Faculty Bibliography

OBJECTIVE:Endovenous ablation of the great saphenous vein (GSV) has traditionally been approached with caution or even delayed in patients with a recent history of superficial venous thrombosis (SVT) due to concern for postprocedural complications. Scant literature has substantiated this theoretical concern. The objective of this study was to characterize the safety of GSV ablation in patients with a recent history of SVT. METHODS:This single-center retrospective cohort study included patients who underwent a GSV ablation with or without concomitant microphlebectomy from March 2016 to December 2023 at an institutional accredited outpatient vein center. Patients were grouped into two cohorts: (1) no history of ipsilateral SVT or (2) a recent history of ipsilateral SVT, defined as a clinical diagnosis within three months of GSV ablation. Patients with no history of SVT were propensity score-matched 1:1 to those with a recent history of ipsilateral SVT using nearest-neighbor matching based on the following covariates: age, sex, race, insurance status, history of DVT, and use of preoperative anticoagulation. The primary endpoint was postprocedural acute DVT. Secondary endpoints included new or worsening SVT, endovenous heat-induced thrombosis (EHIT), and the time interval between the office visit recommending intervention and the procedural date. RESULTS:79 patients with no history of SVT and 79 patients with a recent history of SVT were included. Among the 158 total patients, 46.2% of patients underwent isolated GSV ablation, and 45.6% underwent GSV ablation with concomitant microphlebectomy, and 8.2% underwent GSV ablation with staged microphlebectomy. There was no difference in the preoperative Venous Clinical Severity Score between the two cohorts (6.4 vs. 7.3, p=0.09). Patients without SVT had the longer waiting period from the office visit that planned the procedure to the intervention date (52 vs. 35 days, p=0.005). Postoperatively, those with a recent SVT were more likely to have thrombosed superficial tributaries (30.4% vs. 59.5%, p<0.001). There were no significant differences in other postoperative outcomes including acute DVT (p=0.65), endothermal heat-induced thrombosis (EHIT) (p=0.17), or SVT (p=0.32). CONCLUSIONS:New or worsening SVT was rare (1/158, 0.6%) and did not differ between cohorts (p=0.32); accordingly, intervention in these patients should not be delayed. Moreover, our findings show that there were no differences in procedural outcomes between patients with recent SVT and patients without SVT.

OBJECTIVE:Socioeconomic factors, including insurance status, have been implicated in disparities in surgical outcomes. This study evaluates whether insurance status influences urgency of presentation and postoperative outcomes following endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysms (AAA). METHODS:Patients undergoing infrarenal EVAR for AAA were identified from the prospectively maintained Vascular Quality Initiative database encompassing centers across the United States and Canada, between January 2003 and February 2024. Patients were categorized by insurance status: Medicare, commercial, Medicaid, or uninsured, and stratified by intact versus ruptured AAA (rAAA). Subgroup analyses were performed for patients aged < 65 and ≥ 65 years. The primary outcome was in-hospital mortality. Secondary outcomes included in-hospital major adverse cardiac events and unplanned reoperation. Multivariable logistic regression assessed the association of insurance status with acuity of presentation and postoperative outcomes. RESULTS:Of 76,806 patients undergoing EVAR, 44,555 (58.0%) had Medicare, 21,782 (28.4%) commercial insurance, 9,708 (12.6%) Medicaid, and 761 (1.0%) were uninsured. Uninsured patients presented with larger aneurysms (mean ± standard deviation: 6.2 ± 1.7 cm vs 5.7 ± 1.3 cm; p<.001) and rupture (25.4% vs 5.9% Medicare, 6.3% commercial insurance, and 7.0% Medicaid; p<.001). After risk adjustment, both uninsured (odds ratio [OR], 2.70; 95% confidence interval [CI]: 2.05-3.18; p < .001) and Medicaid patients (OR, 1.12; 95% CI: 1.01-1.24; p = .030) were associated with significantly higher odds of rAAA presentation compared with Medicare beneficiaries. For intact AAA, insurance status was not associated with adverse perioperative outcomes in all age groups. In 4,869 patients presenting with rAAA, uninsured status was associated with higher in-hospital mortality across all age groups (age < 65 years: OR, 4.24; 95% CI: 1.95-9.23; p<.001; age ≥ 65 years: OR, 2.46; 95% CI: 1.27-4.75; p=.008). Among patients ≥ 65 years, Medicaid was also associated with increased mortality compared with Medicare (OR, 1.42; 95% CI: 1.10-1.82; p=.007). CONCLUSION/CONCLUSIONS:Among patients undergoing EVAR, uninsured and Medicaid patients were more likely to present with rAAA, while uninsured and older Medicaid patients were more likely to suffer from higher perioperative mortality after EVAR for rAAA. These disparities may reflect delayed detection and barriers to surveillance. Expanding AAA screening programs, improving insurance coverage, and enhancing perioperative management strategies are critical to addressing inequities and reducing preventable AAA-related deaths.

