Faculty Bibliography

OBJECTIVE:Over the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. While open surgical repair (OR) remains the gold standard for treatment, endovascular repair (ER) has become an attractive alternative in select patient populations. The objective of this study was to compare the outcomes of open versus endovascular repair of PAAs at a single institution. METHODS:We performed a retrospective chart review of all patients between 1998 and 2017 who underwent repair for PAA. Patient baseline, anatomic, and operative characteristics as well as outcomes were compared between the open and endovascular cohorts. The intervention and treatment were at the discretion of the surgeon. RESULTS:Between 1998 and 2017, a total of 64 patients underwent repair of 73 PAAs at our tertiary care center. Twenty-nine patients with 33 PAAs underwent OR, and 35 patients with 40 PAAs underwent ER. When comparing the 2 cohorts, there were no statistically significant differences in demographic characteristics such as age, gender, or number of run-off vessels. There were significantly more patients in the ER group (21/53%) than the OR group (7/21%) with hyperlipidemia (p=.008) and a prior carotid intervention (6% vs. 0%, p=.029). Overall, the presence of symptoms was similar amongst the two groups; however, patients in the OR group had a significantly higher number of patients presenting with acute ischemia (p=.01). Length of stay (LOS) was significantly shorter in the ER cohort (mean 1.8 days [1-11]) compared to the OR group (5.4 days [2-13]) (p<.0001). There was no significant difference in primary or secondary patency rates between the two groups. In the ER group, good runoff (≥2 vessels) was a positive predictor for primary patency at 1 year (3.36 [1.0-11.25]), however, it was not in the OR group. Post-operative single and/or dual anti-platelet therapy did not affect primary patency in either cohort. CONCLUSIONS:The results of our study demonstrate that ER of PAAs is a safe and durable option with comparable patency rates to OR and a decreased LOS, with good run-off being a positive predictor for primary patency in the ER cohort.

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.

Objective: Autogenous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration has remained a source of debate. We compared the outcomes of patients who had undergone LEB using in situ and reversed configuration.
Method(s): The Vascular Quality Initiative database (January 2003 to February 2021) was queried for patients undergoing LEB with in situ and reversed GSV. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary endpoint was primary patency. The second endpoints included freedom from major adverse limb events (MALE; defined as major lower extremity amputation and reintervention), limb salvage, and freedom from reintervention at 1 year. Multivariable models were created to determine the association between bypass configuration and outcomes of interest.
Result(s): Of the 8234 patients who had undergone LEB, in situ and reversed GSV was used in 3546 and 4688 patients, respectively. Patients with in situ bypass were older with higher rates of cardiopulmonary and renal comorbidities. The patients who had undergone reversed bypass were more likely to have undergone previous LEBs and endovascular interventions. The indication for LEB was similar between the in situ and reversed bypass cohorts. In situ bypass had been performed more frequently from the common femoral artery and to more distal targets (tibial or peroneal). Reversed bypass was associated with higher intraoperative blood loss and a longer operative time. Perioperatively, in situ bypass had resulted in greater rates of reintervention (13.2% vs 11.1%; P =.004) and surgical site infection (4.2% vs 3%; P =.003) and lower primary patency (93.5% vs 95%; P =.004). At 1 year, in situ bypass had a lower rate of MALE (22.6% vs 25.6), mainly driven by a lower rate of reintervention (19.4% vs 21.6%). The primary patency and limb salvage rates were not different. On multivariable analysis, in situ bypass was associated with lower primary patency loss (hazard ratio [HR], 0.9; 95% confidence interval [CI], 0.82-0.98), reintervention (HR, 0.88; 95% CI, 0.8-0.97), and MALE (HR, 0.89; 95% CI, 0.81-0.97) but did not affect the rate of limb salvage compared with reversed bypass.
Conclusion(s): Compared with those with reversed GSV, LEBs with in situ GSV confer improved primary patency and MALE at midterm. Our results have demonstrated that an in situ configuration might be a favorable option for appropriately selected patients with suitable anatomy.
Copyright

