Faculty Bibliography

Arteriovenous fistula is a rare and often unrecognized complication of aneurysms, with a varied and frequently inconsistent presentation. We present the case of an ilio-iliac arteriovenous fistula formation in a 71-year-old man associated with a type III endoleak after endovascular iliac branch repair. Because of rapidly progressing congestive heart failure and hepatorenal syndrome, we performed urgent endovascular repair with successful endoleak exclusion. After the procedure, the patient demonstrated a remarkably rapid and complete recovery.

PURPOSE/UNASSIGNED:Acute thromboembolic disease of the innominate artery (IA) poses a unique set of therapeutic challenges, owing to its contribution to both the cerebral and upper extremity circulation, and risks of distal embolization via the carotid and subclavian arteries, respectively. Herein, we present a 74-year-old female who presents with acute IA thrombus treated successfully with right axillary and common carotid exposure and aspiration catheter-directed mechanical thrombectomy (CDT). Furthermore, an emerging use of CDT and its application in acute thromboembolism are outlined. CASE REPORT/UNASSIGNED:A 74-year-old female with history of right lung transplant for pulmonary fibrosis with severe pulmonary hypertension, and stage IIIA left lung adenocarcinoma status post left lower lobectomy undergoing adjuvant chemotherapy presented with acute IA thrombus and right-sided stroke. She was treated successfully with right axillary and common carotid exposure and aspiration CDT. Computed tomography angiography performed 1 month postoperatively confirmed patent IA with no evidence of residual or recurrent thrombus. CONCLUSION/UNASSIGNED:There are currently no standard guidelines on the management of acute IA thromboembolism, with mostly individual cases reported in the literature describing this rare entity. Nevertheless, this unique clinical entity mandates expeditious diagnostic and therapeutic approaches in order to avoid permanent neurologic deficits from distal embolization. Our case demonstrates that aspiration CDT may be an effective treatment modality for patients with acute IA thrombus.

The coronavirus disease 2019 pandemic has impacted millions of people worldwide. This novel virus has a variety of presentations and complications. Notably, patients with this infection have an associated coagulopathy, presenting with symptoms such as gastrointestinal bleeds, deep vein thrombosis, ischemic cerebrovascular events, and pulmonary embolism. Although there are documented cases of venous thromboembolism in patients with coronavirus disease 2019, the authors present an interesting case of upper extremity arterial thromboembolism in a 75-year-old patient surgically treated for arterial thrombus removal. We also discuss diagnosis, medical management, and surgical approach to an upper extremity arterial thromboembolism in a patient with coronavirus disease 2019, to highlight the challenges of hypercoagulability in such patients.

BACKGROUND:A nationwide variation in mortality stratified by hospital volume exists after open repair of complex abdominal aortic aneurysms (AAAs). In the present study, we assessed whether the rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) would better explain the lower mortality rates among higher volume hospitals. METHODS:Using the 2004 to 2018 Vascular Quality Initiative database, we identified all patients who had undergone open repair of elective or symptomatic AAAs, in which the proximal clamp sites were at least above one renal artery. We divided the patients into hospital quintiles according to the annual hospital volume and compared the risk-adjusted outcomes. Multivariable logistic regression, adjusted for patient characteristics, operative factors, and hospital volume, was used to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue. RESULTS:We identified 3566 patients who had undergone open repair of elective or symptomatic complex AAAs (median age, 71 years; 29% women; 4.1% black; 48% Medicare insurance). The unadjusted rates of 30-day postoperative mortality, overall complications, and failure-to-rescue were 5.0%, 44%, and 10%, respectively. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with the specific failure-to-rescue rate ranging from 12% to 22%. On adjusted analysis, the risk-adjusted mortality rate was 2.5 times greater for the lower volume hospitals relative to the higher volume hospitals (7.4% vs 3.0%; P < .01). Although the risk-adjusted complication rates were similar between these hospital groups (30% vs 27%; P = .06), the failure-to-rescue rate was 2.3 times greater for the lower volume hospitals relative to the higher volume hospitals (6.3% vs 2.7%; P = .02). CONCLUSIONS:Higher volume hospitals had lower mortality rates after open repair of complex AAAs because they were better at the "rescue" of patients after the occurrence of postoperative complications. Both an understanding of the clinical mechanisms underlying this association and the regionalization of open repair might improve patient outcomes.

