Faculty Bibliography

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.

OBJECTIVE:Ascending and descending aortic dissection (AD) carry significant morbidity and mortality and require regular follow up in surgery. The aim of this retrospective analysis is to compare the demographics and comorbidities of patients with aortic dissection who followed up in clinic to those who did not. The goal of this study is to identify barriers to follow up in AD to better mitigate complications in vulnerable populations. METHODS:The electronic medical record was queried for all acute presentations of aortic dissection in patients 18 or older during the period of January 2015 through May 2023. Records were reviewed for demographic descriptors, comorbidities, hospital courses, and follow up with vascular or cardiothoracic surgery. Univariate and multivariate regression analyses were conducted to compare follow up and non-follow up cohorts across the entire sample and in ascending and descending groups separately. RESULTS:122 patients with aortic dissection were identified and included. Patients who followed up were younger (p < 0.001) and had higher BMI (p < 0.05). A significantly higher number of patients on public insurance followed up compared to patients with private or union-based insurance (p < 0.05). Patients who underwent surgery on index admission also skewed more heavily into the follow up cohort (p < 0.05). In the ascending group (n = 68) analysis, patients who followed up in clinic were younger (p < 0.001) and had longer hospital and ICU LOS (p < 0.01). In the descending group (n = 54), patients with a history of substance abuse skewed significantly into the non-follow up cohort (p < 0.05). CONCLUSIONS:Age strongly determined follow up in the overall and type A group analyses. Insurance status was a significant factor in the whole sample analysis, while hospital and ICU LOS significantly impacted the type A subgroup. In the descending group, patients with a history of substance abuse showed reduced follow up. Further studies are required to evaluate these findings at other centers.

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.

OBJECTIVE:Spontaneous isolated celiac artery dissection (SICAD) is a rare condition with an unclear natural history and no management consensus. This study evaluated mid-to-long-term outcomes of conservatively managed SICAD. METHODS:This single-center, retrospective cohort study identified patients with SICAD from January 2011-December 2022 in the institutional electronic health record. Demographics, comorbidities, radiographic features, management, and outcomes were reviewed. Clinical endpoints were symptomatic remission, significant organ malperfusion, rupture, and secondary intervention. Radiographic endpoints included dissection remodeling (i.e., shortened dissection length or increased true lumen diameter), celiac aneurysm incidence, and aneurysm diameter growth among <1.5 cm, 1.5-1.9 cm, and ≥2.0 cm size categories. Endpoints were stratified by symptomatic vs. incidental presentation. RESULTS:Forty-nine patients with SICAD were identified. Eighty percent were male, and 57% had hypertension. Extra-celiac aneurysms were present in 25%, including 12% with aortic aneurysms. Forty-nine percent of SICADs were symptomatic on presentation, while 51% were incidentally discovered. Patients with incidental SICAD were older than symptomatic patients (62 ± 15 years vs. 54 ± 8 years, p=0.02) but had similar comorbidities. Ninety-two percent of symptomatic patients experienced complete symptom resolution without operative intervention by the earliest follow-up (182 ± 386 days). No incidental cases developed symptoms over a mean of 3.9 ± 3.5 years. No significant organ malperfusion, rupture, or secondary intervention occurred in this series. Symptomatic SICAD was more likely to undergo remodeling than incidental SICAD (p=0.02) over an average of 3.3 ± 3.7 years. Thirty-two percent of symptomatic cases had partial remodeling, and 37% had no residual dissection. Seventy-one percent of incidental dissections remained stable without remodeling. Celiac thrombus on initial imaging predicted remodeling (p=0.003). Baseline antihypertensive (p=0.006) and antiplatelet use (p=0.047) were associated with remodeling in symptomatic patients only. Aneurysmal degeneration was noted in 46% of all presenting lesions; none were ≥2.0 cm in maximal diameter. Incidental cases presented with more aneurysmal dilatation than symptomatic cases (59% vs. 32%, p<0.001). No celiac aneurysms at presentation grew over an average of 4.8 ± 4.0 years. Forty percent and 13% of incidental and symptomatic cases without initial celiac aneurysms, respectively, developed incident aneurysms by a mean follow-up of 2.0 ± 3.0 years (p=0.3). CONCLUSIONS:Conservative management of uncomplicated SICAD yielded excellent clinical outcomes, even with incomplete remodeling and aneurysmal degeneration, which were common, albeit largely benign. Patients may warrant screening for aneurysms beyond the celiac axis. Antihypertensive and antiplatelet therapy for ≥3-6 months may promote remodeling until dissection stabilization.

