Faculty Bibliography

BACKGROUND:With the exponential increase in the use of endovascular techniques in the treatment of peripheral artery disease, our understanding of factors that affect intervention failures continues to grow. We sought to assess the outcomes of percutaneous transluminal angioplasty for isolated de novo superficial femoral artery (SFA) disease based on balloon diameter. METHODS:The Vascular Quality Initiative database was queried for patients undergoing percutaneous balloon angioplasty for isolated de novo atherosclerotic SFA disease. Based on the diameter of the angioplasty balloon as a surrogate measure of arterial diameter, patients were stratified into two groups: group 1, balloon diameter < 5 mm (354 patients) and group 2, balloon diameter ≥ 5 mm (1,550 patients). The primary patency and major adverse limb event (MALE) were estimated by the Kaplan-Meier method and compared with the log-rank test, based on vessel diameter. multivariable Cox regression analysis was used to determine factors associated with the primary patency. RESULTS:From January 2010 through December 2018, a total of 1,904 patients met criteria for analysis, with a mean follow-up of 13.3 ± 4.5 months. The mean balloon diameters were 3.92 ± 0.26 mm and 5.47 ± 0.55 mm in group 1 and 2, respectively (P<.001). The mean length of treatment and distribution of TASC lesions were not statistically different between the groups. Primary patency at 18 months was significantly lower in group 1, compared with group 2 (55% vs 67%; log-rank P<.001). The MALE rate was higher in group 1 than group 2 (33% vs 26%; log-rank P<.001). Among patients with claudication, there was no significant difference in the primary patency (61% vs 68%; log-rank P=.073) and MALE (27% vs 22%; log-rank P=.176) at 18 months between groups 1 and 2, respectively. However, in patients with CLTI, group 1 had significantly lower 18-month primary patency (47% vs 64%; log-rank P<.014) and higher MALE rates (41% vs 35%; log-rank P=.012) than group 2. Cox proportional hazard analysis confirmed that balloon diameter < 5 mm was independently associated with increased risks of primary patency loss (HR 1.35; 95% CI, 1.04-1.72; P=.021) and MALE (HR 1.29; 95% CI, 1-1.67; P=.048) at 18-months. CONCLUSIONS:In patients undergoing isolated SFA balloon angioplasty for CLTI, smaller SFA (< 5mm) was associated with worse primary patency and MALE. Using balloon size as a surrogate, our findings suggest that patients with a smaller SFA diameter appear to be at increased risk for treatment failure and warrant closer surveillance. Furthermore, these patients may also be considered for alternative approaches, including open revascularization.

BACKGROUND:Autologous vein is considered the preferred conduit for lower extremity bypass. There is, however, limited literature regarding conduit choice for open popliteal artery aneurysm (PAA) repair. We sought to compare outcomes of PAA repair using vein versus prosthetic conduits. METHODS:The Vascular Quality Initiative database (2003-2019) was queried for patients with PAAs undergoing elective conventional revascularization originating from the superficial femoral and popliteal arteries. Conduits were categorized as vein or prosthetic. Primary outcomes were primary graft patency, freedom from major adverse limb event (MALE) and MALE-free survival at 2-years. Kaplan-Meier method with log-rank tests was used for estimation and comparison of patency. RESULTS:A total of 1,146 limbs in 1,065 patients underwent elective open revascularization for popliteal artery aneurysm. Vein was used in 921 limbs (80%), and prosthetic in 225 (20%). Patients in the prosthetic cohort had a shorter procedure time, were older, and had a higher prevalence of COPD. Postoperatively, prosthetic patients were more likely to be started and maintained on anticoagulation without increased incidence of hematoma. There was no significant difference in the rate of surgical site infection (2% vs. 2%; P = .946). There was an increased tendency toward more symptomatic patients in the vein cohort although not statistically significant (49% vein vs. 41% prosthetic; P = .096). On a mean follow-up of 13 ± 5 months, the incidence of MALE and MALE-free survival were comparable between the two groups. The 2-year primary and secondary patency rates were similar, 87% and 96% in the vein, and 91% and 95% in the prosthetic groups, respectively. At multivariable analysis, outflow bypass targets to the infrapopliteal arteries (HR 2.05; 95% confidence interval (CI), 1.16-3.65; P = .014) and symptomatic aneurysm (HR 1.81; 95% CI, 1.04-3.15; P = .037) were independently associated with loss of primary patency. Conduit type did not make a difference in MALE-free survival, or primary graft patency at 2-years. CONCLUSIONS:Our study demonstrates that conventional open PAA repair with prosthetic conduit yields results comparable to those with vein conduit with regard to primary and secondary patency and major adverse limb events at 2-years for targets to the popliteal artery. However, when the distal target was infrapopliteal, worse outcomes were observed with prosthetic conduit. Our results suggest that vein conduit should be preferentially used for infrapopliteal targets, while prosthetic conduit confers comparable outcomes in a subset of patients who do not have suitable autologous vein conduits.