OBJECTIVE:There is a lack of evidence regarding the effect of anticoagulation and antiplatelet medications on aortic remodeling for aortic dissection after endovascular repair. We investigated whether anticoagulation and antiplatelet medications affect aortic remodeling after thoracic endovascular aortic repair (TEVAR) for Type B aortic dissection (TBAD). METHODS:Records of the Vascular Quality Initiative TEVAR registry (2012-2020) were reviewed. Procedures performed for TBAD were included. Aortic reintervention, false lumen thrombosis of the treated aorta and all-cause mortality at follow-up were compared between patients treated with and without anticoagulation medications. A secondary analysis was performed to assess the effect of antiplatelet therapy in patients not on anticoagulation. Cox proportional hazards models were used to estimate the effect of anticoagulation and antiplatelet therapies on outcomes. RESULTS:1,210 patients (mean age, 60.7±12.2 years; 825 (68%) males) were identified with a mean follow-up of 21.2±15.7 months (range 1-94 months). 166 (14%) patients were on anticoagulation medications at discharge and at follow-up. Patients on anticoagulation were more likely to be older (mean age, 65.5 vs 60 years; P<.001) and Caucasian (69% vs 55%; P=.003), with higher proportions of coronary artery disease (10% vs 3%; P<.001), congestive heart failure (10% vs 2%; P<.001) and chronic obstructive pulmonary disease (15% vs 9%; P=.017). There were no differences in the mean preoperative thoracic aortic diameter or the number of endografts used. At 18-month, the rates of aortic reinterventions (8% vs 9% log-rank P=.873), complete false lumen thrombosis (52% vs 45%; P=.175) and mortality (2.5% vs 2.7%; P=.209) were similar in patients with and without anticoagulation, respectively. Controlling for covariates with the Cox regression method, anticoagulation use was not independently associated with a decreased rates of complete false lumen thrombosis (hazard ratio (HR) 0.74; 95% confidence interval (CI), 0.5-1.1; P=.132), increased need for aortic reinterventions (HR 1.02; 95% CI, 0.62-1.68; P=.934), and mortality (HR 1.25; 95% CI, 0.64-2.47; P=.514). On a secondary analysis, antiplatelet medications did not affect the rates of aortic reintervention, complete false lumen thrombosis and mortality. CONCLUSIONS:Anticoagulation and antiplatelet medications do not appear to negatively influence the midterm endpoints of aortic reintervention or death in patients undergoing TEVAR for TBAD. Moreover, it did not impair complete false lumen thrombosis. Anticoagulation and antiplatelet medications do not adversely affect aortic remodeling and survival in this population at midterm.

