Faculty Bibliography

OBJECTIVE:The thoracic branch endoprosthesis (TBE) (W.L. Gore) offers an off-the-shelf single option for thoracic endovascular aortic repair (TEVAR) of aortic arch pathology with sealing in zones 0 to 2. This study reports the early outcomes of TBE-TEVAR for acute indications. METHODS:Clinical data, imaging, and outcomes of patients treated with TBE-TEVAR at seven institutions were retrospectively reviewed (March 2017 to March 2024). Patients treated for complicated aortic dissection, symptomatic aneurysm/pseudoaneurysm, or blunt traumatic aortic injury by urgent/emergent repair were included. End points were 30-day mortality, major adverse events (mortality, myocardial infarction, prolonged intubation, stroke, paraplegia, dialysis, or bowel ischemia), and technical success. RESULTS:Of 356 patients treated by TBE-TEVAR, 107 (69.0% male; mean age, 60 ± 15 years) underwent repair for acute indications including 70 dissections (65%), 21 symptomatic aneurysms/pseudoaneurysms (20%), and 16 blunt traumatic aortic injuries (15%). Eight patients (8%) had repair immediately after open ascending repair of a type A dissection. Proximal sealing was in zone 2 in 91 patients (89%) and zone 0 to 1 in 11 patients (11%) who required cervical debranching. Technical success was achieved in all (99%) except one patient with acute dissection and aneurysmal degeneration requiring staged repair. At 30 days, two patients (2%) died, and 19 patients (18%) developed major adverse events, including stroke in six patients (6%) and paraplegia in six patients (6%). Five patients (5%; all Zone 2) had retrograde dissections, all treated for acute or subacute dissection, with no mortality. Mean follow-up was 55 ± 171 days, and 96 patients (94%) had follow-up imaging. Type IA or III endoleak occurred in seven patients (7%), retrograde branch occlusion in one (1%), and eleven (10%) required reintervention. Cumulative aortic-related mortality was three (3%) from aortic rupture. CONCLUSIONS:Urgent/emergent TEVAR with the Gore TBE device in acute pathology offers low mortality, stroke, and paraplegia risk. Longer follow-up is needed to assess effectiveness of the repair.

BACKGROUND:Thoracic endovascular aortic repair (TEVAR) is the standard of care for type B aortic dissection (TBAD) complicated with visceral malperfusion. TEVAR is considered efficient at relieving malperfusion caused by dynamic obstruction but not static obstruction, and as such, some patients also require adjunctive visceral branch vessel interventions (VBI). The role of VBI in patients undergoing TEVAR for TBAD complicated with visceral malperfusion is a subject of considerable debate. This study aims to compare the postoperative outcomes of TEVAR with VBI vs without for TBAD complicated with visceral malperfusion in a real-world multi-institutional setting. METHODS:The Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database was queried for patients who underwent TEVAR for TBAD complicated with hepatic, intestinal, or renal malperfusion. The cohort was divided into two groups based on the main exposure variable: TEVAR with adjunctive VBI vs without on either celiac artery (CA), superior mesenteric artery (SMA), right renal artery (RRA), or left renal artery (LRA), presenting with malperfusion. Baseline demographic, clinical, and perioperative characteristics, as well as outcomes such as overall 30-day mortality, malperfusion-related mortality, Major Adverse Cardiovascular Events (MACE: death, myocardial infarction, stroke), overall complications, reinterventions, and visceral branch reinterventions, were compared between the groups. Univariable and multivariable analyses were performed. RESULTS:Of all reviewed patients, 477 were involved in the final analysis, 324 (67.9%) underwent TEVAR without a VBI, whereas 153 (32.1%) underwent TEVAR in association with an adjunctive intervention on at least one of the visceral branches (CA, SMA, RRA, LRA), presenting with malperfusion. Patients who underwent TEVAR with a VBI had significantly lower rates of overall 30-day mortality (9.8% vs 17.3%, p=0.032), malperfusion-related mortality (3.3% vs 9.6%, p=0.015), a tendency towards a lower rate of MACE (15.7% vs 22.8%, p=0.071), and a higher rate of visceral branch reinterventions (11.8% vs 6.2%, p=0.035). After adjustment for potential confounders, patients who underwent TEVAR with a VBI had 90% decreased odds of 30-day mortality (OR: 0.10, 95%CI: 0.03-0.40, p=0.001), 78% decreased odds of malperfusion-related mortality (OR: 0.22, 95%CI: 0.05-0.95, p=0.043), 50% decreased odds of MACE (OR: 0.50, 95%CI: 0.25-0.97, p=0.040) and increased odds of visceral branch reinterventions (OR: 2.36, 95%CI: 1.01-5.52, p=0.047). CONCLUSIONS:TEVAR with VBI is associated with significantly reduced odds of 30-day mortality, malperfusion-related mortality, and MACE, but increased odds of visceral branch reinterventions in TBAD patients presenting with visceral malperfusion. Based on these results, a lower threshold for performing VBI is recommended for patients with malperfusion. Further prospective studies are required to confirm these findings and to identify patients who would benefit from VBI the most.