Objective: Statins are often used for primary and secondary prevention of cardiovascular events. Multiple studies have demonstrated a significant reduction in perioperative complications after carotid endarterectomy for patients taking statins. However, data for statin use for patients undergoing transcarotid artery revascularization (TCAR) are limited. We evaluated the effects of statin use on the postoperative outcomes after TCAR.
Method(s): The records of the Vascular Quality Initiative carotid artery stenting registry (2012-2020) were reviewed for patients who had undergone TCAR. The patient demographics, perioperative characteristics, and 30-day outcomes were compared between the patients treated with and without statins (statin and no-statin group, respectively). Multivariable logistic regression models were used to estimate the effect of statins on the postoperative outcomes.
Result(s): A total of 15,797 patients had undergone TCAR, of whom, 10,116 (64%) were men. Of the 15,797 patients, 14,152 (89.6%) were taking a statin preoperatively (Table I). The statin group was more likely to have hypertension (91% vs 87%; P <.001), coronary artery disease (26% vs 23%; P =.008), and diabetes mellitus (33% vs 29%; P <.001). The incidence of both prior ipsilateral stroke (17.2% vs 13.5%; P <.001) and recent ipsilateral stroke (<=30 days; 7.1% vs 5.6%; P =.02) was higher in the statin group. No differences were found in the perioperative characteristics, including median operative time, contrast amount used, technical success, and number of stents used. Perioperative stroke and major adverse cardiac events (MACE; myocardial infarction, congestive heart failure, dysrhythmia) occurred in 1.5% and 2.4% of the statin group and 1.4% and 2.3% of the no-statin group, respectively. Controlling for covariates with the logistic regression method, statin use was associated with a 62% reduction in the odds of mortality (odds ratio, 0.38; 95% confidence interval, 0.19-0.99; P =.047; Table II) for patients who had experienced a perioperative stroke or MACE after TCAR.
Conclusion(s): Statin use was associated with a significant reduction in postoperative mortality for patients who had experienced a stroke or MACE after TCAR. Therefore, strict adherence to statin use is strongly recommended, especially for patients who could be at high risk of major postoperative complications. [Formula presented] [Formula presented]
Copyright

Objective: Data regarding the effect of bilateral internal iliac artery (IIA) occlusion during endovascular abdominal aortic aneurysm repair (EVAR) are conflicting, with reported varied risks of pelvic and gastrointestinal ischemia. The aim of our study was to report the perioperative and long-term outcomes of IIA occlusion with origin graft coverage in patients undergoing elective EVAR.
Method(s): Using the Vascular Quality Initiative database (2010-2020), we retrospectively identified patients who had undergone EVAR for infrarenal abdominal aortic aneurysms and aortoiliac aneurysms with or without IIA occlusion by graft coverage or coils. The patients were stratified into three groups according to IIA occlusion status (none, unilateral, bilateral). The baseline characteristics, procedural details, in-hospital outcomes, and overall survival at 5 years were reviewed. The primary outcomes were in-hospital mortality and complications. The secondary outcomes included 5-year mortality. Cox proportional hazards models were used to determine the predictive factors of perioperative and 2-year mortality.
Result(s): A total of 26,690 patients were identified (mean age, 73.5 years; 82% male) who had undergone elective EVAR with bifurcated endografts. Of the 26,690 patients, 2195 (8.2%) had undergone adjunctive unilateral IIA origin graft occlusion, 523 (2%) had undergone bilateral IIA origin graft occlusion, and 23,970 (89.8%) had not undergone any IIA graft occlusion. Perioperatively, no statistically significant differences were found in the incidence of death (0.4% vs 0.6% vs 0.4%; P =.2), gastrointestinal ischemia (0.1% vs 0.1% vs 0.2%; P =.888), unplanned reoperation (1.5% vs 1.8% vs 2.3%; P =.181), or cardiopulmonary complications (2.5% vs 2.8% vs 3.4%; P =.247) among those with no, unilateral, and bilateral IIA origin graft occlusion, respectively (Table). The Kaplan-Meier estimate demonstrated comparable overall survival at 5 years (none, 86.7%; unilateral, 85.2%; bilateral, 89.4%; P =.133; Fig). On multivariable analysis, the status of IIA origin graft coverage was not associated with increased perioperative mortality or complications.
Conclusion(s): EVAR with bilateral IIA interruption was associated with favorable perioperative outcomes with a low rate of major complications. At the time of EVAR, unilateral and bilateral IIA occlusion with a stent-graft did not appear to confer additional risks of perioperative complications and mortality. Our results showed the safety of bilateral IIA interruption in patients undergoing elective EVAR for abdominal aortic aneurysms and aortoiliac aneurysms. [Formula presented] [Formula presented]
Copyright