OBJECTIVES/OBJECTIVE:Presence of an endoleak can compromise aneurysm exclusion after endovascular abdominal aortic aneurysm repair(EVAR). Type II endoleaks(T2Es) are most common and may cause sac expansion. We report outcomes of translumbar embolization(TLE) of T2Es following EVAR. METHODS:We conducted a retrospective chart review of patients with T2E after EVAR treated with TLE from 2011-2018 at a single academic institution. Treatment indications were the presence of persistent T2E and aneurysm growth ≥5mm. Sac stabilization was defined as growth ≤5mm throughout the follow-up period. RESULTS:Thirty consecutive patients were identified. The majority were men (n=24) with a mean age of 74.3 years (70.9-77.6, 95% CI). The most common comorbidities were hypertension (83.3%) and coronary artery disease (54.0%). The mean maximal sac diameter at T2E discovery was 5.8 cm (5.4-6.2, 95% CI). The mean time to intervention from endoleak discovery was 33.7±28 months with a mean growth of 0.84 cm (0.48-1.2, 95% CI) during that time period. The mean follow-up time after TLE was 19.1 months (11.1-27.2, 95% CI). Twenty-eight patients were treated with cyanoacrylate glue(CyG) alone, and 2 were treated with CyG plus coil embolization(CE). There was immediate complete endoleak resolution as assessed intraoperatively, and sac stabilization in 15 cases (50.0%). Eleven (36.7%) patients had evidence of persistent T2E on initial imaging after the embolization procedure; additional follow-up revealed eventual sac stabilization at a mean of 21.3±7.2 months and therefore these patients did not require further intervention. In the remaining four cases (13.3%) there was persistent T2E after the initial TLE requiring a second intervention. Repeat TLE stabilized growth in three of these four patients after a mean of 17.6±12.9 months. One patient required open sacotomy and ligation of lumbar vessels due to continued persistence of the T2E and continued aneurysm growth. There were no ischemic complications related to the embolization procedures. Factors associated with persistent endoleak after initial embolization were: larger aneurysm diameter at the time of initial endoleak identification (p<0.001), and the use of antiplatelet agents (p<0.02). The use of anticoagulation was not a significant risk factor for endoleak recurrence or aneurysm growth after TLE. CONCLUSIONS:TLE of T2E is a safe and effective treatment option for T2E with aneurysm growth following EVAR. Patients taking antiplatelet medication and those with larger aneurysms at the time of endoleak identification appear to be at increased risk for persistent endoleak and need for subsequent procedures following initial TLE. These patients may require more intensive monitoring and follow-up.

OBJECTIVE:Adjunctive false lumen embolization (FLE) with thoracic endovascular aortic repair (TEVAR) in patients with chronic aortic dissection is thought to induce FL thrombosis and favorable aortic remodeling. However, these data are derived from small single-institution experiences and the potential benefit of FLE remains unproven. In this study, we examined perioperative and midterm outcomes of patients with aortic dissection undergoing concomitant TEVAR and FLE.* METHODS: Patients 18 or older who underwent TEVAR for chronic aortic dissection with known FLE status in the Society for Vascular Surgery Vascular Quality Initiative database between January 2010 and February 2020 were included. Ruptured patients and emergent procedures were excluded. Patient characteristics, operative details and outcomes were analyzed by group: TEVAR with or without FLE. Primary outcomes were in-hospital post-operative complications and all-cause mortality. Secondary outcomes included follow-up mean maximum aortic diameter change, rates of false lumen thrombosis, re-intervention rates, and mortality. RESULTS:884 patients were included: 46 had TEVAR/FLE and 838 had TEVAR alone. There was no significant difference between groups in terms of age, gender, comorbidities, prior aortic interventions, mean maximum pre-operative aortic diameter (5.1cm vs. 5.0cm, P=0.43), presentation symptomatology, or intervention indication. FLE was associated with significantly longer procedural times (178min vs. 146min, P=0.0002), increased contrast use (134mL vs. 113mL, P=0.02), and prolonged fluoroscopy time (34min vs. 21min, P<0.0001). However, FLE was not associated with a significant difference in post-operative complications (17.4% vs. 13.8%, P=0.51), length of stay (6.5 vs. 5.7 days, P=0.18), or in-hospital all-cause mortality (0% vs. 1.3%, P=1). In mid-term follow-up (median 15.5months, IQR 2.2-36.2 months), all-cause mortality trended lower, but was not significant (2.2% vs. 7.8%); and Kaplan-Meier analysis demonstrated no difference in overall survival between groups (P=0.23). By Cox regression analysis, post-operative complications had the strongest independent association with all-cause mortality (HR 2.65, 95% CI 1.56-4.5, P<0.001). In patients with available follow-up imaging and re-intervention status, mean aortic diameter change (n=337, -0.71cm vs. -0.69cm, P=0.64) and re-intervention rates (n=487, 10% vs. 11.4%, P=1) were similar. CONCLUSIONS:Adjunctive FLE, despite increased procedural times, can be performed safely for patients with chronic dissection without significantly higher overall perioperative morbidity or mortality. TEVAR/FLE demonstrates trends for improved survival and increased rates of FL thrombosis in the treated thoracic segment; however, given the lack of evidence to suggest a significant reduction in re-intervention rates or induction of more favorable aortic remodeling compared to TEVAR alone, the overall utility of this technique in practice remains unclear. Further investigation is needed to determine the most appropriate role for FLE in managing chronic aortic dissections.

