Faculty Bibliography

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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OBJECTIVES/OBJECTIVE:With increased focus on the opioid crisis, it was our goal to describe rates and risk factors for postoperative use of opioids in patients undergoing AAA repair as well as identify pain modalities that are underutilized. METHODS:We retrospectively analyzed perioperative analgesic prescriptions for endovascular (EVAR) and open AAA repair between 1/1/2010 to 1/1/2018. Patients' baseline opioid use, demographics, and medical comorbidities were obtained. The EVAR group was further subdivided into percutaneous (pEVAR) and cutdown (cEVAR) groups. Primary outcomes were post-operative and discharge pain medication prescriptions. Relative rates of opioid prescribing were obtained through the electronic medical record and normalized into morphine milligram equivalents (MMEs). RESULTS:Of the 128 patients analyzed in the entire cohort, 21.8% (n=28) underwent open repair and 78.12% (n=100) underwent EVAR (46 pEVAR, 54 cEVAR). As expected, open repair had increased post-operative pain reported compared to EVAR (2.67+/-0.75 vs 0.96+/-0.19, p<0.01). Adjunctive epidural reduced post-operative pain for open repair (0.77 +/-0.48 vs 3.50 +/-0.96 p<0.01). EVAR had less post-operative opioid prescriptions as compared to open repair (35.0% vs 77.3%, p<0.01). In the endovascular group, there was no difference between post-operative opioid prescription based on access, pEVAR vs cEVAR (65.8% vs 80.1% p= 0.11). When stratifying patients by number of cutdowns, patients with bilateral cutdown as opposed to a single cutdown received more opioid prescriptions than pEVAR patients (84.44 vs 65.8% p=0.036). Of those receiving opioids, the average MME for open repair was 320.94 mg compared to 28.82 mg for EVAR (p<0.01). Those undergoing percutaneous repair had significantly less MME use during hospitalization compared to femoral cutdown,17+/-3.52mg vs 31.90+/-5.43mg, respectively (p<0.01). NSAIDs, such as ibuprofen and ketorolac, were rarely used in the post-operative period for open or EVAR (8.3% vs 1.1). Percutaneous EVAR patients reported less pain at discharge compared to cEVAR patients (0.18+/-0.12 vs 0.88+/-0.29, p=0.036). Open and EVAR had comparable low rates of NSAID and acetaminophen prescriptions at discharge. Open patients had longer post-operative length of stay compared to EVAR patients (9.82+/-1.27, 3.86+/-0.47, p<0.01). pEVAR had a shorter length of post-operative course compared to cEVAR (3.2+/-0.26 vs 4.12+/-0.30, p<.01). Patients undergoing EVAR with use of pain medications amounting to <20 MME had a significantly shorter length stay. CONCLUSIONS:This single institutional retrospective study evaluated pain prescription patterns for patients undergoing AAA repair. AAA patients are predominantly treated with opioid pain medications with few adjunctive therapies. Intraoperative epidural and pEVAR may aid in decreasing the total MME used, however, the total number of opioid prescribed are similar for pEVAR and cEVAR despite the difference in approach. Clinicians must consider alternative non-opioid based pain management strategies.

Objective: Transfemoral carotid artery stenting (TFCAS) has higher combined stroke and death rates in elderly patients compared with carotid endarterectomy (CEA). However, transcarotid artery revascularization (TCAR) may have similar outcomes to CEA. This study characterized annual trends in TCAR and compared their outcomes with CEA and TFCAS, focusing on octogenarians.
Method(s): We included all patients with carotid artery stenosis and no prior stenting or endarterectomy who underwent TCAR, CEA, or TFCAS in the Vascular Quality Initiative from September 2016 (TCAR commercially available) to December 2019. We categorized patients into decades: 60s (60-69 years), 70s (70-79 years), and 80s (80-90 years). Outcomes included in-hospital stroke, death within 30 days, a composite stroke/death outcome, and any postoperative neurologic events (includes transient ischemic attacks). Multivariable logistic regressions compared each outcome within every decade category after adjusting for patient demographics, clinical factors, symptoms, urgency, hospital CEA volume, and clustering.
Result(s): We identified 55,828 patients with carotid artery stenosis (35% in their 60s, 44% in their 70s, and 21% in their 80s); half (51%) were symptomatic, and the majority of procedures (86%) were performed electively. The number of TCARs quadrupled from 833 in 2017 to 3206 in 2019. Overall rates of outcomes were as follows: stroke, 1.4%; death, 0.8%; stroke/death, 2.0%; and postoperative neurologic events, 2.0%. Among octogenarians, the adjusted odds of all four outcomes were similar for TCAR relative to CEA: stroke (adjusted odds ratio [aOR], 1.10; 95% confidence interval, 0.75-1.63), death (aOR, 1.19 [0.72-1.97]), stroke/death (aOR, 1.11 [0.80-1.53]), and postoperative neurologic events (aOR, 1.09 [0.80-1.49]). In contrast, TFCAS had higher adjusted odds of all four outcomes compared with CEA. These results remained similar among patients in their 60s and 70s (Table).
Conclusion(s): In this nationwide study, TCARs had similar outcomes relative to CEAs among octogenarians. TCAR may serve as a promising less invasive treatment of carotid disease in older patients who are deemed to be at high anatomic, surgical, or clinical risk for CEA. [Formula presented]
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The novel coronavirus 2019 (SARS-CoV-2) was first identified in January 2020 and has since evolved into a pandemic affecting >200 countries. The severity of presentation is variable and carries a mortality between 1% and 3%. We continue to learn about the virus and the resulting acute respiratory illness and hypercoagulability; however, much remains unknown. In our early experience in a high-volume center, we report a series of four cases of acute peripheral artery ischemia in patients with COVID-19 in the setting of elevated D-dimer levels.

