Faculty Bibliography

Background: To date, few studies adequately evaluate the impact of anticoagulation and antiplatelet medications on aortic remodeling for type B thoracic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). As such, we assessed the relationship between chronic anticoagulation/antiplatelet medications and aortic remodeling of patients with TBAD after TEVAR.
Method(s): Records of the Vascular Quality Initiative TEVAR registry (2011-2019) were reviewed. Procedures performed for dissection-related pathology were included. Primary outcomes included complete false lumen thrombosis, reintervention-free survival and endoleak at 18 months. Primary outcomes were compared between patients with and without chronic anticoagulants (AC and non-AC). A subgroup analysis was performed to assess the effect of antiplatelet medications (none, single antiplatelet, and dual antiplatelets) in the non-AC group. Cox proportional hazards models were used to estimate the effect of different antithrombotic therapies on primary outcomes.
Result(s): We identified 1507 patients (mean age, 60.7 +/- 12.2 years; 68.3% male) with a mean follow-up of 18.9 +/- 13.7 months. Two hundred one (14%) patients were on anticoagulation therapy at follow-up. There were no differences in the mean preoperative thoracic aortic diameter or the number of endografts used. The status of false lumen thrombosis and endoleaks were available in 648 (43%) and 1023 patients (68%), respectively. At 18 months, the rates of complete false lumen thrombosis (51.3% vs 47.5%; P =.182), reinterventions (9% vs 10.6%; P =.175), all-cause mortality (97.6% vs 96.9%; P =.561), and endoleaks (18.8% vs 22%; P =.397) were similar in the AC and non-AC groups, respectively (Fig). Controlling for covariates with the Cox regression method, AC use was not independently associated with a decreased risk of complete false lumen thrombosis (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.54-1.16; P =.235) or increased risks of reintervention (HR, 1.06; 95% CI, 0.9-1.24; P =.484) and endoleak (HR, 0.97; 95% CI, 0.83-1.14; P =.725). Within the non-AC group, antiplatelet medications did not affect the rates of complete false lumen thrombosis, reintervention, or endoleak.
Conclusion(s): The use of chronic anticoagulation and antiplatelet medications did not adversely affect the rate of complete false lumen thrombosis and positive aortic remodeling in patients who underwent TEVAR for TBAD. Anticoagulation and antiplatelet medications may be safely used in patients who undergo TEVAR for TBAD. [Formula presented]
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Aortic mural thrombus in the absence of underlying aortic disease is rare and results in a risk of distant arterial embolization that can result in limb loss or other end organ damage. Current management involves open surgery, anticoagulation, and systemic thrombolysis; however, each carries inherent risks. We report the case of aortic thrombus with distal emboli in two patients, a 56-year-old man and a 68-year-old man, neither with underlying aortic pathology and both presenting with limb threatening ischemia. We performed percutaneous mechanical thrombectomy using the FlowTriever System (Inari Medical, Irvine, Calif) with successful removal of the aortic thrombus in both patients.

BACKGROUND:The ability to ambulate following major lower extremity amputation, either below (BKA) or above knee (AKA), is a major concern for all prospective patients. This study analyzed ambulatory rates and risk factors for nonambulation in patients undergoing a major lower extremity amputation. METHODS:A retrospective review of 811 patients who underwent BKA or AKA at our institution between January 2009 and December 2014 was conducted. Demographic information and co-morbid conditions, including the patients' functional status prior to surgery, at 6 months, and at latest follow up were recorded. Following exclusion criteria, 538 patients were included. Patients who were either independent or used an assistive device were considered ambulatory, while those who were completely wheelchair-dependent or bed-bound were considered nonambulatory. RESULTS:Pre-operatively, 83.1% of BKA patients were ambulatory, significantly more so than those undergoing AKA (44.9%, P < 0.0001). At 6-month follow-up these percentages dropped to 58.0% and 25.2%, respectively, for all patients. For patients who were ambulatory pre-operatively, 182/246 (73.9%) of BKA and 32/51 (62.7%) of AKA remained so post-amputation. Of those patients with both 6-month and greater than 1-year follow-up, there was no change in ambulatory status between the 2 time periods. On multivariable logistic regression, age greater than 70 years and female sex were associated with nonambulation post-operatively (P = 0.001, P = 0.015, respectively). None of the co-morbid conditions recorded (diabetes, renal insufficiency, end-stage renal disease, peripheral vascular disease, or body mass index > 35) was found to have a statistically significant correlation with post-operative ambulation using multivariable analysis. CONCLUSIONS:The majority of ambulatory patients undergoing a major amputation were able to remain ambulatory. Patients who failed to ambulate 6 months after their amputation, failed to resume ambulating. Age greater than 70 and female sex were found to have a statistically significant association with becoming nonambulatory following surgery.

