Faculty Bibliography

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:Perioperative stroke after carotid artery stenting (CAS) is rare. However, the degree of disability and long-term effects from a post-operative stroke remain unclear. Our goal was to assess the degree of disability from a stroke after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) for asymptomatic carotid artery disease, and the associated one-year impact on subsequent neurological events and mortality. METHODS:The Vascular Quality Initiative CAS registry (2016-2023) was queried for CAS performed for asymptomatic disease. Patients with a post-operative stroke had their disability stratified by modified Rankin score (mRS) of 0-1 (mild), 2-3 (moderate), 4-5 (severe), and 6 (deceased). Post-operative stroke-related disability based on mRS for those recorded at discharge and its association with long-term outcomes were analyzed. RESULTS:There were 23,435 TCAR and 7,487 TFCAS procedures performed for asymptomatic disease. Among TCAR patients, the periprocedural stroke and stroke/death rates were 0.8% and 1.03%, respectively, with disability distributed as 33.6% mild, 31% moderate, 28.9% severe, and 7.5% deceased. Among TFCAS patients, the periprocedural stroke and stroke/death rates were 0.92% and 1.19%, respectively, with disability distributed as 37.7% mild, 31% moderate, 27.5% severe, and 2.9% deceased. Multivariable analysis demonstrated that severe early postoperative disability was associated with increased one-year mortality (HR 11.04, 95% CI 6.9 - 17.7, P=.001) and increased subsequent neurological event/death (HR 10.82, 95% CI 6.93 - 16.9, P=.001). Patients with a stroke after TFCAS had a higher risk of one-year mortality (HR 1.27, 95% CI 1.10, 1.47, P=.001) and neurological event/death (HR 1.27, 1.11,1.45, P<.001), as compared to patients with a stroke after TCAR. Among patients who undergo a CAS procedure for asymptomatic disease, hypertension was associated with a higher likelihood of developing severe disability (OR 4.2, 95% CI 1.03-17.32, p =0.045), while pre-operative aspirin (OR 0.51, 95% CI 0.30-0.87, p =0.01) or P2Y12 inhibitor use (OR 0.45, 95% CI 0.27-0.74, p=0.11) was associated with a lower likelihood of developing severe disability. CONCLUSION/CONCLUSIONS:The majority of patients who undergo TCAR and TFCAS for asymptomatic carotid artery disease that suffered a periprocedural stroke had substantial disability. Patients with strokes from TFCAS have worse one-year outcomes, as compared to patients with stroke following TCAR. These findings should help guide patient-provider discussion regarding the surgical management of asymptomatic carotid stenosis, the risks of CAS interventions, as well as aid in the prognostication of postoperative stroke.

INTRODUCTION/BACKGROUND:En-bloc celiac axis resection (CAR) was first proposed by Lyon H. Appleby in 1952 for gastric cancer and later modified for pancreatic resections with gastric preservation by Nimura et al. in 1976. CAR remains uncommon, performed in fewer than 0.2 cases annually. Advancements in preoperative imaging and anatomy understanding, ischemic complication management, and centralization of care have improved outcomes. This report presents a robotic distal pancreatectomy (DP) with CAR and superior mesenteric artery (SMA) divestment. CASE REPORT/METHODS:A 65-year-old woman presented with back pain. Imaging revealed biopsy-proven pancreatic adenocarcinoma in the pancreatic body, encasing the celiac, splenic, and common hepatic arteries with SMA abutment. Following four cycles of neoadjuvant FOLFIRINOX, follow-up imaging demonstrated stable disease without metastasis. The need for hepatic artery reconstruction was assessed intraoperatively, with alternative strategies detailed in the accompanying video. OPERATIVE TECHNIQUE/METHODS:The patient underwent a distal pancreatectomy and splenectomy with class Ia CAR. Surgery was conducted in a caudal approach, lasted 420 minutes with minimal blood loss (100 ml). Laparoscopic ultrasound (lapUS) and indocyanine green (ICG) perfusion were used to assess resectability, vascular perfusion, and targeted blood vessels. The postoperative course was uneventful, except for a Grade B chyle leak managed conservatively. No liver or gastric ischemia occurred. Adjuvant chemotherapy was initiated two months postoperatively. CONCLUSION/CONCLUSIONS:Enhanced visualization, improved dexterity, and adjuncts including lapUS and ICG are potential benefits that are available to surgeons with the robotic platform when performing arterial divestment and CAR via a caudal approach.

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.

OBJECTIVES/OBJECTIVE:In April 2022, the Society for Vascular Surgery (SVS) published the Appropriate Use Criteria (AUC) for the management of intermittent claudication (IC). Our goal was to compare practice patterns before and after publication of the AUC to identify changes. METHODS:The Vascular Quality Initiative (VQI) peripheral vascular intervention (PVI), and suprainguinal, and infrainguinal bypass registries were analyzed for interventions for IC. Relevant patient and intervention characteristics pre-AUC (2018-2019) and post-AUC (May 2022-December 2023) were compared. Key points of the AUC that are analyzable from the VQI include claudication severity, use of optimal medical therapy (OMT), smoking status, high-risk comorbid conditions (as indicators of operative risk), operative management of complex aortoiliac and femoropopliteal disease (TASC II C/D), common femoral artery (CFA) PVIs, and infrapopliteal procedures. RESULTS:There were 15,892 PVI, 2352 suprainguinal bypass, and 3480 infrainguinal bypass procedures analyzed. Changes consistent with the appropriateness ratings for PVI included more interventions for severe symptoms (72% vs 66.6%, P<.001), improvement in post-operative OMT (83% vs 79.7%, P<.001), fewer patients on dialysis undergoing PVI (2% vs 2.7%, P<.002), and less interventions on complex (TASC II C/D) aortoiliac (6.3% vs 9.5%, P<.001) and femoropopliteal (4.5% vs 5.8%, P <.001) anatomy. No changes were seen in the rates of pre-operative smoking and pre-operative OMT use, interventions on octogenarians, or in the use of extra-anatomic suprainguinal bypass, infrapopliteal bypass, or prosthetic conduit. Inconsistent with appropriateness ratings were more patients with congestive heart failure (15.1% vs 12.8%, P<.001) undergoing PVIs, and more PVIs for CFA (5.2% vs 3.4%, P<.001) and isolated infrapopliteal disease (5.7% vs 3.5%, P<.001). CONCLUSION/CONCLUSIONS:Since the publication of the AUC, there have been improvements with better OMT on discharge, fewer patients with ESRD undergoing interventions, and less endovascular treatment of complex disease. However, further work is needed to improve pre-operative medical optimization in patients with IC undergoing an invasive intervention and decrease the use of endovascular interventions for CFA and infrapopliteal disease, extra-anatomic aortoiliac revascularizations, and prosthetic conduit use.

