Faculty Bibliography

BACKGROUND:Endovascular aortic aneurysm repair (EVAR) is utilized to treat abdominal aortic aneurysms, while patients with short infrarenal necks can undergo fenestrated EVAR (FEVAR). Previous studies have demonstrated decreased aortic neck dilation for FEVAR compared to EVAR. Sac regression is a marker of success after EVAR; however, little is known regarding changes in sac volumetrics. This study compares aortic sac regression after EVAR versus FEVAR using volumetric analysis. METHODS:A retrospective review of prospectively collected data from 120 patients who underwent EVAR was performed. Thirty patients underwent FEVAR (Cook Medical Inc, Bloomington, IN) and 90 patients underwent EVAR (30 each with Endurant [Medtronic, Dublin, Ireland], Excluder [Gore, Flagstaff, AZ], and Zenith [Cook]). Demographic data were analyzed. Using 3-dimensional reconstruction software, preoperative and postoperative aneurysm sac volumes were measured, in addition to aneurysm characteristics. RESULTS:, P = 0.005). EVAR patients had greater number of lumbar arteries (7.26 ± 1.68 vs. 5.31 ± 1.93, P < 0.000001). On postoperative follow-up, FEVAR cases had greater sac regression compared to standard EVAR (-22.75 ± 25.7% vs. -5.98 ± 19.66%, P = 0.00031). The percentage of sac regression was greater when measured by volume compared to maximum diameter for FEVAR (-22.75 ± 25.7% vs. -13.90 ± 15.4%, P = 0.01) but not EVAR (-5.98 ± 19.7% vs. -4.51 ± 15.2%, P = 0.246). Those in the top tertile of percent volume of thrombus (>48.5%) were more likely to experience greater than 10% sac regression by volume (55% vs. 33.3%, P = 0.015). On multivariate analysis, FEVAR was associated with sac regression greater than 10% by volume (odds ratio [OR] 4.325, 95% confidence interval [CI] 1.346-13.901, P = 0.014), while endoleak (OR 0.162, 95% CI 0.055-0.479, P < 0.001) and 2 patent hypogastric arteries (OR 0.066, 95% CI 0.005-0.904, P = 0.042) were predictive against. CONCLUSIONS:Fenestrated EVAR is associated with greater sac regression compared to EVAR on volumetric analysis. This difference may be attributable to decreased endotension within the aneurysm resulting from less aortic neck dilatation, while the greater proportion of thrombus may be a protective factor from growth. Patients being evaluated for EVAR with borderline neck anatomy should be considered for FEVAR given increased sac regression.

OBJECTIVE:The objective of this study was to characterize the natural history of incidentally identified asymptomatic mesenteric artery stenosis and to identify clinical and radiographic predictors that differentiate patients with asymptomatic mesenteric artery occlusive disease (MAOD) and patients with symptomatic chronic mesenteric ischemia (CMI) diagnosed at index study. METHODS:This single-institution retrospective analysis included patients diagnosed with >70% stenosis of the celiac or superior mesenteric artery (SMA) on axial imaging or duplex ultrasound in an institutional radiology database. Patients were grouped into asymptomatic MAOD and symptomatic CMI cohorts according to their clinical presentation at index study. The primary endpoint was progression of disease from asymptomatic stenosis to CMI. Demographic, clinical, and imaging features at index study were also compared between asymptomatic and symptomatic cohorts. RESULTS:79 patients met the inclusion criteria, with 43 in the asymptomatic group and 36 in the symptomatic group. Patients in the asymptomatic group were followed for mean 32.7 ± 30.2 months; 60.5% (n=26) were referred to and followed by a vascular surgeon for 21.5 ± 27.8 months. No asymptomatic patients developed symptoms during the follow-up period. All patients in the symptomatic group were evaluated by a vascular surgeon and underwent procedural intervention for CMI within six months of diagnosis. Patients with CMI were more likely to have a history of smoking (p=0.02) and less likely to be anticoagulated (p<0.01) than patients with asymptomatic MAOD. Symptomatic patients trended towards a higher prevalence of coronary artery disease (p=0.06) and a lower prevalence of arrhythmia (p=0.08). On imaging, the symptomatic cohort was more likely to have severe SMA stenosis (p<0.001), multivessel mesenteric disease (p=0.001), calcified aortic plaque (p=0.01), and severe stenosis in one or both internal iliac arteries (p<0.001). On multivariable analysis, a lack of anticoagulation use (p<0.01) and severe SMA stenosis (p<0.001) were independently associated with higher odds of symptomatic mesenteric stenosis. While statistically insignificant, calcified aortic plaque (p=0.08) and smoking history (p=0.06) trended toward higher odds of symptomatic index presentation. CONCLUSIONS:The rate of progression from asymptomatic MAOD to CMI appears exceedingly low in the first two to three years after diagnosis, suggesting that prophylactic revascularization is mostly unnecessary. Surveillance of asymptomatic MAOD may be personalized based on clinical and radiographic features of disease. SMA stenosis severity, anticoagulation use, and possibly smoking history and the presence of aortic plaque calcification may be promising markers to stratify the risk of ischemic progression.