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.

BACKGROUND/UNASSIGNED:Endovascular abdominal aortic aneurysm repair (EVAR) is a preferred surgery to prevent aneurysm sac enlargement and minimize the risk of life-threatening rupture in patients with AAA. Serious complications of type II endoleaks following EVAR can cause sac expansion and increase rupture risk. This study focused on evaluating clinical and blood characteristics in patients with type II endoleaks to refine our understanding of systemic fluctuations associated with unsuccessful EVAR. METHODS/UNASSIGNED:This retrospective study included 146 patients with AAA who underwent primary elective endovascular procedures (EVAR/fEVAR) between 2013 and 2021. Clinical characteristics, complete blood count (CBC) and imaging data were analyzed from patients who did and did not develop type II endoleaks. RESULTS/UNASSIGNED:Mean platelet volume (MPV) was significantly increased in patients who developed type II endoleaks after EVAR. Receiver operating characteristic analysis showed that MPV has a satisfactory discriminatory performance in distinguishing post-EVAR patients who developed type II endoleaks, yielding an area under the curve (AUC) value of 0.64. A risk stratification panel incorporating MPV, type II diabetes history, and administration of dual antiplatelet therapies yielded an AUC of 0.70 and predicted an endoleak-free survival rate with a hazard ratio of 2.94. A nomogram revealed that MPV had the highest scoring weight among all significant variables. CONCLUSION/UNASSIGNED:Patients with type II endoleaks following EVAR have elevated MPV indicative of different phenotypes of circulating platelets. MPV presents an attractive predictive criteria for assessing the occurrence of type II endoleaks in patients with AAA.

OBJECTIVE:Vascular surgeons are often called upon to provide emergent surgical assistance to other specialties for iatrogenic complications, both intraoperatively and in the inpatient setting. The management of iatrogenic vascular injury remains a critical role of the vascular surgeon, especially in the context of the increasing adoption of percutaneous procedures by other specialties. This study aims to characterize consultation timing, management, and outcomes for iatrogenic vascular injuries. METHODS:This study identified patients for whom vascular surgery was consulted for iatrogenic vascular complications from February 1, 2022, to May 12, 2023. Patient information, including demographic information, injury details, and details of any operative intervention, was retrospectively collected from February 1, 2022, to October 13, 2022, and prospectively collected for the remainder of the study period. Analyses were performed with R (version 2022.02.03). RESULTS:There were 87 patients with consultations related to iatrogenic vascular injury. Of these, 42 (46%) were female and the mean age was 59 years (±18 years). The most common consulting services were cardiology (32%), cardiothoracic surgery (26%), general surgery (8%), and neurointerventional radiology (10%). Reasons for consultation included hemorrhage (36%), limb ischemia (36%), and treatment of pseudoaneurysm (23%). A total of 24% of consults were intraoperative, 20% of consults related to extracorporeal membrane oxygenation cannulation, and 16% of consults related to ventricular assist devices including left ventricular assist device and intra-aortic balloon pump. The majority of these consult requests (60%) occurred during evening and night hours (5 PM to 7 AM). Emergent intervention was required in 62% of cases and consisted of primary open surgical repair of arterial injury (54%), endovascular intervention (21%), and open thromboembolectomy (15%). Overall, in-hospital mortality for the patient cohort was 20% and the reintervention rate was 23%, reflecting the underlying complexity of the illness and nature of the vascular injury in this patient group. CONCLUSIONS:Vascular surgeons play an essential role in managing emergent life-threatening hemorrhagic and ischemic iatrogenic vascular complications in the hospitalized setting. The complications require immediate bedside or intraoperative consult and often emergent open surgical or endovascular intervention. Furthermore, many of these require urgent management in the evening or overnight hours, and therefore the high frequency of these events represents a potential significant resource utilization and workforce issue to the vascular surgery workforce.

