Faculty Bibliography

Objectives: Despite the expanded application of thoracic endovascular aortic repair (TEVAR) to patients with significant cardiac comorbidities deemed too high risk for open repair, the effect of decreased left ventricular ejection fraction (EF) on patient outcomes remains unknown. The aim of this study was to compare the outcomes of patients with normal and abnormal EFs undergoing TEVAR.
Method(s): The Vascular Quality Initiative database (2003-2019) was reviewed to identify patients undergoing TEVAR for aortic dissection. Patients were categorized into those with severely reduced EF (SREF; EF <=30%) reduced EF (REF; EF <=50%), and normal EF (NEF; EF >50%). The baseline characteristics, procedural details, and 18-month outcomes were compared. Multivariable logistic regression was used to identify the factors associated with mortality, aortic-related reintervention, and complete false lumen thrombosis of the treated aortic segment.
Result(s): Of 2455 patients, 54 (1%) and 267 (3%) had had SREF and REF, respectively. Patients with an abnormal EF (SREF and REF) were more likely to be African American and to have more cardiac comorbidities compared with those with a NEF. The use of angiotensin-converting enzyme inhibitor and anticoagulant therapy was higher for patients with an abnormal EF postoperatively and at follow-up. At 18 months, mortality was significantly higher among the patients with SREF (35.2%) than for those with REF (13%) and NEF (13.4%; Fig). The rates of aortic-related reintervention and complete false lumen thrombosis were comparable among the three cohorts. On multivariable analysis, SREF was associated with an increased risk of mortality (hazard ratio, 2.52; 95% confidence interval, 1.28-4.96; P =.008) compared with NEF (Table). However, REF showed a comparable risk of mortality (hazard ratio, 0.90; 95% confidence interval, 0.55-1.46; P =.659) compared with NEF. Neither SREF nor REF was associated with an increased risk of aortic-related reinterventions and complete false lumen thrombosis compared with NEF.
Conclusion(s): SREF was independently associated with an increased risk of mortality compared with NEF at midterm follow-up. However, REF had a similar risk of morbidity and mortality compared with NEF. Furthermore, TEVAR-related complications were similar among the three cohorts. As such, the decision to perform TEVAR in patients with SREF requires balancing a careful estimation of the anticipated benefits and competing risk of death. [Formula presented] [Formula presented]
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OBJECTIVE:Data on the efficacy of non-reversed and reversed great saphenous vein bypass (NRGSV and RGSV) techniques are lacking. The aim of the study was to compare the outcomes of patients undergoing open infrainguinal revascularisation using NRGSV and RGSV from a multi-institutional database. METHODS:The Vascular Quality Initiative database was queried for patients undergoing infrainguinal bypasses using NRGSV and RGSV for symptomatic occlusive disease from January 2003 to February 2021. The primary outcome measures included primary and secondary patency at discharge and one year. Secondary outcomes were re-interventions at discharge and one year. Cox proportional hazards models were used to evaluate the impact of graft configuration on outcomes of interest. RESULTS:Of 7 123 patients, 4 662 and 2 461 patients underwent RGSV and NRGSV, respectively. At one year, the rates of primary patency (78% vs. 78%; p = .83), secondary patency (90% vs. 89%; p = .26), and re-intervention (16% vs. 16%; p = .95) were similar between the RGSV and NRGSV cohorts, respectively. Subgroup analysis based on outflow bypass target and indication for revascularisation did not show differences in primary and secondary outcomes between the two groups. Multivariable analysis confirmed that RGSV (NRGSV as the reference) configuration was not independently associated with increased risk of primary patency loss (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.91 - 1.13; p = .80), secondary patency loss (HR 0.94; 95% CI 0.81 - 1.10; p = .44), and re-intervention (HR 1.03; 95% CI 0.91 - 1.16; p = .67) at follow up. CONCLUSION/CONCLUSIONS:The study shows that RGSV and NRGSV grafting techniques have comparable peri-operative and one year primary and secondary patency and re-intervention rates. This effect persisted when stratified by outflow targets and indication for revascularisation. Therefore, optimal selection of vein grafting technique should be guided by the patient's anatomy, vein conduit availability, and surgeon's experience.

OBJECTIVE:The optimal medical management strategy in the periprocedural period for patients undergoing carotid artery interventions is not well described. Renin-angiotensin-system blocking (RASB) agents are considered to be among the first line anti-hypertensive agents; however, their role in the perioperative period is unclear. The objective of this study was to examine the relationship between the use of RASB agents on periprocedural outcomes in patients undergoing carotid interventions-carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). METHOD/METHODS:The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA, and TCAR between 2003 and 2020. Patients were stratified into two groups based upon their use of RASB agents in the periprocedural period. The primary endpoint was periprocedural neurologic events (including both strokes and transient ischemic attacks (TIAs)). The secondary endpoints were peri-procedural mortality and significant cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure. RESULTS:= 0.461). CONCLUSION/CONCLUSIONS:The use of peri-procedural RASB agents was associated with a significantly decreased rate of neurologic events in patients undergoing both CEA and TCAR. This effect was not observed in patients undergoing CAS. As carotid interventions warrant absolute minimization of perioperative complications in order to provide maximum efficacy with regard to stroke protection, the potential neuro-protective effect associated with RASB agents use following CEA and TCAR warrants further examination.