OBJECTIVE:Venous duplex ultrasound (VDUS) is the accepted initial imaging study to rule out lower extremity deep venous thrombosis (DVT). In accordance with the Intersocietal Accreditation Commission (IAC) vascular laboratory policies, many institutions require technicians to additionally assess the asymptomatic contralateral common femoral vein. There is conflicting literature on whether this policy is needed. Therefore, the aim of this study was to investigate the utility of examining the asymptomatic contralateral common femoral vein in patients undergoing a unilateral lower extremity VDUS to rule out DVT by (1) defining the prevalence of DVT in the contralateral asymptomatic limb and (2) identifying risk factors that predispose patients to develop a DVT in the asymptomatic limb. METHODS:and Student's t-tests, respectively. For all tests, a P-value of <0.05 was considered statistically significant. RESULTS:371 patients (170 inpatient vs. 201 outpatient) with unilateral DVT symptoms who underwent VDUS during the study period were identified. Right leg symptoms were present in 186 (50%) patients and left leg symptoms were present in 185 (50%) patients. The overall incidence of acute DVT in the symptomatic limb was 17% (17.4% outpatient vs. 16.5% inpatient, p=NS). Outpatients were more likely to have superficial venous thrombosis (7.0% vs. 0.6%, p=0.002) and chronic venous changes (25.4% vs. 1.2%, p<0.001) in the symptomatic limb. 59% of DVTs in the symptomatic limb were documented in the calf veins, 25% in the proximal veins, and 16% in both the proximal and calf veins. There were no incidences of bilateral DVT in our cohort. Moreover, none of the patients had a DVT isolated to the contralateral common femoral vein. CONCLUSIONS:Scanning the asymptomatic contralateral common femoral vein may not be necessary for patients undergoing unilateral VDUS for symptomatic DVT, regardless of thrombotic risk factors. A single-extremity study will suffice in most cases, and if implemented, it will improve vascular laboratory efficiency and decrease costs without a decline in DVT detection.

Symptomatic carotid artery stenosis is defined as an acute neurologic deficit (transient ischemic attack or stroke) occurring in the last 6 months, that is, ipsilateral to an extracranial carotid artery with at least 50% stenosis. Previous studies have identified the benefit of surgical intervention on symptomatic carotid stenosis, but the ideal timing is less clear. The timing of intervention must balance the risk of perioperative stroke and death (higher during the hyperacute period within 48 hr) and the risk of recurrent stroke while waiting to intervene, particularly if delayed beyond 14 days. Several factors such as acuity of neurologic deficit, degree of stenosis, or contralateral occlusion, and other comorbidities, may contribute to the risk of perioperative stroke or death when intervening within the acute period. The Society for Vascular Surgery recommends carotid endarterectomy as the intervention for symptomatic carotid artery stenosis, but recent studies have shown that transcarotid revascularization may also have similar outcomes.