BACKGROUND:Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU utilization with perioperative and long-term outcomes after EVAR. STUDY DESIGN/METHODS:The Vascular Quality Initiative (2003-2019) was queried for index elective EVARs. Included centers were categorized by percentage of EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and non-routine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers. RESULTS:Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers - 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all P>.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2±3.6 vs. 2±4.2 days, P<.001). 1-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs. 95.4%, P=.085). When compared to nrICU centers, rICU centers had similar 1-year mortality risk (HR 1.15, 95% CI .99-1.34, P=.076), but were associated with longer postoperative LOS (MR 1.1, 95% CI 1.08-1.13, P<.001). CONCLUSION/CONCLUSIONS:Routine ICU utilization after EVAR was associated with prolonged postoperative LOS without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.

OBJECTIVE:Over the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. While open surgical repair (OR) remains the gold standard for treatment, endovascular repair (ER) has become an attractive alternative in select patient populations. The objective of this study was to compare the outcomes of open versus endovascular repair of PAAs at a single institution. METHODS:We performed a retrospective chart review of all patients between 1998 and 2017 who underwent repair for PAA. Patient baseline, anatomic, and operative characteristics as well as outcomes were compared between the open and endovascular cohorts. The intervention and treatment were at the discretion of the surgeon. RESULTS:Between 1998 and 2017, a total of 64 patients underwent repair of 73 PAAs at our tertiary care center. Twenty-nine patients with 33 PAAs underwent OR, and 35 patients with 40 PAAs underwent ER. When comparing the 2 cohorts, there were no statistically significant differences in demographic characteristics such as age, gender, or number of run-off vessels. There were significantly more patients in the ER group (21/53%) than the OR group (7/21%) with hyperlipidemia (p=.008) and a prior carotid intervention (6% vs. 0%, p=.029). Overall, the presence of symptoms was similar amongst the two groups; however, patients in the OR group had a significantly higher number of patients presenting with acute ischemia (p=.01). Length of stay (LOS) was significantly shorter in the ER cohort (mean 1.8 days [1-11]) compared to the OR group (5.4 days [2-13]) (p<.0001). There was no significant difference in primary or secondary patency rates between the two groups. In the ER group, good runoff (≥2 vessels) was a positive predictor for primary patency at 1 year (3.36 [1.0-11.25]), however, it was not in the OR group. Post-operative single and/or dual anti-platelet therapy did not affect primary patency in either cohort. CONCLUSIONS:The results of our study demonstrate that ER of PAAs is a safe and durable option with comparable patency rates to OR and a decreased LOS, with good run-off being a positive predictor for primary patency in the ER cohort.

New York City was one of the epicenters of the COVID-19 pandemic. The management of peripheral artery disease (PAD) during this time has been a major challenge for health care systems and medical personnel. This document is based on the experiences of experts from various medical fields involved in the treatment of patients with PAD practicing in hospitals across New York City during the outbreak. The recommendations are based on certain aspects including the COVID-19 infection status as well as the clinical PAD presentation of the patient. Our case-based algorithm aims at guiding the treatment of patients with PAD during the pandemic in a safe and efficient way.