OBJECTIVE:Previous studies evaluating the association between abdominal aortic aneurysm (AAA) size with postoperative outcomes after open repairs seldom accounted for renal or visceral artery involvement, proximal clamp site, intraoperative renal ischemia time, and hospital volume. This study examined the association between aneurysm size with outcomes after open repairs. METHODS:We identified patients who underwent open repairs of infrarenal versus juxtarenal nonruptured AAAs, defined by proximal clamp site, in the 2004-2019 Vascular Quality Initiative. Outcomes included 30-day mortality, postoperative complications, failure to rescue, and 1-year mortality. Multivariable logistic regressions adjusted for patient characteristics, operative factors, hospital volume, and hospital clustering. RESULTS:We identified 8011 patients (54% infrarenal, 46% juxtarenal). The median aneurysm size did not differ between infrarenal versus juxtarenal aneurysms (5.7 cm vs 5.9 cm; P = .12). For infrarenal aneurysms, every 1-cm increase in size increase the adjusted odds ratio (OR) or hazard ratio (HR) of 30-day mortality by 18% (OR, 1.18; 95% CI, 1.06-1.31), failure to rescue by 20% (OR, 1.20; 95% CI, 1.06-1.34), 1-year mortality by 18% (HR, 1.18; 95% CI, 1.10-1.26), but not complications (OR, 1.03; 95% CI, 0.98-1.07). For juxtarenal aneurysm, larger aneurysm sizes were not associated with any outcome. Proximal clamp site, ischemia time, and volume were associated with outcomes. CONCLUSIONS:The association between AAA size and outcomes matters less with renal and visceral artery aneurysmal involvement, having important implications for surgical decision-making, operative planning, and patient counseling.

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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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: 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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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.

INTRODUCTION/BACKGROUND:The natural history of penetrating aortic ulcers (PAU) and intramural hematomas (IMH) of the aorta is not well described. While repair is warranted for rupture, unremitting chest pain or growth, there is no established threshold for treating incidental findings. Thoracic endovascular aortic repair (TEVAR) offers an attractive approach in treating these pathologies, however, peri-procedural and post-operative outcomes are not well defined. METHODS:Patients 18 or older identified in the VQI database who underwent TEVAR for PAU and/or IMH between 1/2011-2/2020 were included. We identified 1042 patients, of whom 809 had available follow-up data. Patient demographics and comorbidities were analyzed to identify risk factors for major adverse events (MAE), as well as postoperative and late mortality. RESULTS:The cohort was 54.8% female and 69.9% former smokers with a mean age of 71.1 years. Comorbidities were prevalent with 57.8% classified ASA IV; 89.8% had hypertension, 28.3% chronic obstructive pulmonary disease (COPD), 17.9% coronary artery disease, and 12.2% congestive heart failure (CHF). Patients were predominately symptomatic (74%) and 44.5% underwent non-elective repair. MAE incidence was 17%. Independent predictors of MAE were history of CAD, non-Caucasian race, emergent procedural indication, ruptured presentation, and deployment of two or more endografts. In-hospital mortality was 4.3%. Seventy-three percent of index hospitalization mortalities were treatment-related. Of 809 patients with follow-up (mean 25.1 months±19 months), all-cause mortality was 10.6%. Predictors of late mortality in follow-up included age greater than 70 years, ruptured presentation, and history of COPD and ESRD. Subset analysis comparing symptomatic (74%) vs. asymptomatic (26%) patients demonstrated the former were frequently female (58.2% vs. 45.3%, p<.001) with a higher incidence of MAE (20.6% vs. 6.9%, p<.001), notably higher in-hospital reintervention rates (5.9% vs. 1.5%, p=.002) and mortality (5.6% vs. 0.7%, log-rank p=.015), and prolonged length of stay (6.9 vs. 3.7 days, p<.0001) despite similar procedural risks. In follow-up, late mortality was higher in the symptomatic cohort (12.2% vs. 6.5%, log-rank p=.025), with all treatment-related mortalities limited to the symptomatic group. CONCLUSIONS:We demonstrate significantly higher morbidity and mortality in symptomatic patients undergoing repair compared to asymptomatic patients, despite similar baseline characteristics. Asymptomatic patients treated with TEVAR had no treatment-related mortality in follow-up, with overall prognosis largely dependent on pre-existing comorbidities. These findings, in conjunction with growing evidence highlighting the risk of disease progression and attendant morbidity associated with these aortic entities, suggest a need for natural history studies and definitive guidelines on the elective repair of IMH and PAU.