Introduction and Objectives: 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, evidence is limited and the potential benefit of FLE remains unproven.
Method(s): Patients 18+ who underwent TEVAR for chronic aortic dissection with known FLE status in the SVS VQI database 1/2010-2/2020 were included. Ruptured patients and emergent procedures were excluded. Primary outcomes were in-hospital post-operative complications and all-cause mortality. Secondary outcomes included follow-up maximum aortic diameter change, re-intervention rates, and mortality.
Result(s): 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, maximum pre-operative aortic diameter, 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), but 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), all-cause mortality trended lower, but was not significant (2.2% vs. 7.8%); Kaplan-Meier analysis demonstrated no difference in overall survival between groups (p=0.23). 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.
Conclusion(s): Adjunctive FLE can be performed safely in chronic thoracic aortic dissections without significantly higher perioperative morbidity or mortality. However, given lack of reduction in re-intervention rates, induction of significant favorable aortic remodeling, or definitive survival benefit compared to TEVAR alone, FLE utility remains unclear.
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BACKGROUND/UNASSIGNED:In many facilities, the coronavirus disease (COVID-19) pandemic caused suspension of elective surgery. We therefore sought to determine the impact of this on the surgical experience of vascular trainees. METHODS/UNASSIGNED:Surgical case volume, breadth, and the participating trainee post-graduate level from 3 large New York City Hospitals with integrated residency and fellowship programs (Mount Sinai, Montefiore Medical Center/Albert Einstein College of Medicine, and New York University) were reviewed. Procedures performed between February 26 to March 25, 2020 (pre-pandemic month) and March 26 to April 25, 2020 (peak pandemic period) were compared to those performed during the same time period in 2019. The trainees from these programs were also sent surveys to evaluate their subjective experience during this time. RESULTS/UNASSIGNED:The total number of cases during the month leading into the peak pandemic period was 635 cases in 2019 and 560 cases in 2020 (12% decrease). During the peak pandemic period, case volume decreased from 445 in 2019 to 114 in 2020 (74% reduction). The highest volume procedures during the peak pandemic month in 2020 were amputations and peripheral cases for acute limb ischemia; during the 2019 period, the most common cases were therapeutic endovascular procedures. There was a decrease in case volume for vascular senior residents of 77% and vascular junior and midlevel residents of 75%. There was a 77% survey response rate with 50% of respondents in the senior years of training. Overall, 20% of respondents expressed concern about completing ACGME requirements due to the COVID-19 pandemic. CONCLUSIONS/UNASSIGNED:Vascular surgery-specific clinical educational and operative experiences during redeployment efforts have been limited. Further efforts should be directed to quantify the impact on training and to evaluate the efficacy of training supplements such as teleconferences and simulation.

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.

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.

Deep vein thrombosis is relatively rare in the pediatric setting, though it carries significant risk for pulmonary embolism and post-thrombotic syndrome. We report a case of a 10-year-old girl diagnosed with pulmonary embolism and right iliofemoral vein deep vein thrombosis with concomitant granulomatosis with polyangiitis (formerly Wegener's granulomatosis) and acute glomerulonephritis. Owing to lifestyle-limiting venous claudication, we performed percutaneous, mechanical thrombectomy using the ClotTriever system with successful removal of likely both acute and chronic thrombus. After the procedure, the patient had near complete resolution of her venous claudication symptoms.

Objective: Aortic neck dilation (AND) can occur in nearly 25% of patients after EVAR, resulting in loss of proximal seal and aortic rupture. Fenestrated endovascular aneurysm repair (FEVAR) affords increased treatment options for patients with shorter infrarenal aortic necks; however, AND has not been well characterized in these patients. This study sought to compare AND in patients undergoing FEVAR vs standard endovascular aneurysm repair (EVAR).
Method(s): Retrospective review was conducted of prospectively collected data of 20 consecutive FEVAR patients (Cook Zenith fenestrated; Cook Medical, Bloomington, Ind) and 20 EVAR patients (Cook Zenith). Demographic and anatomic characteristics, procedural details, and clinical outcome were analyzed. Preoperative, 1-month postoperative, and longest follow-up computed tomography scans were analyzed using a dedicated three-dimensional workstation. Abdominal aortic aneurysm (AAA) neck diameter was measured in 5-mm increments from the lowest renal artery. Standard statistical analysis was performed.
Result(s): Demographic characteristics did not differ significantly between the two cohorts. The FEVAR group had larger mean aortic diameter at the lowest renal artery, shorter infrarenal aortic neck length, increased prevalence of nonparallel neck shape, and longer AAA length (Table). On follow-up imaging, the suprarenal aortic segment dilated significantly more at all suprarenal locations in the FEVAR cohort, whereas the infrarenal aortic neck segment dilated significantly less compared with the EVAR group (Table). The FEVAR group demonstrated significantly greater sac regression vs the EVAR group. Positive aortic remodeling, as evidenced by increased distance from the celiac axis to the most cephalad margin of the AAA, occurred to a more significant degree in the FEVAR cohort. Device migration, endoleak occurrence, and need for reintervention were similar in both groups.
Conclusion(s): Compared with EVAR, patients undergoing FEVAR had greater extent of suprarenal AND, consistent with a more diseased native proximal aorta. However, the infrarenal neck, which is shorter and also more diseased in FEVAR patients, appears more stable in the postoperative period compared with EVAR cases. Moreover, the FEVAR cohort had significantly greater sac shrinkage and improved aortic remodeling. The suprarenal seal zone in FEVAR may confer a previously undescribed increased level of protection against infrarenal neck dilation and lessen endotension, resulting in more rapid and dramatic sac shrinkage and contributing to a more durable aortic repair. [Formula presented]
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