BACKGROUND:Patients with intermediate-risk pulmonary embolism (PE) have outcomes worse than uncomplicated ST elevation myocardial infarction. Yet, no large-scale study has compared the outcomes of large-bore mechanical thrombectomy (LBMT) with anticoagulation alone (AC). The aim of this study was to compare the clinical outcomes among patients receiving LBMT vs AC alone. METHODS:This was a two-center retrospective study that included patients with intermediate-risk PE from October 2016 - October 2023 from the institution's Pulmonary Embolism Response Team (PERT) database. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest or hemodynamic decompensation. Inverse probability of treatment weighting (IPTW) was used to balance covariates; Kaplan Meir curves and IPTW multivariable Cox regression were used to assess the relationship between treatment groups and outcomes. RESULTS:Of the 273 patients included in the analysis, 192 (70 %) patients received AC alone and 81 (30 %) patients received LBMT and AC. A total of 30 (10.9 %) patients experienced the primary composite outcome over a median follow-up of 30 days. The primary composite outcome was significantly lower in the group that received LBMT compared to those on AC alone (1.2 % vs 15.1 %, log-rank p < 0.001; adjusted HR: 0.02; 95 % CI: 0.002-0.17, p < 0.001) driven by a lower rate of 30-day all-cause mortality (0 % vs 7.3 %, log-rank p = 0.01), resuscitated cardiac arrest (0 % vs 6.8 %, log-rank p = 0.016) and new or worsening hemodynamic instability (4 % vs 11.1 %, log-rank p = 0.007). CONCLUSION/CONCLUSIONS:In this largest cohort to date comparing LBMT versus AC alone in acute intermediate-risk PE, LBMT had a significantly lower rate of the primary composite outcome including a lower rate of all-cause mortality when compared to AC alone. Ongoing randomized trials will test these associations.

OBJECTIVE:This study compared outcomes in patients with and without preoperative stress testing undergoing carotid revascularization including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid revascularization (TCAR). METHODS:Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network (VQI VISION) database who underwent elective carotid revascularization 2016-2020 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 (evidence of ischemia or MI). Outcomes of interest were postoperative MI/neurologic events, 90-day re-admission rates, as well as long-term mortality. RESULTS:We analyzed 18,364 patients (78.8% CEA, 9.3% TF-CAS, 11.9% TCAR). Of these, 35.8% underwent preoperative stress testing (37.4% of CEA patients, 27.5% of TF-CAS patients, and 31.9% of TCAR patients). While comorbidities were significantly higher amongst patients undergoing CEA with preoperative stress test compared to those without stress testing, the overall prevalence of co-morbidities was higher amongst patients undergoing TF-CAS or TCAR irrespective of preoperative stress test status. Compared to patients with a negative stress test, patients with positive stress test undergoing any form of carotid revascularization had a significant increase in 90-day re-admission rates (CEA 19.6% vs 15.8%, p=0.003; CAS 33.3% vs. 18.6%, p<0.001; TCAR 25% vs. 17.5%, p=0.04). No group demonstrated a difference in the incidence of in-hospital postoperative neurologic events or CHF, but those undergoing CEA (but not CAS or TCAR) experienced a significant increase in-hospital post-operative MI (1.7% vs 0.6%, p<0.001). In 3-year follow-up, those with a positive compared to negative stress test were more likely to undergo CABG/PCI in the CEA (adjusted HR 1.87 [1.42-2.27], p<0.0001) and CAS groups (adjusted HR 3.89 [1.77-8.57], p<0.01), but not the TCAR cohort. Notably those undergoing CEA with a positive compared to negative stress test, but not CAS or TCAR, exhibited a 28% increase in mortality (adjusted HR 1.28 [1.03-1.58], p=0.03) at 3 years. Conversely, those patients with a negative stress test compared to no stress test undergoing CEA experienced a 14% reduction in mortality at 3 years (adjusted HR 0.86 [0.76-0.98], p=0.02); this mortality difference was not observed in similar stress test cohort undergoing TF-CAS or TCAR. CONCLUSIONS:Our study highlights that a positive stress test in appropriately selected, asymptomatic patients undergoing elective carotid revascularization can predict select perioperative and long-term cardiovascular outcomes. However, given the high follow-up mortality associated with those undergoing CEA for elective carotid revascularization, our findings call into question whether these patients should be preferentially offered optimal medical management and/or stenting.

