Faculty Bibliography

BACKGROUND:There is a paucity of literature on the natural history of extracranial carotid artery occlusion (CAO). This study reviews the natural history of this patient cohort. METHODS:This single-institution retrospective analysis studied patients with CAO diagnosed by duplex ultrasound between 2010 and 2021. Patients were identified by searching our office-based Intersocietal Accreditation Commission accredited vascular laboratory database. Imaging and clinical data were obtained via our institutional electronic medical record. Outcomes of interest included ipsilateral stroke, attributable neurologic symptoms, and ipsilateral intervention after diagnosis. RESULTS:The full duplex database consisted of 5,523 patients who underwent carotid artery duplex examination during the study period. The CAO cohort consisted of 139 patients; incidence of CAO was 2.5%. Mean age at diagnosis was 69.7 years; 31.4% were female. Hypertension (72.7%), hyperlipidemia (64.7%), and prior smoking (43.9%) were the most common comorbid conditions. Of the CAO cohort, 61.3% (n = 85) of patients were asymptomatic at diagnosis; 38.8% (n = 54) were diagnosed after a stroke or transient ischemic attack occurring within 6 months prior to diagnosis, with 21.6% occurring ipsilateral to the CAO and 10.1% occurring contralateral to the CAO. 7.2% (n = 10) had unclear symptoms or laterality at presentation. Of the CAO cohort, 95 patients (68.3%) had duplex imaging follow-up (mean 42.7 ± 31.3 months). Of those with follow-up studies, 7 patients (5.0%) developed subsequent stroke ipsilateral to the CAO with mean occurrence 27.8 ± 39.0 months postdiagnosis. In addition, 5 patients (3.6%) developed other related symptoms, including global hypoperfusion (2.4%) and transient ischemic attack (1.2%). Of those, 95 patients with follow-up duplex ultrasound imaging, 6 (4.3%) underwent eventual ipsilateral intervention, including carotid endarterectomy (n = 4), transfemoral carotid artery stent (n = 1), and carotid bypass (n = 1), with mean occurrence 17.7 ± 23.7 months postdiagnosis. The aggregate rate of ipsilateral cerebrovascular accident, attributable neurologic symptoms, or ipsilateral intervention was 11.5%. Of 95 patients with follow-up duplex ultrasound imaging, 5 underwent subsequent duplex studies demonstrating ipsilateral patency, resulting in a 5.3% discrepancy rate between sequential duplex studies. All 6 patients undergoing intervention received periprocedural cross-sectional imaging (magnetic resonance angiography or computed tomography angiography). In 5 of these 6 patients, cross-sectional demonstrated severe stenosis rather than CAO, disputing prior duplex ultrasound findings. CONCLUSIONS:In this large, institutional cohort of patients with a CAO diagnosis on duplex ultrasound, a clinically meaningful subset of patients experienced cerebrovascular accident, related symptoms, or intervention. We also found a notable rate of temporal duplex discrepancies among patients with CAO diagnoses and discrepancies between CAO diagnosis per duplex ultrasound and findings on cross-sectional imaging for those patients who underwent intervention. These results suggest that use of a single duplex ultrasound as a sole diagnostic tool in CAO may not be sufficient and that physicians should consider close duplex ultrasound surveillance of these patients, potentially in conjunction with additional confirmatory imaging modalities. Further investigation into optimal workup and surveillance protocols for CAO is needed.