OBJECTIVE:Patients with polyvascular disease are considered high risk for major adverse cardiac events (MACEs). This retrospective study utilised the Vascular Quality Initiative (VQI) database to quantify the effect of polyvascular disease on outcomes after endovascular aneurysm repair (EVAR). METHODS:The VQI database was queried from to 2012 - 2022 for elective EVAR. Patients were identified as having peripheral arterial disease, coronary artery disease, or cerebrovascular disease, and then stratified based on the number of arterial beds involved (one to three). Primary outcomes were peri-operative death and MACEs. Multivariate analysis was performed to find associations between comorbidities and primary outcomes. RESULTS:Of the 21 160 patients with arterial disease included in the study, 83.7% were male and the mean age was 73.73 ± 8.57 years. After stratification, 16 892 patients had atherosclerosis in one arterial bed, 3 869 in two arterial beds, and 399 in three arterial beds. Pre-operatively, patients with atherosclerosis in three arterial beds were more likely to have hypertension, diabetes, and renal failure (all p < .001). Post-operatively, patients with disease in three arterial beds were more likely to experience a post-operative complication (11.5% vs. 8.3% vs. 5.4%; p < .001), including MACE (4.6% vs. 4.1% vs. 2.8%; p < .001) and death (3.0% vs. 2.5% vs. 1.7%; p < .010). On multivariate analysis, polyvascular disease was associated with MACEs (odds ratio 1.54, 95% confidence interval 1.29 - 1.84; p < .001). Kaplan-Meier analysis estimates showed statistically significant differences in survival at approximately the three year follow up (p < .001). CONCLUSION/CONCLUSIONS:In this review of patients undergoing elective EVAR, patients with polyvascular disease experienced worse peri-operative outcomes, including death and MACEs, the latter of which was confirmed on multivariable analysis. These patients should be considered high risk and managed accordingly.

Treatment of pregnancy-related venous thromboembolism is limited by considerations of the health risks to both the patient and fetus. Anticoagulation is the cornerstone treatment for pregnancy-related venous thromboembolism; however, early thrombus removal may be preferred for prompt symptom resolution and to decrease the risk of post-thrombotic syndrome. We report the successful treatment of a patient in the second trimester of pregnancy with symptomatic iliofemoral deep venous thrombosis and May-Thurner syndrome using percutaneous mechanical thrombectomy.

OBJECTIVES/OBJECTIVE:Total contact casting (TCC) is used to promote wound closure in diabetic foot ulcers (DFUs); however, this technique is underused today. This study aims to further evaluate the efficacy of TCC in a large cohort, including patients with peripheral artery disease (PAD). METHODS:This was a retrospective analysis of patients with DFUs who underwent TCC from 2017 to 2021. PAD was defined as absence of pedal pulse or ABI <0.9. Demographic data, DFU characteristics, and peripheral arterial intervention were evaluated. Outcomes included complete healing, healing time, and rate of major amputation. Subgroup analysis was performed on patients undergoing peripheral intervention. RESULTS:= .0008) compared to patients without intervention. CONCLUSIONS:TCC remains an effective option for treatment of DFUs, as most were completely healed. Patients with PAD may benefit from TCC and revascularization, however, healing rates are lower in this cohort, necessitating the need for close observation.

BACKGROUND:There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets. METHODS:The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into 3 cohorts based on outflow targets (above-knee [AK] popliteal, below-knee [BK] popliteal, and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival (AFS), and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes. RESULTS:Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the AK popliteal was used in 116 (28.8%), the BK popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. BK popliteal and tibial bypasses, compared to AK popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (69.5% and 69.9% vs. 48.3%; P < 0.001). Vein conduit was more often used for tibial bypass than for AK and BK popliteal bypasses (46.3% vs. 21.9% and 16.3%; P < 0.001). In the perioperative period, BK popliteal and tibial bypass patients had higher reoperation rates (16.9% and 13.2% vs. 5.2%; P = 0.02) and lower primary patency (89.4% and 89% vs. 95.7%; P = 0.04) than AK bypass patients. At 1 year, compared with AK popliteal bypasses, BK and tibial bypasses demonstrated lower primary patency (81.9% vs. 56.7% vs. 52.4%, P < 0.001) and freedom from MALE (77.6% vs. 70.2% vs. 63.1%, P = 0.04), although AFS was not significantly different (89.7% vs. 90.6% vs. 83.8%, P = 0.19).On multivariable analysis, compared with AK popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, P = 0.04). Subanalysis of patients with chronic limb-threatening ischemia demonstrated significantly higher primary patency in the AK popliteal cohort at discharge and 1 year, but no difference in AFS or freedom from MALE between the cohorts at follow-up. CONCLUSIONS:LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE or AFS.