BACKGROUND:Advances in pancreatic cancer surgery involve hepatotoxic chemotherapies and hepatic vasculature resections, increasing the risk of clinically relevant postpancreatectomy liver injury. The study aimed to analyze the incidence and impact of clinically relevant postpancreatectomy liver injury after pancreatectomy with hepatic vessel resection. METHODS:In this single-institutional study, patients undergoing pancreatectomy with resection of hepatic vessels (portal vein/superior mesenteric vein, celiac axis, and hepatic arteries) were analyzed. Arterial lactate, total bilirubin, alanine aminotransferase, aspartate aminotransferase, international normalized ratio, and Doppler ultrasound-derived resistive index were assessed postoperatively. Postoperative outcomes were assessed through 90 days. Clinically relevant postpancreatectomy liver injury was defined as American Association for the Study of Liver Diseases-defined liver failure and/or need for invasive treatment of liver complications. RESULTS:Among 116 patients (67% portal vein/superior mesenteric vein resection alone, 7% celiac axis/hepatic arteries alone, 26% portal vein/superior mesenteric vein + celiac axis/hepatic artery resection), 15 (13%) developed clinically relevant postpancreatectomy liver injury. Mortality was significantly higher in the clinically relevant postpancreatectomy liver injury group (47% vs 3%; P < .001). The proper hepatic artery resistive index was lower in the clinically relevant postpancreatectomy liver injury group (0.52 vs 0.65; P = .034), whereas the following 48-hour-peak blood tests were significantly higher in this group: Lac, bilirubin, aspartate aminotransferase, and alanine aminotransferase (all P < .01). Combined portal vein/superior mesenteric vein + celiac axis/hepatic arteries and elevated alanine aminotransferase 48-hour peak above 1680 U/L remained significantly associated with the occurrence of clinically relevant postpancreatectomy liver injury in multivariable analyses. Forty percent of clinically relevant postpancreatectomy liver injury occurred in the absence of vascular complications. CONCLUSION/CONCLUSIONS:Clinically relevant postpancreatectomy liver injury is associated with significant mortality. Low resistive index and markedly elevated biochemical markers within the first 48 hours correlate with clinically relevant postpancreatectomy liver injury and may be used to trigger earlier intervention. Given the associated morbidity and mortality, defining, preventing, and mitigating clinically significant postpancreatectomy liver injury is of the utmost importance.

OBJECTIVE:While bovine aortic arch (BAA) is the most common aortic arch variant and has been associated with an increased risk of stroke in the general population, limited data exist on the impact of BAA on outcomes following carotid artery stenting (CAS). This study evaluates the association between BAA and post-operative outcomes in patients undergoing CAS. METHODS:A retrospective analysis of the multi-institutional Vascular Quality Initiative database identified all patients undergoing CAS for atherosclerotic carotid stenosis from January 2017 to February 2024. Patients were stratified by the presence of BAA. Procedures included transcarotid artery revascularisation (TCAR) with flow reversal, transfemoral CAS (TF-CAS), and transbrachial/transradial CAS (TB/TR-CAS) using distal embolic protection. The primary outcome was in hospital stroke or death. Secondary outcomes included stroke, death, myocardial infarction (MI), access-related complications, and stroke/transient ischaemic attack (TIA). Baseline characteristics were compared, and multivariable logistic regression was performed to adjust for potential confounders. RESULTS:Among 18 254 patients undergoing CAS, 2 037 (11.1%) had BAA. Patients with BAA were more likely to present with symptomatic and left sided carotid stenosis. After adjustment, BAA was not associated with increased odds of post-operative stroke, death, MI, or composite adverse events. Within the BAA cohort, peri-operative outcomes were comparable across TCAR, TF-CAS, and TB/TR-CAS, regardless of symptomatic status. Independent predictors of in hospital stroke or death included history of congestive heart failure and advanced age. Outcomes did not differ by lesion laterality in patients with BAA. CONCLUSION/CONCLUSIONS:In this large, contemporary, multicentre study, BAA was not independently associated with increased peri-operative risk following CAS. In current practice, where access selection is guided by pre-operative imaging and clinical judgement, CAS can be performed with comparable post-operative outcomes in select patients with BAA.