OBJECTIVES/OBJECTIVE:While the use of endovascular intervention for peripheral artery disease (PAD) has expanded in recent years, there remains relatively few studies focused on the endovascular treatment of isolated popliteal artery occlusive disease. The popliteal artery presents a particular challenge for endovascular intervention due to the constant flexion at the knee. We sought to assess the outcomes for endovascular management of isolated popliteal artery occlusive disease based on type of intervention performed. METHODS:The Vascular Qualitative Initiative (VQI) database was queried for patients with isolated popliteal artery occlusive disease who underwent endovascular intervention from January 2011 to December 2019. Patients were excluded from analysis if they did not have Medicare FFS entitlement, had a history of prior intervention in the ipsilateral limb, or had vessels treated in addition to the popliteal artery. Patients were stratified into groups based on their initial presenting symptom (claudication vs. chronic limb threatening ischemia (CLTI)) and were analyzed by endovascular procedure performed (plain old balloon angioplasty (POBA) vs. adjunctive stent/atherectomy). The POBA group underwent only plain balloon angioplasty whereas the adjunctive stent/atherectomy group underwent any type of balloon angioplasty and adjunctive stenting or atherectomy or both. The primary outcome was amputation-free survival, a composite outcome of freedom from major amputation and/or death. RESULTS:A total of 1,740 patients met criteria for analysis who underwent endovascular intervention for isolated popliteal artery occlusive disease. Among patients with claudication, the amputation-free survival rate was significantly higher at 1 year and 3 years for patients treated with adjunctive stent/atherectomy compared to POBA (1 year: 94.2% vs. 88.9%, p = 0.03; 3 years: 83.0% vs. 76.6%, p = 0.04). This difference appeared to be driven by mortality, as mortality was significantly better for adjunctive stent/atherectomy compared to POBA (1 year: 4.6% vs. 10.2%, p = 0.01; 3 years: 15.4% vs. 23.3%, p = 0.02), whereas major amputation rates were not significantly different. However, multivariable analysis showed that use of adjunctive stent/atherectomy was not independently associated with improved amputation-free survival (adjusted HR 0.74, 95% CI 0.48-1.16, p = 0.19). In the CLTI group, amputation-free survival rates were not significantly different for patients treated with adjunctive stent/atherectomy compared to POBA (1 year: 65% vs. 64.6%, p = 0.78; 3 years: 47.1% vs. 42.6%, p = 0.30). Re-intervention rates were not statistically different when stratified by use of adjunctive therapies in either the claudication or CLTI groups. CONCLUSION/CONCLUSIONS:Our results suggest that across all patients with isolated popliteal artery occlusive disease, amputation-free survival rates were comparable regardless of endovascular treatment modality. As expected, amputation-free survival for patients presenting with claudication was favorable compared to those with CLTI, and was driven primarily by mortality. Re-intervention rates were similar across all patients regardless of treatment modality. This study underscores the clinical challenge of treating isolated popliteal artery occlusive disease and stresses the need for further study of adjunctive modalities in treating complex lesions.