OBJECTIVE:The existing renal artery aneurysm (RAA) literature is largely composed of reports of patients who underwent intervention. The objective of this study was to review the natural history of RAA. METHODS:This single-institution retrospective analysis studied all patients with RAA diagnosed by computed tomography imaging between 2015 and 2019, identified by our institutional radiology database. Imaging, demographic, and clinical data were obtained via the electronic medical record. He growth rate was calculated for all patients with radiological follow-up. RESULTS:The cohort consists of 331 patients with 338 RAAs. Most patients were female (61.3%), with 11 (3.3%) of childbearing age. The mean age at diagnosis was 71.5 years (range, 24-99 years). Medical comorbidities included hypertension (73.7%), prior smoking (34.4%), and connective tissue disease (3.9%). Imaging indications included abdominal pain (33.5%), unrelated follow-up (29.6%), and follow-up of an RAA initially diagnosed before the study period (10.7%). Right RAA (61.9%) was more common than left (35.1%); 3% of patients had bilateral RAA. The mean diameter at diagnosis was 12.9 ± 5.9 mm. Size distribution included lesions measuring less than <15 mm (69.9%), 15 to 25 mm (27.1%), and more than 25 mm (3.0%). Anatomic locations included the distal RA (26.7%), renal hilum (42.4%), and mid-RA (13.1%). The majority were true aneurysms (98%); of these, 72.3% were fusiform and 27.7% were saccular. Additional characteristics included calcification (82.2%), thrombus (15.9%), and dissection (0.9%). Associated findings included aortic atherosclerosis (65.6%), additional visceral aneurysms (7.3%), and abdominal aortic aneurysm (5.7%). The mean clinical follow-up among 281 patients was 41.0 ± 24.0 months. The mean radiological follow-up among 137 patients was 26.0 ± 21.4 months. Of these, 43 patients (31.4%) experienced growth, with mean growth rate of 0.23 ± 4.7 mm/year; the remainder remained stable in size. Eight patients eventually underwent intervention (5 endovascular), with the most common indications including size criteria (4/8) and symptom development (3/8). No patient developed rupture. On multivariate analysis, obesity (P = .04) was significantly associated with growth. An initial diameter of more than 25 mm was significantly associated with subsequent intervention (P = .006), but was not significantly associated with growth. Four of five RAAs with an initial diameter 30 mm or greater did not undergo intervention. The mean clinical follow-up for these patients was 24 months; none developed rupture and two remained stable in size. CONCLUSIONS:This large institutional cohort found that the majority of RAAs remained stable in size, with few patients meeting indications for repair based on societal guidelines. Current guidelines recommending intervention for asymptomatic aneurysms more than 30 mm seem to be appropriate given their slow progression.

INTRODUCTION/BACKGROUND:Endovascular aneurysm repair (EVAR) has improved outcomes for ruptured abdominal aortic aneurysms (rAAA) compared to open repair. We examined the impact of aorto-uni-iliac (AUI) versus standard bifurcated endograft configuration on outcomes in rAAA. METHODS:Patients 18 years or older in the VQI database who underwent EVAR for rAAA from January 2011 to April 2020 were included. Patient characteristics were analyzed by graft configuration: AUI or standard bifurcated. Primary and secondary outcomes included 30-day mortality, post-operative major adverse events (MAE; myocardial infarction, stroke, heart failure, mesenteric ischemia, lower extremity embolization, dialysis requirement, re-operation, pneumonia or re-intubation) and 1-year mortality. A subset propensity-score matched (PSM) cohort was also analyzed. RESULTS:We included 2717 patients: 151 had AUI and 2566 had standard bifurcated repair. There was no significant difference between groups in terms of age, major medical comorbidities, anatomic aortic neck characteristics, or rates of conversion to open repair. Patients undergoing AUI were more commonly female (30% vs. 22%, p=0.011) and had a history of CHF (19% vs. 12%, p=0.013). Perioperatively, patients undergoing AUI had a significantly higher incidence of cardiac arrest (15% vs. 7%, p<0.001), greater intra-operative blood loss (1.3L vs. 0.6L, p<0.001), longer operative duration (218min vs. 138min, p<0.0001), higher incidence of MAE (46.3% vs. 33.3%, p=0.001), as well as prolonged ICU (7 vs. 4.7 days p=0.0006) and overall hospital length of stay (11.4 vs. 8.1 days, p=0.0003). Kaplan-Meier survival analyses demonstrated significant differences in 30-day (31.1% vs. 20.2%, log-rank p=0.001) and 1-year mortality (41.7% vs. 27.7%, log-rank p=0.001). The PSM cohort demonstrated similar results. CONCLUSION/CONCLUSIONS:The AUI configuration for rAAA appears to be implemented in a sicker cohort of patients and is associated with worse perioperative and 1-year outcomes compared to a bifurcated graft configuration, which was also seen on propensity matched analysis. Standard bifurcated graft configuration may be the preferred approach in the management of rAAA unless AUI configuration is mandated by patient anatomy or other extenuating circumstances.

