortic repair (FB-EVAR) has shown favorable outcomes for repair of complex aneurysms and thoracoabdominal aortic aneurysms. Physician-modified endografting (PMEG) and the Gore thoracoabdominal multibranch endoprosthesis (TAMBE) provide custom and off-the-shelf devices for FB-EVAR, respectively. This study compares the outcomes of TAMBE and PMEG at a single institution. METHODS:A retrospective review of patients who underwent TAMBE as part of the multicenter pivotal trial or PMEG as part of a prospective physician-sponsored investigational device exemption at a single institution between 2020 and 2022 were completed. Patient demographics, characteristics, and perioperative and midterm outcomes were compared. RESULTS:A total of 68 patients were included, with 12 in the TAMBE group and 56 in the PMEG group. Baseline characteristics were comparable between groups. Aneurysm type was most often thoracoabdominal aortic aneurysm in both groups (58% TAMBE and 52% PMEG). TAMBE had a higher rate of upper extremity access (100% vs 63%; P = .013) and longer mean procedure time (247 ± 36 minutes vs 189 ± 49 minutes; P < .001). Other intraoperative metrics were similar between groups. Technical success was 100% in TAMBE and 95% in PMEG (P = .412). There was no 30-day mortality in either group. No major adverse events occurred with TAMBE, whereas in PMEG cases, 2% had respiratory failure, 2% required dialysis, and 4% experienced spinal cord ischemia. Although the overall endoleak rates were similar (50% of TAMBE vs 41% of PMEG; P = .57), type II endoleaks accounted for all of the endoleaks in the TAMBE group, whereas type I or III endoleaks were seen in 11% of PMEG patients. At a median follow-up of 26.7 months for the TAMBE group and 21.2 months for the PMEG group, target vessel instability was seen in 10.4% of TAMBE, and 6.9% of PMEG targeted branches (P = .401). Reintervention was required in 33% of TAMBE patients and 27% of PMEG patients (P = .646). Estimated freedom from reintervention rates at 3 years were similar (56% TAMBE vs 62% PMEG, log-rank P = .910). Freedom from visceral renal target vessel instability at 3 years was 89% for both groups (log-rank P = .459). The Kaplan-Meier 3-year estimated survival was 100% for patients in the TAMBE group and 77% for patients in the PMEG group (log-rank P = .157). CONCLUSIONS:At experienced centers, FB-EVAR can be completed with PMEG or TAMBE with comparable, excellent perioperative and midterm outcomes. Reinterventions are frequently needed for both TAMBE and PMEG.

PURPOSE/UNASSIGNED:Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) remains a devastating complication following endovascular thoracoabdominal aortic repairs. Novel strategies to preserve key intercostal/lumbar arteries have been described. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular incorporation of fenestrations/branches or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVARs). MATERIALS AND METHODS/UNASSIGNED:A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. RESULTS/UNASSIGNED:Among 317 patients who underwent FBEVAR during the study period, 12 patients were included. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in 8 patients and supraceliac coverage >10 cm was required in 4. Nine patients received endovascular incorporation, including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (2/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene (PTFE) and venous conduit. Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain (CSFD) for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic CSFD was placed in 9 patients. One patient had unsuccessful drain placement attempts. The other 2 patients had previous unsuccessful attempts at CSFD placement. Median number of target vessels for FBEVAR was 4 with fluoroscopy time 66±31 minutes, contrast usage 109±51 ml. There were no in-hospital mortalities. Tarlov grade II SCI (ASIA grade D) were seen in 2 patients (1 endovascular and 1 extra-anatomic bypass), which resolved before discharge. At mean follow-up of 472±447 days, 3 patients had thrombosed intercostal/lumbar branches (1 extra-anatomic bypass and 2 endovascular branches) with no new SCI symptoms. CONCLUSIONS/UNASSIGNED:In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing segmental arteries and optimization of revascularization strategies. CLINICAL IMPACT/CONCLUSIONS:This study demonstrates the feasibility of Endovascular and extra-anatomic bypass to preserve segmental artery flow, aimed at reducing the risk of spinal cord ischemia during endovascular thoracoabdominal aortic repairs.

OBJECTIVE:Penetrating cerebrovascular injuries (PCVI) are associated with a high incidence of mortality and neurological events. The optimal treatment strategy of PCVI, especially when damage control measures are required, remains controversial. The aim of this study was to describe the management of PCVI and patient outcomes at a level 1 trauma center where vascular injuries are managed predominantly by trauma surgeons. METHODS:An institutional trauma registry was queried for patients with PCVI from 2011 to 2021. Patients with common carotid artery (CCA), internal carotid artery (ICA), or vertebral artery injuries were included for analysis. The primary outcome was in-hospital stroke. The secondary outcomes were in-hospital mortality and in-hospital stroke or death. A subgroup analysis was completed of arterial repair (primary repair or interposition graft) vs ligation or embolization vs temporary intravascular shunting at the index procedure. RESULTS:We analyzed 54 patients with PCVI. Overall, the in-hospital stroke rate was 17% and in-hospital mortality was 26%. Twenty-one patients (39%) underwent arterial interventions for PCVI. Ten patients underwent arterial repair, six patients underwent ligation or embolization, and five patients underwent intravascular shunting as a damage control strategy with a plan for delayed repair. The rate of in-hospital stroke was 30% after arterial repair, 0% after arterial ligation or embolization, and 80% after temporary intravascular shunting. There was a significant difference in the stroke rate between the three subgroups (P = .015). Of the 32 patients who did not have an intervention to the CCA, ICA, or vertebral artery, 1 patient with ICA occlusion and 1 patient with CCA intimal injury developed in-hospital stroke. The mortality rate was 0% after arterial repair, 50% after ligation or embolization, and 60% after intravascular shunting. The rate of stroke or death was 30% in the arterial repair group, 50% in the ligation or embolization group, and 100% in the temporary intravascular shunting group. CONCLUSIONS:High rates of stroke and mortality were seen in patients requiring damage control after PCVI. In particular, temporary intravascular shunting was associated with a high incidence of in-hospital stroke and a 100% rate of stroke or death. Further investigation is needed into the factors related to these finding and whether the use of temporary intravascular shunting in PCVI is an advisable strategy.

OBJECTIVE:Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease. METHODS:All consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30 days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30 days, technical success, and <30% residual stenosis. RESULTS:Fifty-eight patients (62% male; mean age, 78 ± 6.6 years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87 ± 27 minutes and 25 ± 14 minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29 mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having <30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30 days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P = .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P = .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132 days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period. CONCLUSIONS:IVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30 days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.