IntroductionThis study assessed the relationship between venous leg ulcers (VLUs) and overall survival among patients treated for chronic venous insufficiency.MethodsPatients with CEAP C2-C6 disease who underwent superficial venous interventions at a single center from May 2016-April 2024 were identified from the Vascular Quality Initiative Varicose Vein Registry. Demographics, comorbidities, and venous disease severity were recorded at the index database procedure. Mortality was recorded from the electronic health record and Social Security Death Index. Patient characteristics and all-cause mortality were compared between VLU (C5-C6) and non-VLU (C2-C4) cohorts.ResultsAmong 7084 patients, 8.9% (n = 632) had a VLU history. Compared with non-VLU patients, those with a VLU history were older (p < .001) and disproportionately male (p < .001), Black/African American (p < .001), and Medicaid-insured (p = .009). They had greater body mass indices (p < .001), revised venous clinical severity scores (rVCSS) (p < .001), HASTI scores (p = .015), and work/activity limitations (p < .001). Prior venous thromboembolism (p < .001), anticoagulation use (p < .001), previous varicose vein (VV) treatment (p = .042), and deep venous reflux (DVR) (p < .001) were also more common. Mortality was higher among VLU patients than non-VLU patients (3.6% vs 0.7%, p < .001) over a similar mean follow-up (2.8 vs 3.0 years, p = .070). VLU history was associated with worse survival (HR 5.03, 95% CI [2.96-8.53], p < .001), in addition to older age (p < .001), male sex (p = .003), White race (p = .003), no prior VV treatment (p = .026), anticoagulation use (p < .001), higher rVCSS (p < .001), and DVR (p = .016). After adjusting for these latter variables, VLU history remained independently associated with mortality (adjusted HR 2.01, 95% CI [1.00-4.01], p = .049). Compared with C2, only C6 -not C3-C5 -was associated with increased mortality after multivariable adjustment (adjusted HR 3.40, 95% CI [1.08, 10.69], p = .036).ConclusionAmong patients undergoing superficial venous interventions, VLUs were associated with a two-fold hazard of all-cause death. The mechanism driving their increased mortality warrants further study.

OBJECTIVE:Fragmentation of care (FOC) is referred to as receipt of care across multiple unaffiliated health systems (HS). We evaluated whether FOC was associated with outcomes in patients with uncomplicated type B aortic dissection (uTBAD). METHODS:The Healthcare Cost and Utilization Project State Inpatient Databases, for California (2018-2021), New York/Maryland/Florida (2016-2020) were queried using International Classification of Disease-10th (ICD-10) edition to identify patients who underwent medical management for uTBAD. Patient's hospital affiliation and its linkage to a HS during follow up were verified using the American Hospital Association data (AHA). FOC was defined as receipt of care across multiple unaffiliated, AHA defined HS, care delivered among transitions within the same HS was not classified as FOC. Univariate analyses were conducted to compare outcomes between patients with and without FOC, employing Chi-square or Fisher's exact tests as appropriate. Multivariable logistic regression models were constructed to investigate associations between FOC and outcomes. Model validation was performed using Hosmer-Lemeshow test, and receiver operating characteristic curve analysis. RESULTS:Among 5,476 patients included in the analysis, FOC was observed in 3,046 (55.6%). Baseline characteristics between those with and without FOC differed significantly. During follow-up, while mortality rates were similar between groups, FOC group had significantly more computed tomography scans, higher rates of aortic interventions, and elevated complication rates. Furthermore, total costs were markedly higher with FOC. Multivariable analysis also showed that FOC was associated with increased aortic interventions [TEVAR: OR 1.47, 95%CI 1.26-1.74] and complication rates (renal failure [OR 1.3, 95% CI 1.17-1.50], paraplegia [OR 1.60, 95% CI 1.07-2.42], and stroke [OR 1.31, 95%CI 1.09-1.58]) during follow-up. Total costs were 31% higher in the FOC group (p<0.001). CONCLUSIONS:FOC in uTBAD patients is associated with increased likelihood of intervention with higher post-procedural complications and elevated healthcare costs. Coordinated care within a single HS should be prioritized to improve outcomes and reduce healthcare cost.

