Faculty Bibliography

BACKGROUND:Aortic morphology is an important consideration in patients who present with acute type B aortic dissection (TBAD). This study evaluates the relationship between the distal extent of dissection with malperfusion syndromes, clinical outcomes after thoracic endovascular aortic repair (TEVAR) and mortality. METHODS:The Vascular Quality Initiative (VQI) database was queried from 2012 to 2022 for patients undergoing TEVAR for acute TBAD. Primary exposure variable was distal extent of dissection, categorized as thoracic (zones 2-5), abdominal (zones 6-9) or iliac (zones 10-11). Primary endpoints were 30-day and 2-year mortality. Secondary endpoints included postoperative malperfusion, resolution of malperfusion following TEVAR, and reoperation. Outcomes were compared between cohorts. RESULTS:2,455 patients were included. A more distal extent of dissection was associated with a stepwise increase in risk of lower extremity (5.8% vs. 8.7% vs. 27.4%), intestinal (5.1% vs. 13.6% vs. 19.8%) and renal (6.7% vs. 17.7% vs. 27.3%) ischemia on presentation (p<0.0001 for all). Distal extent of dissection was associated with increased rates of postoperative mesenteric (2.4% vs. 4.6% vs. 6.1%, p=0.0009) and renal (2.7% vs. 5.5% vs. 6.0%, p=0.0036) ischemia, and increased rates of reoperation (11.3% vs. 15.0% vs. 17.3%, p=0.0017). Distal extent of dissection was not associated with resolution of malperfusion after TEVAR, and not independently associated with 30-day or 2-year mortality (p>0.05 for all). CONCLUSION/CONCLUSIONS:Although a more distal extent of aortic dissection is associated with increased rates malperfusion on presentation and increased rates of complications after TEVAR, it is not independently associated with mortality.

BACKGROUND:Thoracic endovascular aortic repair (TEVAR) is the standard of care for type B aortic dissection (TBAD) complicated with visceral malperfusion. TEVAR is considered efficient at relieving malperfusion caused by dynamic obstruction but not static obstruction, and as such, some patients also require adjunctive visceral branch vessel interventions (VBI). The role of VBI in patients undergoing TEVAR for TBAD complicated with visceral malperfusion is a subject of considerable debate. This study aims to compare the postoperative outcomes of TEVAR with VBI vs without for TBAD complicated with visceral malperfusion in a real-world multi-institutional setting. METHODS:The Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database was queried for patients who underwent TEVAR for TBAD complicated with hepatic, intestinal, or renal malperfusion. The cohort was divided into two groups based on the main exposure variable: TEVAR with adjunctive VBI vs without on either celiac artery (CA), superior mesenteric artery (SMA), right renal artery (RRA), or left renal artery (LRA), presenting with malperfusion. Baseline demographic, clinical, and perioperative characteristics, as well as outcomes such as overall 30-day mortality, malperfusion-related mortality, Major Adverse Cardiovascular Events (MACE: death, myocardial infarction, stroke), overall complications, reinterventions, and visceral branch reinterventions, were compared between the groups. Univariable and multivariable analyses were performed. RESULTS:Of all reviewed patients, 477 were involved in the final analysis, 324 (67.9%) underwent TEVAR without a VBI, whereas 153 (32.1%) underwent TEVAR in association with an adjunctive intervention on at least one of the visceral branches (CA, SMA, RRA, LRA), presenting with malperfusion. Patients who underwent TEVAR with a VBI had significantly lower rates of overall 30-day mortality (9.8% vs 17.3%, p=0.032), malperfusion-related mortality (3.3% vs 9.6%, p=0.015), a tendency towards a lower rate of MACE (15.7% vs 22.8%, p=0.071), and a higher rate of visceral branch reinterventions (11.8% vs 6.2%, p=0.035). After adjustment for potential confounders, patients who underwent TEVAR with a VBI had 90% decreased odds of 30-day mortality (OR: 0.10, 95%CI: 0.03-0.40, p=0.001), 78% decreased odds of malperfusion-related mortality (OR: 0.22, 95%CI: 0.05-0.95, p=0.043), 50% decreased odds of MACE (OR: 0.50, 95%CI: 0.25-0.97, p=0.040) and increased odds of visceral branch reinterventions (OR: 2.36, 95%CI: 1.01-5.52, p=0.047). CONCLUSIONS:TEVAR with VBI is associated with significantly reduced odds of 30-day mortality, malperfusion-related mortality, and MACE, but increased odds of visceral branch reinterventions in TBAD patients presenting with visceral malperfusion. Based on these results, a lower threshold for performing VBI is recommended for patients with malperfusion. Further prospective studies are required to confirm these findings and to identify patients who would benefit from VBI the most.

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:Cerebral hyperperfusion syndrome (CHS) is a rare but serious complication following carotid artery revascularization. Considering the varying rates observed among carotid endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR), identifying the predictors and complications of CHS is essential for improving patient outcomes. This study utilizes a national database to investigate the predictors and complications of CHS following carotid revascularizations. METHODS:We conducted a retrospective analysis of all patients undergoing CEA, TFCAS, and TCAR for carotid artery stenosis in the Vascular Quality Initiative database from 2020 to 2023. Multivariate logistic regression was applied to identify CHS predictors, which were used to develop a risk score calculator. Moreover, we compared the stroke and mortality rates following CHS among the 3 revascularization techniques. RESULTS:The final cohort in our study included 59,130 (53%) CEAs, 14,064 (13%) TFCAS's, and 37,565 (34%) TCARs. There were 281 cases of CHS (0.25%), and TFCAS was associated with the highest rate of CHS (0.78% vs. 0.22% vs. 0.15%; P < 0.001). After adjusting for potential confounders, TFCAS was associated with almost 3-fold higher risk compared to CEA (adjusted odds ratio (aOR) = 2.87 [95% confidence interval (CI): 1.65-4.9] P < 0.001). On the other hand, TCAR was comparable to CEA. Other predictors of CHS included uncontrolled hypertension, insulin-dependent diabetes, symptomatic status, prior carotid procedure, urgent intervention, and postoperative blood pressure medication. These predictors were used to develop an interactive CHS risk calculator (C-statistic = 0.8). Among patients who developed CHS, TFCAS was associated with a 70% higher risk of inhospital stroke (aOR = 1.7 [95% CI: 1.4-2] P < 0.001) and almost triple the risk of inhospital death (aOR = 2.9 [95% CI: 2.3-3.8] P < 0.001). TCAR and CEA were comparable except for a slight risk of inhospital stroke after TCAR (aOR = 1.2 [95% CI: 1-1.3] P = 0.03). CONCLUSION/CONCLUSIONS:In this multi-institutional national study, we have demonstrated that the type of carotid revascularization significantly influences the risk of CHS and subsequent stroke and mortality, with TFCAS associated with the highest risk. Uncontrolled hypertension was associated with a 2-fold increased risk of CHS, underscoring the importance of tight blood pressure control. We were able to provide a prediction model for CHS based on preoperative factors. Prospective use of this risk calculator might benefit in postoperative monitoring.

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.

Acute aortic dissection is a life-threatening event that requires immediate medical attention and surgical intervention. Aortic dissections affect 4 to 5 per 10,000 individuals in the USA. These emergency events can have as high as a 50% mortality risk. Twenty percent of patients who develop a thoracic aortic dissection have an underlying genetic cause for their increased risk for aortic aneurysm and dissection, which can be identified using genetic testing. Genes associated with abdominal aortic aneurysm and dissection have been identified but have not been reported for clinical use or management at this time.