Objective: There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using suprainguinal inflow for infrainguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infrafemoral targets.
Method(s): The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB originating from the aortoiliac arteries and to the popliteal and tibial arteries. Patients were stratified into three cohorts based on outflow targets (above-knee popliteal, below-knee popliteal and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival, and major adverse limb events (MALEs) were compared, and the Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes.
Result(s): Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, whereas the remaining from the aorta and common iliac artery. A total of 116 (28.8%), 151 (27.5%), and 136 (43.7%) were to the above-knee popliteal, below-knee popliteal, and tibial arteries, respectively (Table). In total, 194 (48%) and 186 (46%) patients had prior ipsilateral LEB and percutaneous vascular interventions, respectively. Below-knee popliteal and tibial bypasses were performed more frequently in patients with chronic limb-threatening ischemia (70% and 70% vs 48%; P <.001). Vein conduit was more often used for tibial bypass than for above- and below-knee popliteal bypasses (46% vs 22% and 17%; P <.001). In the perioperative period, below-knee popliteal and tibial bypass patients had higher reoperation rates (17% and 14% vs 5%; P =.015) and lower primary patency (91% and 90% vs 96%; P =.044) than above-knee bypass patients. Perioperative pulmonary complication and mortality rates were similar among the cohorts. At 1 year, compared with above-knee popliteal bypasses, below-knee and tibial bypasses demonstrated lower primary patency (60.9% and 62.3% vs 83.3%; P <.001; Fig) and amputation-free survival (69.1% and 66.4% vs 79.4%; P =.0223), but freedom from MALEs were similar (87.2% and 82.8% vs 90.9%; P =.0585). On multivariable analysis, compared with above-knee popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio, 1.9; 95% confidence interval, 1.03-3.51; P =.039), but with similar major ipsilateral amputation/death and MALEs.
Conclusion(s): Compared with those using historic infrainguinal inflow, LEBs with suprainguinal inflow appear to have accepTable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency. [Formula presented] [Formula presented]
Copyright

Objective: Type II endoleaks (T2E), commonly identified after EVAR, are associated with late endograft failure and secondary rupture. Quantity and size of aortic aneurysm sac outflow vessels (AASOV), namely the inferior mesenteric, lumbar, and accessory renal arteries, have been implicated as known risk factors for persistent T2E. Given technical difficulties associated with post-EVAR embolization, prophylactic coil embolization of AASOV-related T2E has been advocated to prevent retrograde T2E; however, current evidence is limited. We sought to examine the effect of concomitant prophylactic AASOV coil embolization in patients undergoing EVAR.
Method(s): Patients 18 and older in the Society for Vascular Surgery Vascular Quality Initiative database who underwent elective EVAR for intact aneurysms between January 2009 and November 2020 were included. Patients with a history of prior aortic repair and those without available follow-up data were excluded. Patient demographics, operative characteristics, and outcomes were analyzed by group: EVAR with or without prophylactic AASOV embolization (emboEVAR). Primary outcomes of interest were rates of in-hospital postoperative complications, incidence of aneurysmal sac regression (>=5 mm), and rates of reintervention in follow-up.
Result(s): A total of 15,060 patients were included: 272 had emboEVAR and 14,788 had EVAR alone. There was no significant difference between groups in terms of age, comorbidities, or anatomic characteristics including mean maximum preoperative aortic diameter (5.5 vs 5.6 cm, P =.48) (Table I). emboEVAR was associated with significantly longer procedural times (148 vs 124 minutes, P <.0001), prolonged fluoroscopy (32 vs 23 minutes, P <.0001), increased contrast use (105 vs 91 mL, P <.0001), without significant reduction in T2E at completion (17.7% vs 16.3%, P =.54). Incidences of postoperative complications (3.7% vs 4.6%, P =.56), index hospitalization reintervention rates (0.7% vs 1.3%, P =.59), length of stay (1.8 vs 2 days, P =.75), and 30-day mortality (0% vs 0%, P = 1) were similar between groups. In mid-term follow-up (14.6 +/- 6.2 months), the emboEVAR group had a significant mean reduction in maximum aortic diameter (0.69 vs 0.54 cm, P =.006) with a higher proportion experiencing sac regression >=5 mm (53.5% vs 48.7%) and reintervention rates were similar between groups. On multivariate analysis, prophylactic AASOV (odds ratio: 1.34, confidence interval: 1.04-1.74, P =.024) was a significant independent predictor of sac regression (Table II).
Conclusion(s): Prophylactic AASOV embolization can be performed safely for patients with intact aortic aneurysms undergoing elective EVAR without significant associated perioperative morbidity or mortality. emboEVAR is associated with significant sac regression compared with EVAR alone in mid-term follow-up. This technique shows promise and future efforts should focus on elucidating the role of concomitant selective vs complete prophylactic AASOV embolization in patients undergoing EVAR. [Formula presented] [Formula presented]
Copyright