OBJECTIVE:MATERIALS AND METHODS: Patients at our tertiary referral center were identified for inclusion based on a search for the term "penetrating ulcer" in abdominal computed tomography and magnetic resonance imaging reports between January 2014 and December 2017. Patients' electronic medical records were retrospectively reviewed to determine baseline medical characteristics, imaging indication, as well as subsequent clinical course, interventions and outcomes. Aortic diameters and ulcer depths were measured by a single observer on initial and follow-up imaging to assess for association with concomitant aortic pathology, evolving aortic disease, and ulcer progression, defined as increase in depth of ≥ 1mm. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC), and a threshold p-value of < 0.05 set for significance. RESULTS:Ninety-two patients with PUAA were identified; 57 (62%) were male. The mean age at diagnosis was 79.3 years, and comorbidities included hypertension (74%), hyperlipidemia (65%) and malignancy (34%). The most common indication for imaging was chest, back, or abdominal pain (19%). On initial imaging, mean ulcer depth was 1cm (range from 0.2cm to 3.4cm). Concomitant abdominal aortic dilation ≥ 3cm was found in 34 (37%) patients. Thirty-six (39%) patients had a vascular surgery consultation immediately following radiographic diagnosis. Follow-up axial imaging was performed on 27 (29%) untreated patients. The overall sample's mean ulcer depth remained essentially unchanged from initial measurement (p = .99); however, 14 (52%) patients with follow-up imaging were found to have increased overall aortic diameter. Of the total 92 patients, nine (10%) underwent an endovascular abdominal aortic intervention during the review period: two for symptomatic PUAA and the remainder for progression of concomitant aneurysmal disease. All cause mortality was 5% during mean follow-up period of 21.9 months (range 0 to 72.5 months). Of the patients lost to follow-up, 61% did not receive vascular referral after initial diagnosis. CONCLUSIONS:PUAA are typically incidental findings identified in elderly, comorbid patients undergoing imaging for an unrelated indication. Though isolated findings of an asymptomatic PUAA rarely require surgical intervention, these patients we argue would benefit from vascular surgery referral for long-term follow-up and interval imaging to assess for disease progression as well as concomitant aortic degeneration, which may necessitate repair. In addition, we observed that the majority of those patients lost to follow-up did not receive vascular consultation, suggesting that lack of involvement of vascular specialists at the time of diagnosis is a missed opportunity to secure appropriate follow-up and management.

BACKGROUND:The aim of this study was to analyze litigation involving compartment syndrome to identify the causes and outcomes of such malpractice suits. A better understanding of such litigation may provide insight into areas where clinicians may make improvements in the delivery of care. METHODS:Jury verdict reviews from the Westlaw database from January 1, 2010 to January 1, 2018 were reviewed. The search term "compartment syndrome" was used to identify cases and extract data on the specialty of the physician defendant, the demographics of the plaintiff, the allegation, and the verdict. RESULTS:A total of 124 individual cases involving the diagnosis of compartment syndrome were identified. Medical centers or the hospital was included as a defendant in 51.6% of cases. The most frequent physician defendants were orthopedic surgeons (45.96%), and emergency medicine physicians (20.16%), followed by cardiothoracic/vascular surgeons (16.93%). Failure to diagnose was the most frequently cited claim (71.8% of cases). Majority of plaintiffs were males, with a mean age of 36.7 years, suffering injuries an average of 5 years prior to their verdict. Traumatic compartment syndrome of the lower extremity causing nerve damage was the most common complication attributed to failure to diagnose, leading to litigation. Forty cases (32.25%) were found for the plaintiff or settled, with an average award of $1,553,993.66. CONCLUSION/CONCLUSIONS:Our study offers a brief overview of the most common defendants, plaintiffs, and injuries involved in legal disputes involving compartment syndrome. Orthopedic surgeons were most commonly named; however, vascular surgeons may also be involved in these cases due to the large number of cases with associated arterial involvement. A significant percentage of cases were plaintiff verdicts or settled cases. Failure to diagnosis or delay in treatment were the most common causes of malpractice litigation. Compartment syndrome is a clinical diagnosis and requires a high level of suspicion for a timely diagnosis. Lack of objective criteria for diagnosis increase the chances of medical errors and makes it an area vulnerable to litigation.