BACKGROUND:Anemia is highly prevalent in patients with peripheral vascular disease and has been associated with postoperative cardiac events and mortality and adverse limb events after revascularization procedures. Allogenic blood transfusions have also been associated with adverse events including hospital-acquired infections, cardiac morbidity, and reduced survival. The aim of this study was to evaluate the impact of blood transfusion on major adverse cardiac events (MACE) and major adverse limb events (MALE) in patients undergoing infrainguinal lower extremity bypass (LEB) operations. METHODS:We performed a retrospective cohort analysis of patients undergoing infrainguinal LEB in the Society for Vascular Surgery Vascular Quality Initiative database between 2003 and 2020. Patients were first grouped by their preoperative hemoglobin (Hgb) number (severe anemia: Hgb 7-10 g/dL; moderate anemia: 10-12 g/dL; normal Hgb: >12 g/dL) and then stratified by their transfusion status (perioperative transfusion versus no perioperative transfusion). Primary end points were MACE, defined as myocardial infarction, new congestive heart failure, dysrhythmia, or stroke in the postoperative period, and MALE, defined as return to operating room for thrombosis, loss of primary patency on follow-up, and major ipsilateral amputation on follow-up. Secondary outcomes included wound complications, graft infections, 30-day mortality, and 1-year survival. Outcomes were compared between patients who received transfusions and those who did not at every anemic threshold. Multivariable logistic regression was performed to evaluate the impact of blood transfusion on primary outcomes. RESULTS:A total of 55,884 patients were included for analysis, of which 16.3% had severe anemia, 25.9% had moderate anemia, and 57.8% had normal Hgb. Anemia severity was associated with increased rates of MACE (9.8% vs. 8.3% vs. 5.2%, P < 0.0001) and MALE (32.2% vs. 24.8% vs. 18.6%, P < 0.0001). On univariate analysis, transfusion was consistently associated with increased rates of MACE and MALE at every anemic threshold (P < 0.0001 for all). Transfusion was also associated with increased rates of 30-day mortality at all anemic thresholds (P < 0.0001 for all) and reduced 1-year survival at all anemic thresholds (log-rank P < 0.0001 for all). On multivariable analysis for MACE, an interaction factor was observed between preoperative Hgb and transfusion status (P < 0.0001). At every anemic threshold, transfusion was independently associated with MACE (severe: odds ratio [OR] 2.4 [95% confidence interval [CI]: 2.0-2.9]; moderate: OR 2.8 [95% CI: 2.5-3.2]; normal: OR 4.5 [95% CI: 4.0-5.0]). On multivariable analysis for MALE, an interaction factor was also observed between preoperative Hgb and transfusion status (P < 0.0001). At every anemic threshold, transfusion was independently associated with MALE (severe: OR 2.1 [95% CI: 1.9-2.3]; moderate: OR 1.8 [95% CI: 1.7-2.0]; normal: OR 2.6 [95% CI: 2.4-2.8]). CONCLUSIONS:Perioperative blood transfusion in patients undergoing infrainguinal LEB is independently associated with MACE and MALE in all patients with preoperative Hgb >7 g/dL. Despite the morbidities associated with anemia, these findings highlight that transfusion may not be the optimal treatment modality, particularly in patients with higher preoperative Hgb. Future research is needed to define the transfusion threshold in this population.