Objectives: In patients with carotid stenosis, both the severity of the stenosis as well as the plaque morphology influence the likelihood of future transient ischemic attack or stroke. In general, severely stenotic lesions are presumed to have a higher embolic potential than moderately stenotic lesions. Carotid intervention is indicated in patients with both moderate and severe stenosis with related cerebrovascular symptoms. However, the effect of the degree of carotid stenosis in symptomatic patients upon the outcome of carotid intervention has not been extensively studied.
Method(s): The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing transfemoral carotid stenting (CAS), carotid endarterectomy (CEA), and transcervical carotid stenting (TCAR) between 2003 and 2020. Patients undergoing interventions for symptomatic disease were included in the analysis. Patients were stratified into two cohorts based on the severity of stenosis-moderate (0%-69%) and severe (greater than or equal to 70%). Primary endpoints were perioperative neurologic events (strokes and transient ischemic attacks [TIAs]). Secondary endpoints were perioperative mortality and postoperative complications.
Result(s): Over 50,000 patients were included in the analysis: 5296 patients (8.9%) underwent TCAR, 7844 (13.3%) underwent CAS, and 45,853 (77.8%) underwent CEA for symptomatic carotid artery disease. In the TCAR and CEA cohorts, patients with moderate stenosis had a significantly higher rate of perioperative neurologic events than patients with severe stenosis (TCAR 4.3% vs 3.0%; P =.033; CEA 3.0% vs 2.3%; P <.001). In contrast, in patients undergoing CAS, there was no significant difference noted in the perioperative neurologic event rate (3.5% in moderate stenosis group vs 3.8% in severe stenosis group; P =.518). There were no differences in perioperative myocardial infarction or mortality (Table). On multivariable analysis, moderate stenosis was significantly and independently associated with an increased rate of neurologic events in the TCAR (odds ratio [OR], 0.833; 95% confidence interval, 0.693-1.000; P =.05), and CEA (odds ratio, 0.901; 95% confidence interval, 0.861-0.944; P <.001) cohorts.
Conclusion(s): Moderate carotid stenosis was associated with increased perioperative neurologic events in patients undergoing TCAR and CEA, but not CAS. Therefore, this effect was noted only in the cohorts that require direct open surgical manipulation of the cervical carotid artery (TCAR and CEA). Moderately stenotic lesions that become symptomatic likely have worse intrinsic plaque morphology than severely stenotic lesions, producing cerebrovascular symptoms at a lower degree of stenosis. The mechanism of such events warrants further evaluation with a particular focus on plaque morphology and brain physiology. [Formula presented]
Copyright