OBJECTIVE:While ambulatory capacity is a readily assessable clinical indicator of functional status, its association with outcomes after endovascular aneurysm repair (EVAR) remains underexplored. This study aimed to investigate the association between pre-operative ambulatory status and outcomes following elective EVAR. METHODS:A retrospective review of the multi-institutional Vascular Quality Initiative database was conducted for all patients who underwent elective infrarenal EVAR from 2009 - 2022. Patients were categorised into independent ambulation and impaired ambulation groups. A propensity score matched analysis was performed to produce two well matched cohorts in a 1:1 ratio without replacement. The primary outcome was 30 day death. Secondary outcomes included one year survival and in hospital major complications. RESULTS:Among 11 474 patients, 10 539 (91.8%) were independently ambulatory pre-operatively. Propensity score matching resulted in 885 matched pairs. The impaired ambulation group, although older (mean 77.6 vs. 76.3 years; p = .001), showed comparable baseline characteristics. Post-operatively, the impaired ambulation group had higher cumulative in hospital complications and death as well as 30 day death. Even after adjustment for age, impaired pre-operative ambulation was associated with increased in hospital and 30 day death (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.26 - 3.95; p = .006). Multivariable analysis demonstrated increasing cumulative risk of 30 day death in the setting of impaired pre-operative ambulatory status with age > 75 years requiring post-operative red blood cell transfusion > 2 units (HR 5.75, 95% CI 2.09 - 15.88; p < .001). Beyond 30 days, impaired pre-operative ambulation was not associated with increased one year death (HR 1.09, 95% CI 0.81 - 1.48; p = .570). CONCLUSION/CONCLUSIONS:Among patients who underwent elective infrarenal EVAR in this matched analysis, impaired pre-operative ambulatory capacity was associated with an increased risk of in hospital and 30 day death, further compounded by advanced age and post-operative transfusion. As such, a threshold higher than the traditional size criteria should be considered in shared decision making when determining options for the management of abdominal aortic aneurysm in this high risk cohort.

OBJECTIVE:Patients with peripheral artery disease (PAD) undergo lower extremity revascularization (LER) for symptomatic relief or limb salvage. Despite LER, patients remain at increased risk of platelet-mediated complications, such as major adverse cardiac and limb events (MACLEs). Platelet activity is associated with cardiovascular events, yet little is known about the dynamic nature of platelet activity over time. We, therefore, investigated the change in platelet activity over time and its association with long-term cardiovascular risk. METHODS:Patients with PAD undergoing LER were enrolled into the multicenter, prospective Platelet Activity and Cardiovascular Events study. Platelet aggregation was assessed by light transmission aggregometry to submaximal epinephrine (0.4 μmol/L) immediately before LER, and on postoperative day 1 or 2 (POD1 or POD2) and 30 (POD30). A hyperreactive platelet phenotype was defined as >60% aggregation. Patients were followed longitudinally for MACLEs, defined as the composite of death, myocardial infarction, stroke, major lower extremity amputation, or acute limb ischemia leading to reintervention. RESULTS:Among 287 patients undergoing LER, the mean age was 70 ± 11 years, 33% were female, 61% were White, and 89% were on baseline antiplatelet therapy. Platelet aggregation to submaximal epinephrine induced a bimodal response; 15.5%, 16.8%, and 16.4% of patients demonstrated a hyperreactive platelet phenotype at baseline, POD1, and POD30, respectively. Platelet aggregation increased by 18.5% (P = .001) from baseline to POD1, which subsequently returned to baseline at POD30. After a median follow-up of 19 months, MACLEs occurred in 165 patients (57%). After adjustment for demographics, clinical risk factors, procedure type, and antiplatelet therapy, platelet hyperreactivity at POD1 was associated with a significant hazard of long-term MACLE (adjusted hazard ratio, 4.61; 95% confidence interval, 2.08-10.20; P < .001). CONCLUSIONS:Among patients with severe PAD, platelet activity increases after LER. Platelet hyperreactivity to submaximal epinephrine on POD1 is associated with long-term MACLE. Platelet activity after LER may represent a modifiable biomarker associated with excess cardiovascular risk.