OBJECTIVE:Management of acute limb ischemia (ALI) has seen greater utilization of catheter-based interventions over the last two decades. Data on their efficacy is largely based on comparisons of catheter-directed thrombolysis (CDT) and open thrombectomy. During this time, many adjuncts to CDT have emerged with different mechanisms of action, including pharmacomechanical thrombolysis (PMT) and aspiration mechanical thrombectomy (AMT). However, the safety and efficacy of newer adjuncts like AMT have not been well established. This study is a retrospective analysis of the contemporary management of ALI comparing patients treated with aspiration mechanical thrombectomy to patients treated with the more established CDT adjunct, pharmacomechanical thrombolysis. METHODS:Patients undergoing peripheral endovascular intervention for ALI using an adjunctive device were identified through query of the Vascular Quality Initiative (VQI) Peripheral Vascular Intervention (PVI) module from 2014 to 2019. Patients with a nonviable extremity (Rutherford ALI Stage 3), prior history of ipsilateral major amputation, popliteal aneurysm, procedures that were deemed elective (>72 h from admission), procedures that did not utilize an endovascular adjunctive device, and patients without short-term follow-up were all excluded from analysis. The primary outcome was a composite outcome of freedom from major amputation and/or death in the perioperative time period. RESULTS:= 0.05) were associated with the composite outcome. CONCLUSIONS:Short-term amputation-free survival rates of endovascular management of acute limb ischemia are adequate across all modalities. However, aspiration mechanical thrombectomy was associated with significantly worse amputation-free survival compared to other endovascular adjuncts alone (i.e., pharmacomechanical thrombolysis). Severe limb ischemia (Rutherford ALI Stage 2B) and prior supra-inguinal bypass were associated with worse amputation-free survival regardless of the choice of endovascular intervention.

OBJECTIVES/OBJECTIVE:Carotid interventions are indicated for both patients with symptomatic and a subset of patients with severe asymptomatic carotid artery stenosis (CAS). Symptomatic CAS accounts for up to 12%-25% of overall carotid interventions, but predictors of symptomatic presentation remain poorly defined. The aim of this study was to identify factors associated with symptomatic CAS in our patient population. METHODS:Between January 2015 and February 2022, an institutional retrospective cohort study of prospectively collected data on patients undergoing interventions for CAS was performed. Procedures included carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS). Demographic data, comorbidities, procedural details, and anatomic features from various imaging modalities were collected. Comparisons were made between symptomatic (symptoms within the prior 6 months) and asymptomatic patients. RESULTS:< .001), and symptomatic patients with ulcerated plaques more frequently had less than 50% compared to moderate/severe CAS. Nine patients who presented with symptoms had mild CAS and underwent intervention. CONCLUSIONS:Symptomatic CAS was associated with a history of remote prior symptoms and lack of anti-platelet therapy at time of presentation. Furthermore, symptomatic patients not on anti-platelet agents were more likely to have a greater area of parenchymal involvement when presenting with stroke and symptomatic patients with ulcerated plaques were more likely to have mild CAS, suggesting the role of plaque instability in symptomatic presentation. These findings underscore the importance of appropriate medical management and adherence in all patients with CAS and perhaps a role for more frequent surveillance in those with potentially unstable plaque morphology.