OBJECTIVE:inhibitors for CAS. METHODS:inhibitors as well as symptomatic status. Primary endpoints were perioperative neurologic events (strokes and transient ischemic attacks (TIAs)). Secondary endpoints were mortality and myocardial infarction. RESULTS:inhibitors used revealed that all appeared to be equally effective in reducing the periprocedural neurological event rate. CONCLUSIONS:inhibitors in the periprocedural period, leaving room for significant improvement.

INTRODUCTION/BACKGROUND:The finding of concurrent deep venous reflux (DVR) when interrogating superficial venous reflux is common and might be a marker for more severe chronic venous insufficiency. However, the safety, clinical and patient reported outcomes in patients undergoing superficial venous treatment in the presence of DVR remains underreported. Moreover, factors associated with persistence and disappearance of DVR after superficial vein treatments have not been evaluated. This study sought to address these questions. METHODS:This study was a review of the institutional vascular quality initiative (VQI) database from June 2016 to June 2021. Consecutive patient-limbs were identified who underwent a superficial venous intervention and had duplex evaluation. These patients were then divided into those with and without DVR. Those with DVR were further reviewed for anatomical details and persistence or resolution of DVR following the procedure. The primary outcome was the venous clinical severity score (VCSS) at follow-up greater than 3 months. Secondary outcomes included the incidence of any postoperative deep vein thrombosis (DVT) or endovenous heat-induced thrombosis (EHIT), differences in patient-reported outcomes, rate of resolution of DVR, and factors associated with DVR persistence. Both univariate analysis and multivariate logistic regression were applied. RESULTS:In patients who underwent superficial venous treatments 644 patient-limbs had DVR and 7812 did not, for a prevalence of 7.6%. The former group was associated with a higher burden of chronic venous insufficiency. On univariate analysis, patient-limbs, both with and without DVR, improved significantly in VCSS at less than 3 months follow-up, and were not significantly different. At greater than 3 months follow-up, the VCSS score again improved significantly compared to less than 3 months follow-up, but the two groups differed significantly at the longer interval. The magnitude of improvement in VCSS between the two groups at the longer follow-up were statistically similar (3.17±3.11 vs 3.03±2.93, P =0.739). HASTI score similarly improved significantly in both groups, but remained significantly higher in the DVR group on follow-up. On multivariate logistic regression, DVR was not associated with an increased VCSS at greater than 3 months follow-up. There was no intergroup difference in postoperative DVT or EHIT. 40.8% of limbs with DVR no longer had evidence of detectable DVR at the latest follow-up venous duplex, and DVR limited to single segment were more likely to be no longer detectable versus multi-segments. CONCLUSIONS:Superficial venous procedures are safe and effective in patients with DVR, leading to improvements in clinical and patient reported outcomes as they would for those without DVR. In a large proportion of the treated limbs, especially in those with DVR in a single segment, there is no longer evidence of DVR following superficial venous intervention. Although patients with DVR have a higher burden of chronic venous insufficiency, they appear to still derive significant benefit from superficial venous treatments.

OBJECTIVE:Severe presentations of chronic venous insufficiency can result from reflux or obstruction at the deep venous, perforator, or superficial venous levels. Iliofemoral venous stenting can be used to address central venous obstruction; however, its effects on deep venous reflux (DVR) have remained unclear. The purpose of the present study was to evaluate the effects of iliac vein stenting on femoropopliteal DVR with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting. METHODS:The present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. The patients were divided into two cohorts according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions. RESULTS:A total of 275 consecutive patients had undergone iliofemoral venous stenting. Of the 275 patients, 58 had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (P = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (P = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; P = .0078]; group B, 19 of 217 [8.8%; P = .0203]). CONCLUSIONS:For patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation. Prospective studies are required to corroborate the safety, efficacy, and durability of iliofemoral venous stenting for patients with DVR.