OBJECTIVES/OBJECTIVE:Clopidogrel is effective at decreasing cardiovascular events in patients with peripheral artery disease (PAD); however, its effect on limb outcomes are less known. This study investigated the variability in response to clopidogrel and its relationship with clinical limb outcomes. METHODS: RESULTS: CONCLUSIONS:Among patients undergoing lower extremity revascularization on clopidogrel, higher baseline percent aggregation is associated with increased risk for major adverse limb events.

OBJECTIVE:Autologous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration remains the source of debate. We compared outcomes of patients undergoing LEB using in-situ and reversed techniques. METHODS:The Vascular Quality Initiative database was queried for patients undergoing LEB with a single-segment GSV in in-situ (ISGSV) and reversed (RGSV) configurations for symptomatic occlusive disease from 2003 to 2021. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary outcome measures included primary patency at discharge or 30 days and one year. Secondary outcomes were secondary patency, and reinterventions at discharge or 30 days and one year. Cox proportional hazards models were created to determine the association between bypass techniques and outcomes of interest. RESULTS:= 0.985) at follow-up, compared to reversed bypass. A subgroup analysis of bypasses to crural targets showed that in-situ and reversed bypasses had similar rates of primary patency loss and reinterventions at 1 year. Among patients with chronic limb-threatening ischemia, in-situ bypass was associated with a decreased risk of reinterventions but similar rates of primary and secondary patency and major amputations at 1 year. CONCLUSIONS:In patients undergoing LEBs using the GSV, in-situ configuration was associated with more perioperative reinterventions and lower primary patency rate. However, this was offset by decreased risks of loss of primary patency and reinterventions at 1 year. A thorough intraoperative graft assessment with adjunctive imaging may be performed to detect abnormalities in patients undergoing in-situ bypasses to prevent early failures. Furthermore, closer surveillance of reversed bypass grafts is warranted given the higher rates of reinterventions.

OBJECTIVES/OBJECTIVE:Patients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR) and/or complex EVAR. Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI). However, these results are largely based on single-center experiences with limited multi-institutional and national data assessing clinical outcomes in these patients. The objective of this study was to evaluate the effect of prior infrarenal aortic surgery on SCI. METHODS:The Society for Vascular Surgery Vascular Quality Initiative database was retrospectively reviewed to identify all patients ≥18 years old undergoing TEVAR/complex EVAR from January 2012 to June 2020. Patients with previous thoracic or suprarenal aortic repairs were excluded. Baseline and procedural characteristics and postoperative outcomes were compared by group: TEVAR/complex EVAR with or without previous infrarenal aortic repair. The primary outcome was postoperative SCI. Secondary outcomes included postoperative hospital length of stay (LOS), bowel ischemia, renal ischemia, and 30-day mortality. Multivariate regression was used to determine independent predictors of postoperative SCI. Additional analysis was performed for patients undergoing isolated TEVAR. RESULTS:A total of 9506 patients met the inclusion criteria: 8691 (91.4%) had no history of infrarenal aortic repair and 815 (8.6%) had previous infrarenal aortic repair. Patients with previous infrarenal repair were older with an increased prevalence of chronic kidney disease (p=0.001) and cardiovascular risk factors including hypertension, chronic obstructive pulmonary disease, and smoking history (p<0.001). These patients presented with larger maximal aortic diameters (6.06±1.47 cm versus 5.15±1.76 cm; p<0.001) and required more stent grafts (p<0.001) with increased intraoperative blood transfusion requirements (p<0.001), and longer procedure times (p<0.001). Univariate analysis demonstrated no difference in postoperative SCI, postoperative hospital LOS, bowel ischemia, or renal ischemia between the two groups. Thirty-day mortality was significantly higher in patients with prior infrarenal repair (p=0.001). On multivariate regression, prior infrarenal aortic repair was not a predictor of postoperative SCI, while aortic dissection (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.26-2.16, p<0.001), number of stent grafts deployed (OR 1.45; 95% CI 1.30-1.62, p<0.001), and units of packed red blood cells transfused intraoperatively (OR 1.33; 95% CI 1.03-1.73, p=0.032) were independent predictors of SCI. CONCLUSIONS:Although TEVAR/complex EVAR patients with prior infrarenal aortic repair constituted a sicker cohort with higher 30-day mortality, the rate of SCI was comparable to patients without prior repair. Previous infrarenal repair was not associated with risk of SCI.