Objective: The two feared complications of pelvic flow disruption include buttock ischemia and mesenteric ischemia. In cases of extensive aortic coverage, spinal cord ischemia is also a risk. Unilateral or bilateral hypogastric artery flow interruption, either from atherosclerosis or intentionally, is considered problematic in endovascular repair and has not been well studied in open abdominal aortic aneurysm repair (OAR). We examined the effect of the interruption of flow to one or both hypogastric arteries on the outcomes after OAR.
Method(s): The Society for Vascular Surgery Quality Initiative database was queried for all patients who had undergone elective OAR between 2003 and 2020. All patients who had undergone elective OAR were included. Patients with data on their hypogastric arteries were stratified into two groups-patent bilaterally (normal pelvic perfusion) and unilateral or bilateral occlusion or ligation (compromised pelvic perfusion [CPP]). The primary endpoints were 30-day major morbidity (myocardial infarction, respiratory complications, renal injury, and lower extremity or intestinal ischemia) and mortality.
Result(s): During the study period, 9492 patients underwent elective OAR-860 (9.1%) with CPP and 8632 (90.9%) with patent bilateral hypogastric arteries. The two groups had similar cardiac risk factors, including a history of coronary artery disease, prior coronary intervention, and the use of P2Y12 inhibitors and statins (Table I). Most patients in the CPP cohort had concurrent iliac aneurysms (63.3% vs 24.8%; P <.001). Perioperative mortality was significantly higher in the CPP group (5.5% vs 3.1%; P <.001). Bilateral flow interruption resulted in greater perioperative mortality compared with unilateral interruption (7.1% vs 4.7%; P <.001). The CPP group also had increased rates of myocardial injury (6.7% vs 4.7%; P =.012), renal complications (18.9% vs 15.9%; P =.024), leg ischemia (3.5% vs 2.1%; P =.008), and bowel ischemia (5.7% vs 3.4%; P <.001). On multivariable analysis, CPP was associated with increased perioperative mortality (odds ratio, 1.47; 95% confidence interval, 1.14-1.88; P =.003). Intraoperative blood transfusion, chronic obstructive pulmonary disease, and renal insufficiency were other factors associated with perioperative mortality (Table II).
Conclusion(s): CPP is associated with increased perioperative complications and higher mortality in patients undergoing OAR. Hypogastric artery occlusion or the need to ligate these vessels likely signifies the presence of more complex disease. Careful technique and appropriate patient selection are critical in this cohort of patients. Furthermore, the differences in physiology of pelvic circulation in open and endovascular repair warrant further examination. [Formula presented] [Formula presented]
Copyright

Objective: Although beta-blocker (BB) use is routine for type B aortic dissections (TBADs), its effect in patients undergoing thoracic endovascular aortic repair (TEVAR) is unclear. Furthermore, the effect of BB use on the perioperative outcomes after TEVAR has not been evaluated. We evaluated the effect of BB use on the perioperative outcomes in patients with TBAD undergoing TEVAR.
Method(s): The Society for Vascular Surgery Vascular Quality Initiative database was queried for all patients who had undergone TEVAR for TBAD between September 2012 and February 2020. BB use was defined as the use of such medications for >=30 days preoperatively. Patients were dichotomized according to preoperative BB use (no-BB and BB cohorts). The patient characteristics, procedural details, and postoperative outcomes were compared. The primary endpoints were 30-day mortality and overall postoperative complications, including myocardial infarction, new dysrhythmia, congestive heart failure, access site complications, respiratory, cerebrovascular symptoms, and arm, leg, renal, spinal cord, and gastrointestinal ischemia requiring surgical intervention.
Result(s): Of 2283 patients undergoing TEVAR for TBAD, 1130 (49%) were receiving a BB preoperatively. The BB cohort was older with greater proportions of hypertension, coronary artery disease, congestive heart failure, diabetes, chronic kidney disease, and end-stage renal disease (Table I). Additionally, the BB cohort were more likely to be taking aspirin, a P2Y12 antagonist, a statin, or an ACE inhibitor, and/or receiving anticoagulation therapy preoperatively. The non-BB cohort had more nonelective, symptomatic, and acute dissections. The procedural details, including rates of open conversion and general anesthesia, estimated blood loss, transfusion requirements, and operative times were comparable. On univariate analysis, the BB cohort had a lower risk of overall postoperative complications (22% vs 33%; P <.001) and mortality (4.7% vs 7.7%; P =.003) compared with the non-BB cohort. On multivariable analysis, BB use was associated with a 22% reduction in the odds of postoperative complications (odds ratio, 0.78; 95% confidence interval, 0.62-0.99; P =.044) but did not influence mortality (odds ratio, 1.14; 95% confidence interval, 0.73-1.71; P =.562; Table II).
Conclusion(s): BB use was associated with a significant reduction in postoperative complications for patients undergoing TEVAR for TBAD. Therefore, BB use should be strongly encouraged for appropriately selected patients undergoing TEVAR. [Formula presented] [Formula presented]
Copyright