OBJECTIVE:Studies assessing the effect of anticoagulants on endovenous thermal ablation (ETA) are limited to patients on warfarin. As such, the aim of this study was to assess the efficacy and safety of ETA in patients taking direct oral anticoagulants (DOACs). We hypothesized that the outcome of ETA in patients taking DOAC is not superior to the outcome in patients taking DOAC. METHODS:A retrospective review was performed to identify patients undergoing radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) with 1470 nm diode laser fibers for symptomatic great or small saphenous venous reflux from 2018 to 2020. Patients were dichotomized into those receiving therapeutic dose of DOACs peri-procedurally and those not receiving anticoagulants (control). Outcomes of interest included the rates of treated vein closure at 7-days and 9-months, deep venous thrombosis (DVT), endothermal heat-induced thrombosis (EHIT) and bleeding peri-procedurally. RESULTS:There were 87 procedures performed in 69 patients receiving DOACs and 295 procedures in 232 control patients. Patients receiving DOACs were more often older (mean, 65 years vs 55 years; P<.001) and male (70% vs 37%; P<.001), with higher prevalence of venous thromboembolism and more severe CEAP classification (5 or 6), compared to control patients. Those receiving DOAC were more likely to have history of DVT (44% vs 6%; P<.001), PE (13% vs 0%; P<.001) and phlebitis (32% vs 15%; P<.001). Procedurally, RFA was used more frequently in the control group (92% vs 84%; P=.029), with longer segments of vein treated (mean 38 mm vs 35 mm, respectively; P=.028). No major or minor bleeding events nor any EHITs occurred in either group. Two patients (0.7%) in the control group developed DVT whereas no DVT was observed in the those receiving DOAC (P=.441). At 9-months, the treated vein remained ablated after 94.4% of procedures performed in patients receiving DOACs and 98.4% of controls (P=.163). On multivariable analysis, DOAC was not associated with an increased risk of vein recanalization (hazard ratio, 5.76; 95% confidence interval, 0.57-58.64; P=.139). An increased pre-procedural vein diameter and EVLA were associated with an increased risk of recanalization. CONCLUSION/CONCLUSIONS:In this study of patients undergoing ETA for symptomatic saphenous venous reflux, peri-procedural use of DOAC did not adversely affect the efficacy of endovenous ablation to at least 9-months. Furthermore, it did not confer additional risk of bleeding, DVT and EHIT peri-procedurally. As such, the early outcome of ETA in patients not taking DOAC may not be superior to the outcome in patients taking DOAC.

Background: Interventions for carotid occlusions are infrequently undertaken and the outcomes are poorly defined. We sought to study patients undergoing urgent carotid revascularization for symptomatic occlusions.
Method(s): The Society for Vascular Surgery Vascular Quality Initiative was queried from 2003 to 2020 to identify patients with carotid occlusions undergoing carotid endarterectomy. Only symptomatic patients undergoing urgent interventions, defined within 24 hours of presentation, were included in this analysis. This cohort was compared to patients undergoing urgent intervention for severe stenosis (>=80%). Patients were identified based on computed tomography and magnetic resonance imaging, only. The primary end points were perioperative stroke, death, myocardial infarction (MI), and composite outcomes.