OBJECTIVE:The aim of this study was to evaluate the performance and predictors of failure of paclitaxel drug-eluting stents and paclitaxel coated balloons in the treatment of long-segment femoropopliteal disease. We report a retrospective cohort analysis of patients treated with paclitaxel eluting stents and paclitaxel coated balloons in lesions >100 mm, which were not included in any of the pivotal trials. METHODS:Ninety-seven patients with peripheral vascular disease (Rutherford III-VI) underwent long-segment (≥100 mm) femoropopliteal paclitaxel eluting stent (DES) implantation or angioplasty with paclitaxel coated balloons (DCB). Patients were followed after their initial procedure for target lesion restenosis, defined as a reduction in lumen diameter by greater than 50% as measured by duplex ultrasonography (ratio>2). RESULTS:The median length of the affected arterial segments was 110 mm (interquartile range [IQR] 100-150, absolute range 100-260) using up to 4 overlapping stents. During the median 13-month follow-up (IQR 7-16), no early thrombotic occlusions occurred within 30 days, but 28 (29%) patients developed a target lesion restenosis after 1 year. Cumulative primary patency at 6 and 12 months was 87% and 71% overall, respectively. The cumulative patency during the same follow-up periods, varied between patients treated with different paclitaxel modalities with 88% and 80% primary patency in patients treated with DES (n=63) versus 81% and 49% in patients treated with DCB (n=21) (adjusted hazard ratio 2.46, p=0.03). Lesion length, concurrent tibial intervention and recurrent target lesions were not associated with restenosis. CONCLUSION/CONCLUSIONS:Short-term outcomes in patients treated with paclitaxel eluting stents and paclitaxel coated balloons in long lesions, mirror results from the clinical trials. The primary patency observed in patients treated with DES was significantly higher than in patients treated with DCBs.

OBJECTIVE:Ischemic complications (including in the lower extremity, visceral, spinal, and pelvic territories) following standard endovascular aortic repair (EVAR) are well recognized but fortunately uncommon. The incidence of such complications following fenestrated and branched aortic repair (F/BEVAR) has not been well defined in the literature. The objective of this study was to compare the incidence of ischemic complications between EVAR and F/BEVAR and to elucidate potential risk factors for these complications. METHODS:We identified all patients who underwent EVAR from 2003 to 2017 or F/BEVAR from 2012 to 2017 in the national Vascular Quality Initiative database. We assessed differences in perioperative ischemic outcomes with methods including logistic regression and inverse probability of treatment propensity score weighting, using a composite endpoint of lower extremity ischemia, intestinal ischemia, stroke, or new dialysis as the primary endpoint. RESULTS:The data comprised 35,379 EVAR patients and 3374 F/BEVAR patients. F/BEVAR patients were more likely to be female, have had previous aneurysm repairs, and be deemed unfit for open aneurysm repair; they were less likely to have ruptured aneurysms; and they had higher estimated blood losses, contrast volumes, and fluoroscopy and procedure times. The incidence of any ischemic event (7.7% vs 2.2%) as well as the incidences of the component endpoints of lower extremity ischemia (2.3% vs 1.0%), intestinal ischemia (2.7% vs 0.7%), stroke (1.5% vs 0.3%), and new hemodialysis (3.1% vs 0.4%) were all significantly increased (all P < .001) in F/BEVAR compared with standard EVAR. After propensity adjustment, F/BEVAR conferred increased odds of any ischemic complication (1.8), intestinal ischemia (2.0), lower extremity ischemia (1.3), new hemodialysis (10.2), and stroke (2.3). CONCLUSIONS:Rates of lower extremity ischemia, intestinal ischemia, new dialysis, and stroke each range from 0% to 1% for standard EVAR and 1% to 3% for F/BEVAR. The incidence of perioperative ischemic complications following F/BEVAR is significantly increased compared to EVAR. The real-world data in this study should help guide decision-making for surgeons and patients as well as serve as one metric for progress in device and technique development. Improvements in ischemic complications may come from continued technology development such as smaller sheaths, improved imaging to decrease procedure time and contrast volume, embolic protection, and increased operator skill with wire and catheter manipulation.