BACKGROUND:Treatment of iliac artery aneurysms (IAAs) with the iliac branch endoprosthesis (IBE) during endovascular repair of infrarenal abdominal aortic aneurysm (endovascular aortic repair (EVAR)) has been well-documented as effective. However, limited data exist evaluating the safety and efficacy of treating complex abdominal (cAAAs) and thoracoabdominal aortic aneurysms (TAAAs) with associated IAA with combined physician-modified fenestrated-branched EVAR (PM-FBEVAR) and IBE. Moreover, limited studies exist assessing the impact of adding IBE on the outcomes following PM-FBEVAR. Therefore, we compared the clinical outcomes of patients who underwent PM-FBEVAR with and without IBE for the treatment of cAAA and TAAA. METHODS:A single-institution retrospective review of consecutive patients who underwent PM-FBEVAR between September 2015 and February 2021 was conducted. Patients with both unilateral and bilateral IBE implantation were included. Infected aneurysms and pseudoaneurysms were excluded. Demographics, technical success, and operative factors were analyzed. Primary outcomes were incidence of pelvic ischemia including buttock and thigh claudication, bowel and spinal cord ischemia, patency of internal and external limbs of IBE, and target vessel instability. Secondary outcomes included technical success, 30-day major adverse events, 30-day and all-cause mortality, and endoleaks. RESULTS:Among 183 patients identified who underwent PM-FBEVAR, 22 patients underwent PM-FBEVAR and IBE with 3 patients treated with bilateral IBEs. There was no pelvic ischemia in the PM-FBEVAR and IBE group. Technical success, fluoroscopy time, and procedure time were comparable between the 2 groups. Contrast usage was higher in the PM-FBEVAR and IBE group (P = 0.01). Thirty-day major adverse event and mortality were not statistically different between the 2 groups. At a mean follow-up of 23 months, all-cause mortality was similar for both groups (21% vs. 27%; P = 0.47). Patency of internal iliac artery limb and external iliac artery limb of the IBE were 96% (24 of 25) and 100%, respectively, during mean follow-up of 23 months. The patient with occlusion of internal iliac limb was asymptomatic and received no reintervention. CONCLUSIONS:Treatment of cAAA and TAAA associated with IAA using combined PM-FBEVAR and IBE is feasible with high efficacy and safety, and without adverse effect on outcomes. Long-term follow-up is planned to assess durability of repair with PM-FBEVAR and IBE.

BACKGROUND:Several recent small trials have suggested that there is a potential benefit of early thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), even for uncomplicated patients. We studied patients enrolled in the Gore Global Registry for Endovascular Aortic Treatment (GREAT) to compare outcomes of TEVAR in the early-acute phase with and without complicated presentation. METHODS:The GREAT registry was queried for patients treated with TEVAR for TBAD. Acute phase of TBAD was defined as hospitalization within 14 days of symptom onset. Time to treatment was computed as time from first symptoms to time of TEVAR implantation regardless of the preoperative duration of hospitalization. Complicated presentation of acute TBAD was designated by the treating clinical sites, and treatment strategy was determined at the physician's discretion, as was common practice at the time of registry conception in 2010; therefore, the designation of "complicated" presentation in this study differs from the most recent Society for Vascular Surgery/Society of Thoracic Surgeons reporting standards, which refers exclusively to malperfusion and rupture. All patients received TEVAR with Gore TAG or CTAG devices (W.L. Gore & Associates, Flagstaff, Arizona). The primary exposure variable was time from symptom onset to TEVAR, stratified by complicated versus uncomplicated presentation. The primary outcome was postoperative aortic complications, defined as endoleak, extended or new dissection (including retrograde type A dissection), rupture, enlargement or aneurysmal degeneration, requirement for reinterventions, conversion to open repair, and graft infection. Univariate data were analyzed by contingency table and unpaired t-test or Wilcoxon rank sum, and adjusted analyses were conducted using stratified and multiple logistic and Cox regression techniques. Data were analyzed by an independent academic research team. RESULTS:Of the 5,014 patients enrolled in the GREAT registry between 2011 and 2016, there were 172 patients who received TEVAR for TBAD; 40 of 172 (23%) were female and the mean age was 61 ± 12 years. There were 102 (59%) with complicated presentations. After adjustment for complicated presentation, TEVAR performed within 3 days of symptom onset was independently associated with increased rate of short-term (odds ratio, 2.4, P < 0.039), and intermediate-term (hazard ratio 2.31, P < 0.024) aortic complications. TEVAR performed within 3 days was also associated with increased rates of aortic reinterventions, branch vessel complications, renal complications, and aortic complication/death at 6 months when compared with delayed repair. CONCLUSION/CONCLUSIONS:These data suggest that TEVAR performed at least 3 days after acute TBAD is associated with less morbidity and mortality. When possible, TEVAR should be delayed by at least 3 days for patients with uncomplicated acute TBAD to offer maximum risk reduction.