Result(s): A total of 390 patients were identified who underwent urgent carotid endarterectomy for symptomatic occlusions. The mean age was 67.4 +/- 10.2 years with a range from 39 to 90 years. The cohort was predominantly male (60%), and had significant risk factors for cerebrovascular disease, including hypertension (87.4%), diabetes (34.4%), coronary artery disease (21.6%), current smoking (38.7%), chronic obstructive pulmonary disease (21.6%), and congestive heart failure (10.3%). Medications included statin therapy (78.6%), P2Y12 inhibitors (32.0%), aspirin (77.9%) and renin-angiotensin inhibitor use (43.7%). The perioperative rate of neurologic events was 4.9%%, associated mortality was 2.8% and rate of MI was 1.0%. The composite end point of stroke/death/MI was 7.7%. When compared to patients undergoing urgent endarterectomy for severe stenosis (>=80%), the two cohorts were well matched with regards to risk factors, but the severe stenosis cohort appeared to be better medically managed based on reported medications. In the severe stenosis group, the perioperative rate of neurologic events was 3.3%, associated mortality was 0.9% and rate of MI was 1.2%. The perioperative outcomes were significantly worse for the carotid occlusion cohort, primarily driven by the perioperative mortality, which was nearly threefold, 2.8% versus 0.9% (P <.001). The composite end point of stroke/death/MI was also significantly worse in the occlusion cohort (7.7% vs 4.9%; P =.014).
Conclusion(s): Revascularization for symptomatic carotid occlusion constitutes approximately 2% of carotid interventions captured in the Vascular Quality Initiative, affirming the rarity of this undertaking. These patients have acceptable rates of perioperative neurologic events but are at an elevated risk of overall perioperative adverse events, primarily driven by a significantly higher mortality. While intervention for a symptomatic carotid occlusion may be performed with acceptable rate of perioperative complications, judicious patient selection is warranted in this high-risk cohort.
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Background: There is a paucity of data regarding outcomes of patients with premature cerebrovascular disease (<=55 years) who undergo carotid endarterectomy (CEA). The objective of this study was to analyze demographics, presentation, perioperative, and later outcomes of younger patients undergoing CEA.
Method(s): The Society for Vascular Surgery Vascular Quality Initiative was queried for CEA cases (2003-2020). Patients were stratified based on age 55 years or less or greater than 55 years. Primary end points were periprocedural stroke, death, myocardial infarction, and composite outcomes. Secondary end points analyzed included ipsilateral restenosis (>=80%) or occlusion, late ipsilateral neurologic events, and reintervention.
Result(s): Of 144,416 patients undergoing CEA, 8264 (5.7%) were aged 55 years or younger. The mean age was 51.3 years (range, 36 to 55 years). Younger patients were more likely to be female (44.5% vs 39.1%) and to be current smokers (58.8% vs 24.4%) (P <.001). They were less likely than older patients to have hypertension (82.2% vs 89.7%), coronary artery disease (25.6% vs 27.9%), and congestive heart failure (7.6% vs 11.2%; P <.001). Younger patients were less likely than older patients to be on aspirin, statins, or beta-blockers, but were more likely to be on P2Y12 inhibitors (P <.001). Younger patients were more likely to present with symptomatic disease (59% vs 47.2%) and were more likely to undergo nonelective CEA (19.3% vs 12.7%; P <.001). Younger patients had similar rates of perioperative stroke/death (1.8% vs 1.9%) and postoperative neurological events (1.7% vs 1.7%), but had lower rates of overall postoperative complications (3.8% vs 4.8%; P <.001). Sixty percent of patients had recorded follow-up (mean, 13 months). During follow-up, younger patients were significantly more likely than older patients to experience complete occlusion or significant (>=80%) restenosis of the operated artery (2.3% vs 1.6%), and were more likely to experience an ipsilateral neurological event (1.4% vs 0.9%) or any neurological event (3.2% vs 2.2%; P <.001).
Conclusion(s): Young patients undergoing CEA are more likely to be female, active smokers, and symptomatic. Although perioperative outcomes are similar, younger patients are more likely to experience carotid occlusion or restenosis as well as subsequent neurological events, during relatively short follow-up. These data suggest that younger CEA patients require more diligent follow-up, and a continued aggressive approach to medical management of atherosclerosis to prevent future events related to the operated artery.
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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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