Objective: The continuation of antiplatelet agents in the periprocedural period around carotid stenting (transfemoral carotid artery stenting [TF-CAS] and transcarotid artery revascularization [TCAR]) procedures is believed to be mandatory to minimize the risk of periprocedural stroke.
Method(s): The Society for Vascular Surgery Vascular Quality Initiative database was queried from 2007 to 2020. All TCAR and TF-CAS procedures were included. The patients were stratified by preoperative use of P2Y12 inhibitors. The primary endpoints were perioperative neurologic events (ie, stroke, transient ischemic attack). The secondary endpoints were mortality and myocardial infarction. The P2Y12 inhibitors included in the analysis were clopidogrel, prasugrel, and ticagrelor.
Result(s): A total of 31,036 carotid stent procedures were included for analysis (49.8% TCAR and 50.2% TF-CAS; 63.8% of the patients were men). Overall, 82.3% of the patients were taking a P2Y12 inhibitor. P2Y12 inhibitor use was significantly more common for men, asymptomatic patients, those aged >70 years, and those with concurrent statin use (Table I). P2Y12 inhibitors were significantly more likely to be used with TCAR cases than with TF-CAS cases (87.3% vs 76.8%; P <.001). The rate of periprocedural neurologic events in the whole cohort was 2.6%. Patients taking P2Y12 inhibitors were significantly less likely to experience a periprocedural neurologic event (2.3% vs 3.9%; P <.001) and periprocedural mortality (0.6% vs 2.1%; P <.001) than were those not taking a P2Y12 inhibitor. No effect was seen on the rates of myocardial infarction. On multivariate analysis, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33; Table II). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all appeared to be equally effective in reducing the periprocedural neurologic event rate.
Conclusion(s): Continuation of P2Y12 inhibitors in the periprocedural period appears to markedly reduce the perioperative neurologic event rate with TCAR and TF-CAS and should be considered mandatory. Patients with contraindications to P2Y12 inhibitors might not be appropriate candidates for any carotid stenting procedure. Additionally, alternative types of P2Y12 inhibitors appear to be equally effective as clopidogrel. Finally, analysis of the Vascular Quality Initiative demonstrated that even for TCAR cases, only 87.3% of patients were receiving P2Y12 inhibitor therapy in the periprocedural period, leaving room for significant improvement. [Formula presented] [Formula presented]
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OBJECTIVE:Contemporary commercially available endovascular devices for the treatment of abdominal aortic aneurysm (AAA) include standard endovascular aortic repair (sEVAR) or fenestrated EVAR (fEVAR) endografts. However, aortic neck dilatation (AND) can occur in nearly 25% of patients following EVAR, resulting in loss of proximal seal with risk of aortic rupture. AND has not been well characterized in fEVAR, and direct comparisons studying AND between fEVAR and sEVAR have not been performed. This study aims to analyze AND in the infrarenal and suprarenal aortic segments, including seal zone, and quantify sac regression following fEVAR implantation compared to sEVAR. METHOD/METHODS:A retrospective review of prospectively collected data on 20 consecutive fEVAR patients (Cook Zenith® Fenestrated) and 20 sEVAR (Cook Zenith®) patients was performed. Demographic data, anatomic characteristics, procedural details, and clinical outcome were analyzed. Pre-operative, post-operative (1 month), and longest follow-up CT scan at an average of 29.3 months for fEVAR and 29.8 months for sEVAR were analyzed using a dedicated 3D workstation (iNtuition, TeraRecon Inc, Foster City, California). Abdominal aortic aneurysm neck diameter was measured in 5 mm increments, ranging from 20 mm above to 20 mm below the lowest renal artery. Sub-analysis comparing the fEVAR to the sEVAR group at 12 months and at greater than 30 months was performed. Standard statistical analysis was done. RESULTS:Demographic characteristics did not differ significantly between the two cohorts. The fEVAR group had a larger mean aortic diameter at the lowest renal artery, shorter infrarenal aortic neck length, increased prevalence of nonparallel neck shape, and longer AAA length. On follow-up imaging, the suprarenal aortic segment dilated significantly more at all locations in the fEVAR cohort, whereas the infrarenal aortic neck segment dilated significantly less compared to the sEVAR group. Compared to the sEVAR cohort, the fEVAR patients demonstrated significantly greater positive sac remodeling as evident by more sac diameter regression, and elongation of distance measured from the celiac axis to the most cephalad margin of the sac. Device migration, endoleak occurrence, re-intervention rate, and mortalities were similar in both groups. CONCLUSION/CONCLUSIONS:Compared to sEVAR, 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 post-operative period as compared to sEVAR. Moreover, the fEVAR cohort had significantly greater sac shrinkage and improved aortic remodeling. The suprarenal seal zone in fEVAR may result in a previously undescribed increased level of protection against infrarenal neck dilatation. We hypothesize that the resultant decreased endotension conferred by better seal zone may be responsible for a more dramatic sac shrinkage in fEVAR.

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.