OBJECTIVE:Spinal cord ischemia (SCI) remains one of the most devastating complications in both open and endovascular stent graft repair of thoracoabdominal aortic aneurysms. The endovascular aortic aneurysm repair (EVAR) can be either thoracic (TEVAR) when it targets the thoracic aortic aneurysm or fenestrated branched when repair involves the visceral and/or renal arteries. Even though EVAR interventions are less invasive than open repair, they are still associated with a significant risk of SCI. The current primary strategy to prevent SCI after TEVAR is to increase and/or maintain spinal cord perfusion pressure (blood flow) by increasing the mean arterial pressure while simultaneously draining CSF. Although the benefit of CSF drainage in EVAR procedures remains uncertain, it provides an opportunity to study the changes in cytokine and oxidative stress markers that may signal the pathophysiology of SCI following EVAR. The aim of this study was to evaluate the temporal relationship between stent deployment and CSF cytokine and oxidative stress marker levels as predictors of delayed SCI in patients undergoing an EVAR procedure. METHODS:There were 16 EVAR cases across 15 patients enrolled in this study, with 1 patient undergoing the procedure twice 1 year apart. The levels of oxidative stress (8-hydroxy-2'-deoxyguanosine [8-OHdG], glial fibrillary acidic [GFAP], and lactic acid) and proinflammatory (tumor necrosis factor-alpha [TNF-α], interleukin (IL)-6, and IL-1β) and antiinflammatory (IL-4) markers were quantified at different time points between 0 and 48 hours after EVAR by enzyme-linked immunosorbent assay. The changes in protein levels of both oxidative stress and inflammatory markers were expressed as fold change from the time of the lumbar drain insertion prior to surgery. RESULTS:Following the EVAR procedure, 8-OHdG resulted in the highest upregulation at later time points postoperatively (48 hours) and this increase was positively correlated with TNF-α level. The data also revealed that IL-6 peaked during the stent deployment intervention and this pattern of expression was positively correlated with the expression of lactic acid. No significant changes were noted in the expression levels of GFAP, lactic acid, and IL-1β. CONCLUSIONS:There appears to be a temporal relationship between lumbar CSF drainage and CSF cytokines and oxidative stress markers that may help 1) identify patients at risk for developing delayed SCI and 2) modify patient management to prevent the damage from delayed SCI.

PURPOSE/UNASSIGNED:Despite advances in complex endovascular aortic repair techniques, spinal cord ischemia (SCI) remains a devastating complication following endovascular thoracoabdominal aortic repairs. Novel strategies to preserve key intercostal/lumbar arteries have been described. We report our early results of patients who underwent direct intercostal/lumbar artery revascularization using endovascular incorporation of fenestrations/branches or extra-anatomic approaches for fenestrated-branched endovascular aortic repairs (FBEVARs). MATERIALS AND METHODS/UNASSIGNED:A retrospective review of consecutive patients who underwent FBEVAR with intercostal/lumbar artery revascularization from 2018 to 2022 was performed. Patient characteristics, intraoperative details, and outcomes including SCI and branch occlusions were evaluated. RESULTS/UNASSIGNED:Among 317 patients who underwent FBEVAR during the study period, 12 patients were included. Aortic pathologies consisted of degenerative aneurysms (33%), postdissection aneurysms (33%), extensive penetrating aortic ulcers with intramural hematoma (25%), and visceral patch pseudoaneurysm (8%). Full thoracoabdominal coverage was required in 8 patients and supraceliac coverage >10 cm was required in 4. Nine patients received endovascular incorporation, including directional branches (5/9), unstented fenestrations (2/9), and stented fenestration (2/9). Three patients received extra-anatomic subcutaneous femoral-to-radicular artery bypass using a composite graft of polytetrafluoroethylene (PTFE) and venous conduit. Our institutional SCI prevention protocol, consisting of prophylactic cerebral spinal fluid drain (CSFD) for high-risk patients, hemodynamic augmentation, and oxygen supplementation, was followed. Prophylactic CSFD was placed in 9 patients. One patient had unsuccessful drain placement attempts. The other 2 patients had previous unsuccessful attempts at CSFD placement. Median number of target vessels for FBEVAR was 4 with fluoroscopy time 66±31 minutes, contrast usage 109±51 ml. There were no in-hospital mortalities. Tarlov grade II SCI (ASIA grade D) were seen in 2 patients (1 endovascular and 1 extra-anatomic bypass), which resolved before discharge. At mean follow-up of 472±447 days, 3 patients had thrombosed intercostal/lumbar branches (1 extra-anatomic bypass and 2 endovascular branches) with no new SCI symptoms. CONCLUSIONS/UNASSIGNED:In patients at high risk for SCI undergoing FBEVAR, direct revascularization of an intercostal or lumbar artery is feasible using endovascular or extra-anatomic bypass approach. Further studies are planned to identify key contributing segmental arteries and optimization of revascularization strategies. CLINICAL IMPACT/CONCLUSIONS:This study demonstrates the feasibility of Endovascular and extra-anatomic bypass to preserve segmental artery flow, aimed at reducing the risk of spinal cord ischemia during endovascular thoracoabdominal aortic repairs.