OBJECTIVES/OBJECTIVE:Chronic limb threatening ischemia (CLTI) in patients with end-stage renal disease (ESRD) confers a significant survival disadvantage and is associated with a high major amputation rate. Moreover, diabetes mellitus (DM) is an independent risk factor for developing CLTI. However, the interplay between end stage renal disease (ESRD) and DM on outcomes after peripheral revascularization for CLTI is not well established. Our goal was to assess the effect of DM on outcomes after an infrainguinal bypass for CLTI in patients with ESRD. METHODS:Using the Vascular Quality Initiative dataset from January 2003 to March 2020, records for all primary infrainguinal bypasses for CLTI in patients with ESRD were included for analysis. One-year and perioperative outcomes of all-cause mortality, reintervention, amputation-free survival (AFS) and major adverse limb event (MALE) were compared for patients with DM versus those without DM. RESULTS:Of a total of 1,058 patients (66% male) with ESRD, 726 (69%) patients had DM, and 332 patients did not have DM. The DM group was younger (median age, 65 years vs. 68 years; P=.002), with higher proportions of obesity (body-mass index>30kg/m2; 34% vs. 19%; P<.001) and current smokers (26% vs. 19%; P=.013). The DM group presented more frequently with tissue loss (76% vs. 66%; P<.001). A distal bypass anastomosis to tibial vessels was more frequently performed in the DM group compared to the non-DM group (57% vs. 45%; P<.001). DM was independently associated with higher perioperative MALE (OR 1.34; 95% CI, 1.06-1.68; P=.013), without increased risks of loss of primary patency and composite outcomes of amputation or death. On the mean follow-up of 11.4 ± 5.5 months, DM patients had a significantly higher rate of one-year MALEs (43% vs. 32%; P=.001). However, the one-year primary patency and AFS, did not differ significantly. After adjusting for confounders, the risk-adjusted hazards for MALE (HR 1.34; 95% CI, 1.06-1.68; P=.013) were significantly increased in patients with DM. However, DM was not associated with increased risk of AFS (HR 1.16; 95% CI, 0.91-1.47; P=.238), or loss of primary patency (HR 1.04; 95% CI, 0.79-1.37; P=.767). CONCLUSION/CONCLUSIONS:DM and ESRD each independently predict early and late major adverse limb events after an infrainguinal bypass in patients presenting with CLTI. However, in the presence of ESRD, DM may increase perioperative adverse events, but does not influence primary patency and AFS at one-year. The risk profile associated with ESRD appears to supersede that of DM, with no additive effect.

OBJECTIVES/OBJECTIVE:The pandemic of Coronavirus disease 2019 (COVID-19) has caused devastating morbidity and mortality worldwide. In particular, thromboembolic complications have emerged as a key threat in COVID-19. We assessed our experience with deep venous thrombosis (DVT) in patients with COVID-19. METHODS:We performed a retrospective analysis of all patients with COVID-19 undergoing upper or lower extremity venous duplex ultrasonography at an academic health system in New York City between March 3 2020 and April 12 2020 with follow-up through May 12 2020. A cohort of hospitalized patients without COVID-19 (non-COVID-19) undergoing venous duplex ultrasonography from December 1 2019 to December 31 2019 was used for comparison. The primary outcome was DVT. Secondary outcomes included pulmonary embolism (PE), in-hospital mortality, admission to intensive care unit, and antithrombotic therapy. Multivariable logistic regression was performed to identify risk factors for DVT and mortality. RESULTS:Of 443 patients (188 COVID-19 and 255 non-COVID-19) undergoing venous duplex ultrasonography, patients with COVID-19 had higher incidence of DVT (31% vs. 19%; P=0.005), compared to the non-COVID-19 cohort. The incidence of PE was not statistically different between the COVID-19 and non-COVID-19 cohorts (8% vs. 4%; P=.105). The DVTs in the COVID-19 group were more distal (63% vs. 29%; P<.001) and bilateral (15% vs. 4%; P<.001). The result of duplex ultrasonography had a significant impact on the antithrombotic plan; 42 (72%) patients with COVID-19 in the DVT group had their therapies escalated while 49 (38%) and 3 (2%) patients had their therapies escalated and de-escalated in the non-DVT group, respectively (P<.001). Within the COVID-19 cohort, the D-dimer was significantly higher in the DVT group at the time of admission (2,746 ng/mL vs 1,481 ng/mL; P=.004) and at the time of the duplex exam (6,068 ng/mL vs. 3,049 ng/mL; P<0.01). At multivariable analysis, male sex (odd ratio (OR) 2.27; 95% confidence interval (CI), 1.06-4.87; P=.035), ICU admission (OR 3.42; 95% CI, 1.02-11.44; P=.046) and extracorporeal membrane oxygenation (OR 5.5; 95% CI, 1.01-30.13; P=.049) were independently associated with DVT. CONCLUSION/CONCLUSIONS:Given the high incidence of venous thromboembolic events in this population, we support the decision to empirically initiate therapeutic anticoagulation in patients with low bleeding risk and severe COVID-19 infection, with duplex ultrasonography reserved for patients with high clinical suspicion of VTE in which anticoagulation may pose a life-threatening consequence. Further study is warranted in patients with COVID-19 to elucidate the etiology of vascular thromboembolic events and guide prophylactic and therapeutic interventions in these patients.