Faculty Bibliography

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.

BACKGROUND:While preoperative anemia is prevalent among surgical patients, its impact on patients undergoing transcarotid artery revascularization (TCAR) remains poorly understood. This study aims to assess the relationship between the severity of preoperative anemia and outcomes following TCAR. METHODS:A retrospective analysis of the Vascular Quality Initiative database (2016-2021) was performed to identify patients who underwent TCAR for carotid stenosis. Anemia was defined according to World Health Organization guidelines as a hemoglobin (Hb) level <12 g/dL in females and <13 g/dL in males. The severity of anemia was further classified as mild (Hb: 10-11.9 g/dL in females and 11-12.9 g/dL in males) or moderate to severe (Hb < 10 g/dL in females and <11 g/dL in males). Patients were stratified into three cohorts as follows, based on the presence and severity of preoperative anemia: no anemia, mild anemia, and moderate-to-severe anemia. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital stroke, in-hospital death, myocardial infarction (MI), and prolonged postoperative hospitalization (>1 day). Univariable and multivariable logistic regression analyses were conducted to evaluate the association between the severity of preoperative anemia and clinical outcomes. RESULTS:Among 21,648 patients who underwent TCAR, 4,240 (19.8%) had mild anemia, and 3,401 (15.8%) had moderate-to-severe anemia preoperatively. After adjusting for relevant clinical factors and confounders, moderate-to-severe preoperative anemia was associated with significantly increased odds of in-hospital MI (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI]: 1.53-3.74; P < 0.001), in-hospital death (aOR, 2.65; 95% CI: 1.62-4.34; P < 0.001), and 30-day mortality (aOR, 1.89; 95% CI: 1.32-2.72; P < 0.001) compared to nonanemic patients. Among patients with moderate-to-severe anemia, factors such as a history of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), urgent or emergent procedures, and symptomatic carotid stenosis were the strongest predictors of 30-day mortality. In contrast, mild anemia was not associated with increased odds of adverse postoperative outcomes compared to the nonanemic cohort. Preoperative anemia, regardless of severity, was not associated with an increased risk of postoperative stroke following TCAR. However, the severity of preoperative anemia was associated with a stepwise increase in the adjusted odds of prolonged hospitalization (aOR, 1.19 [mild anemia] and 1.57 [moderate-to-severe anemia]). CONCLUSION/CONCLUSIONS:In this multi-institutional retrospective study of patients undergoing TCAR, moderate-to-severe preoperative anemia was independently associated with higher adjusted odds of in-hospital MI, in-hospital death, and 30-day mortality, without an increased risk of postoperative stroke. These findings highlight moderate-to-severe preoperative anemia as a potential independent prognostic marker for identifying high-risk patients. Furthermore, incorporating the severity of anemia into preoperative risk stratification may aid in tailoring perioperative cardiac assessment and optimization strategies, potentially mitigating the risk of adverse outcomes following TCAR.

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.

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.

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:Cryopreserved vein grafts serve as alternative conduits for infrainguinal bypass when autogenous vein is unavailable or inadequate. Anticoagulation has been advocated to improve outcomes, but published studies demonstrate conflicting results. We assessed the association of anticoagulation on outcomes after infrainguinal bypass with cryopreserved vein in patients with chronic limb threatening ischemia (CLTI). METHODS:The Vascular Quality Initiative was queried (2003-2022) for infrainguinal bypass performed using cryopreserved vein graft for CLTI. Baseline characteristics, procedural details, and outcomes between those discharged with or without anticoagulation were recorded. Univariable, Kaplan-Meier, and multivariable analyses were performed. RESULTS:There were 2336 patients who underwent an infrainguinal bypass with cryopreserved vein conduit. The average age was 70.6 years and 63.5% were male. Bypass targets were femoral/popliteal (27.5%) and tibial (72.5%). Indication for intervention included rest pain (25.7%) and tissue loss (74.3%). Patients were discharged with aspirin (80.1%), a P2Y12 inhibitor (45.6%), and anticoagulation (47.3%). Patients discharged on postoperative anticoagulation more often were treated for rest pain (28.1% vs. 23.5%), had a tibial bypass target (78.4% vs. 67.2%), and less often underwent endarterectomy (27.8% vs. 34.2%) (all P<.05). Kaplan-Meier analysis at one-year demonstrated that postoperative anticoagulation had similar freedom from loss of primary patency/death (28.9% vs. 34.3%), major amputation/death (62.3% vs. 63.8%), and reintervention/major amputation/death (50.6% vs. 53.8%) (all P>.05), but higher survival (85.1% vs. 81.7%, P=.03). Multivariable analysis at one-year demonstrated that postoperative anticoagulation had a similar likelihood for loss of primary patency/death (HR .95, 95% CI .83.-1.09), major amputation/death (HR .88, 95% CI .74-1.05), and reintervention/major amputation/death (HR .93, 95% CI .79-1.08) (all P>.05), but lower likelihood for death (HR .59, 95% CI .46-.74, P<.001) compared to no anticoagulation. Postoperative aspirin was associated with decreased likelihood for amputation/death (HR .74, 95% CI .61-.91, P=.003) and reintervention/major amputation/death (HR .76, 95% CI .64-.9, P=.002). Postoperative P2Y12 inhibitor was associated with decreased likelihood for amputation/death (HR .75, 95% CI .63-.9, P=.002) and reintervention/major amputation/death (HR .78, 95% CI .67-.91, P=.001). Results were similar when analyzing patients who were not on anticoagulation preoperatively. CONCLUSIONS:Postoperative anticoagulation following infrainguinal bypass using cryopreserved vein did not affect patency or limb salvage. Antiplatelet agents were associated with improved outcomes. Overall patency and limb salvage rates at one year were poor. When cryopreserved vein is used, surgeons should consider antiplatelet therapy for cryopreserved graft patency rather than anticoagulation.

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.

BACKGROUND:The National Comprehensive Cancer Network guidelines consider pancreatic cancer with celiac axis (CA), proper hepatic artery (PHA), and superior mesenteric artery (SMA) involvement unresectable. Thus, technical reports and video illustrations of these operations are rare. We report the stepwise management of multivascular reconstruction for Mayo Clinic class IIIb CA resections at New York University Langone Health, a dedicated center of excellence in pancreatic surgery. METHODS:We illustrated the management of a 56-year-old patient with biopsy-confirmed pancreatic ductal adenocarcinoma arising from the pancreatic body and involving the CA, PHA, SMA, and mesentericoportal venous axis. PERIOPERATIVE MANAGEMENT/UNASSIGNED:The preoperative stepwise considerations include: 1) mandatory patient selection; 2) planning vascular reconstructability; 3) tailoring risk assessment while carefully considering the need for total pancreatectomy, total gastrectomy, and mesenteric/hepatic revascularization; and 4) 3D-reconstruction for arterial evaluation. The key intraoperative considerations include: 1) selective and sequential clamping for vascular reconstruction in a "domino" fashion, to minimize warm ischemic time 2) a combined multi-surgeon approach to comprehensively tackle vascular reconstructions; 3) a low threshold for total pancreatectomy to avoid pancreatic leak; and 4) two-stage surgery to reassess the blood supply to the liver and stomach for on-demand gastric preservation instead of a theoretically advised total gastrectomy. CONCLUSION/CONCLUSIONS:Liver, stomach, and bowel vascularization present life-threatening risks that require an extensive preoperative evaluation and a multidisciplinary approach. Our stepwise management for these extensive operations includes total pancreatectomy, "domino" vascular reconstruction, and two-stage surgery.