BACKGROUND:This study examined the efficacy of an interdisciplinary limb preservation service (LPS) in improving surgical outcomes for diabetic foot ulcer (DFU) patients compared to traditional care. METHODS:Data from January 1, 2017 to September 30, 2020 were retrospectively reviewed. An interdisciplinary LPS clinic began on August 1, 2018, coexisting with a preexisting single specialty service. Primary outcomes were major/minor amputation rates and ratios and hospital length of stay. Surgical endpoints pre- and post-LPS launch were compared. RESULTS:Among 976 procedures for 731 unique DFU patients, most were male (80.4%) and Hispanic (89.3%). Patient demographics were consistent before and after LPS initiation. Major amputation rates decreased by 45.5% (15.4%-8.4%, p = 0.001), with outpatient procedures increasing over 5-fold (3.3% pre-LPS to 18.7% post-LPS, p < 0.001). Hospital stay reduced from 10.1 to 8.5 days post-LPS (p < 0.001). The major to minor amputation ratio declined from 22.4% to 12.7%. CONCLUSIONS:The interdisciplinary LPS improved patient outcomes, marked by fewer major amputations and reduced hospital stays, suggesting the model's potential for broader application.

OBJECTIVE:The technical aspects of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), specifically the location of proximal seal zone (PSZ) (need to cover the left subclavian artery [LSA]), distal seal zone (DSZ) (length of aortic coverage), benefit of LSA revascularization, and prophylactic lumbar drainage are still debated. Each of these issues has potential benefits but also has known risks. This study aims to identify factors associated with reintervention and spinal cord ischemia (SCI) following TEVAR for acute TBAD with a zone 3 entry tear. METHODS:analysis, and multivariable logistic regression was used to evaluate association with outcomes. RESULTS:Of 583 patients who met inclusion criteria, 266 had PSZ 2 and 317 had PSZ 3. On univariate analysis, PSZ 2 was associated with a higher rate of reintervention, but PSZ2 was not significant on multivariable analysis after accounting for age, sex, race, smoking, PSZ, DSZ, prophylactic lumbar drain, and LSA patency. PSZ 2 was not associated with SCI, arm ischemia, or RTAD. PSZ 2 was associated with a trend towards a higher rate of stroke. DSZ 4 and DSZ 5 were performed in 161 and 422 TEVARs, respectively, and DSZ 5 was associated with a higher rate of SCI on univariate (3 [1.9%] vs 39 [9.2%]; P = .01) and multivariable (odds ratio, 7.384; 95% confidence interval, 2.193-24.867; P = .001) analyses. Prophylactic lumbar drain placement was not statistically significantly associated with SCI, but lack of postoperative LSA patency was associated with SCI (odds ratio, 2.966; 95% confidence interval, 1.016-8.656; P = .05). CONCLUSIONS:This study found that PSZ 2 was not associated with lower reinterventions or higher rates of SCI but trended towards a higher rate of stroke than PSZ 3. Additionally, DSZ 5 was strongly associated with SCI when compared with DSZ 4, highlighting the importance of limiting aortic coverage to coverage of the proximal entry tear when possible.