Pancreatic ductal adenocarcinoma (PDAC) with extensive peripancreatic vessel involvement is classified as locally advanced pancreatic cancer (LAPC). For this group of patients, the current standard of care does not include considering a potentially curative oncologic resection. However, recent advances in multiagent chemotherapy and surgical techniques are challenging this paradigm. Moreover, the current determination of anatomic resectability is vague and unreliable. Here we propose a definition of local resectability, based on pre- and intra-operative assessment. This anatomic definition of resectability assumes careful patient selection based on tumor biology and patient condition. The pre-operative evaluation of vascular anatomy and tumor involvement is conducted using 3D-rendering of pancreas-protocol computed tomography. Identifying a disease-free arterial or venous segment above and below the tumor involvement ("suitable target") is the single critical factor that determines anatomic resectability. Intraoperative isolation of these target vessels confirms the feasibility of vascular reconstruction before resection. This approach, which focuses on identifying target vessels rather than circumferential involvement, offers a more straightforward and clinically relevant method for assessing surgical eligibility in LAPC patients at centers of excellence. In summary, reconstructability-based on surgical expertise and guided by tumor biology-now defines the modern paradigm of resectability in LAPC.

The presence of calcification in the femoral arteries can, at times, preclude patients from undergoing percutaneous endovascular repair of the aorta. Here, we present a case of endovascular aortic repair performed using lithotripsy-assisted femoral artery access. A heavily calcified common femoral artery was able to be treated using a lithotripsy balloon inserted from the contralateral femoral artery to allow percutaneous large-bore access. The purpose of this technique was to allow for endovascular aortic repair while avoiding the morbidity and increased hospital stay associated with open exposure of the femoral artery.

OBJECTIVES/OBJECTIVE:The Best Endovascular versus Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial found that in patients with an adequate (≥ 3.0 mm) single-segment great saphenous vein (GSV), surgical bypass resulted in superior outcomes when compared to endovascular intervention. Thus, the prevalence of an adequate GSV is an essential factor in planning appropriate intervention for patients with chronic limb-threatening ischemia (CLTI). However, the percentage of patients with an adequate GSV remains unknown. The objective of this study was to report the prevalence of an adequate GSV in patients with CLTI. METHODS:This was a single-center retrospective analysis of patients with CLTI, defined as an ankle-brachial index (ABI) ≤ 0.60 with appropriate symptoms (ie, rest pain, arterial ulceration), who underwent bilateral sonographic GSV mapping from May 2023 to November 2023. Ipsilateral GSV was defined as the symptomatic limb with the lowest recorded ABI. GSV diameter measurements were collected in seven locations from the saphenofemoral junction (SFJ) to the distal calf. To be considered an adequate GSV, all unilateral GSV diameter measurements from the SFJ to the mid-calf must have been at least 3.0 mm. Patients who underwent previous lower extremity bypass procedures were excluded. RESULTS:Seventy patients with CLTI were identified during the study period. Only 11.4 % (8/70) of patients had a completely adequate ipsilateral GSV; if the contralateral vein was also included, rates of GSV adequacy increased to 14.3% (10/70). There were no differences in demographics between patients who had adequate GSV and those who did not. Seven patients (10%) were missing an ipsilateral GSV due to a previous coronary bypass, and one patient (1.4%) had superficial venous thrombosis in their GSV. Patients with an inadequate ipsilateral GSV were less likely to have an adequate contralateral GSV (4.8% vs. 50.0%, p<0.001). The rates of GSV diameter ≥ 3 mm decreased as measurements were recorded more distally: 80% of GSVs were adequate at the level of the SFJ, 21% were adequate at the proximal-calf level, and only 9% were adequate at the distal-calf level. CONCLUSIONS:The majority of patients presenting with CLTI at our institution did not have a sonographically adequate ipsilateral nor contralateral GSV available for surgical bypass to the infrageniculate popliteal or tibial arteries. The rates of GSV diameter ≥ 3 mm in the calf were extremely low overall. Despite the improved outcomes in surgical bypass patients demonstrated in BEST-CLI, endovascular intervention will likely remain frequently utilized due to the low prevalence of an adequate GSV.