Faculty Bibliography

Objective: Renal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR.
Method(s): The Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes.
Result(s): Of 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P <.001), with higher incidence of hypertension (92% vs 84%; P =.004) and diabetes (29% vs 21%; P =.005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P <.001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P <.001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P <.001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P =.039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P <.001), but the need for new RRT was similar (1.1% vs 0.4%; P =.15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P <.001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P =.02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P =.235).
Conclusion(s): Among patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI. Keywords: End-stage renal disease, Endovascular abdominal aortic aneurysm, Multi-institutional study, Renal transplant, Renal transplant recipient, Vascular Quality Initiative database
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BACKGROUND:Peripheral vascular interventions (PVIs) for lower extremity peripheral artery disease have been increasing, particularly in the office-based setting. Our goal was to evaluate practice patterns for PVI by site of service using a contemporary real-world dataset. METHODS:The Vascular Quality Initiative PVI registry was queried from 2010-2021. Site of service was classified as hospital/inpatient, hospital/outpatient, and ambulatory/office-based center. Patient demographics, comorbidities, procedural details, and periprocedural outcomes were analyzed. RESULTS:There were 54,897 hospital/inpatient (43.2%), 64,105 hospital/outpatient (50.4%), and 8,179 ambulatory/office-based center (6.4%) PVI. When comparing the 2 outpatient settings, ambulatory/office-based center patients were older than hospital/outpatient (mean age 70.7 vs. 68.7 years), more often female sex (41.4% vs. 39.1%), never smokers (27.5% vs. 18.5%), primary Medicare (61.6% vs. 55.9%), nonambulatory (6.5% vs. 4.7%), less often with coronary artery disease (30.2% vs. 34.1%), chronic obstructive pulmonary disease (18.1% vs. 26.9%), congestive heart failure (13% vs. 17.2%), obesity (30.9% vs. 33.6%), and less often on a statin (71.4% vs. 76.1%) (P < 0.001). Ambulatory/office-based center procedures were more likely for claudication (60.1% vs. 55.8%), more often involved femoro-popliteal (73.1% vs. 64.6%) and infrapopliteal (36.7% vs. 24.3%), and less often iliac interventions (24.1% vs. 33.6%) (P < 0.001).Overall, atherectomy was used in 14.2% of hospital/inpatient, 19.4% of hospital/outpatient, and 63.4% of ambulatory/office-based center procedures. Stents were used in 41.8% of hospital/inpatient, 45.1% of hospital/outpatient, and 48.8% of ambulatory/office-based center procedures. However, stent grafts were used in 12.5% of hospital/inpatient, 8.8% of hospital/outpatient, and only 1.3% of ambulatory/office-based center procedures. On multivariable analysis, compared with hospital/inpatient, atherectomy use was associated with ambulatory/office-based center setting (Odds ratio 10.9, 95% confidence interval 10.3-11.5, P < 0.001) and hospital/outpatient setting (Odds ratio 1.57, 95% confidence interval 1.51-1.62, P < 0.001). Periprocedure complications including hematoma requiring intervention (0.3%), any stenosis/occlusion (0.2%), and distal embolization (0.6%) were quite low across all settings. CONCLUSIONS:There are substantial variations in patient populations, procedural indications, and types of interventions undertaken during PVI across different locations. Ambulatory/office-based procedures more commonly treat claudicants, use atherectomy, and less often use stent grafts. Further research is warranted to investigate long-term trends in practice patterns and long-term outcomes, for PVI in the ever-expanding ambulatory/office-based setting.

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.

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.

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: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.

OBJECTIVE:Beta-blockers are first-line anti-impulse therapy in patients presenting with acute type B aortic dissection (TBAD). However, little is understood about their impact after aortic repair. The aim of this study was to evaluate the role of postoperative beta-blocker use on outcomes of thoracic endovascular aortic repair (TEVAR) in TBAD. METHODS:The Vascular Quality Initiative database was queried for all patients undergoing TEVAR for TBAD from 2012 to 2020. Aortic-related reintervention, all-cause mortality and effect of TEVAR on false lumen thrombosis of the treated aortic segment were assessed and compared between patients treated with and without beta-blocker postoperatively. Cox proportional hazards models were used to estimate the effect of beta-blocker therapies on outcomes. RESULTS:1,114 patients undergoing TEVAR for TBAD were identified with a mean follow-up of 18±12 months. The mean age was 61.1±11.9 years, and 791 (71%) were male. 935 (84%) patients were maintained on beta-blocker at discharge and follow-up. Patients on beta-blocker were more likely to have an entry tear originating in zones 1-2 (22% vs 13%; P=.022). The prevalence of acute, elective and symptomatic AD, concurrent aneurysm, number of endografts used, distribution of the proximal and distal zones of dissection and operative time were comparable between the two cohorts. At 18-months, significantly more complete false lumen thrombosis (58 vs 47%; log-rank P=.018) was observed in patients on beta-blocker while the rates of aortic-related reinterventions (13% vs 9%; log-rank P=.396) and mortality (0.2% vs 0.7%; log-rank P=.401) were similar in patients with and without beta-blocker, respectively. Even after adjusting for clinical and anatomic factors, postoperative beta-blocker use was associated with increased complete false lumen thrombosis (HR 1.56; 95% CI: 1.10-2.21; P=.012) but did not affect mortality or aortic-related reintervention. A secondary analysis of beta-blocker use in acute versus chronic TBAD showed a higher rate of complete false lumen thrombosis in patients on beta-blocker in chronic TBAD (59% vs 38%; log-rank P=.038). In contrast, there was no difference in the rate of complete false lumen thrombosis in acute TBAD between the two cohorts (58% vs 51%; log-rank P=.158). When analyzed separately, postoperative ACE inhibitor use did not affect the rates of complete false lumen thrombosis, mortality and aortic-related reintervention. CONCLUSIONS:Beta-blocker use was associated with promotion of complete false lumen in patients undergoing TEVAR for TBAD. In addition to its role in acute setting, anti-impulse control with beta-blocker appears to confer favorable aortic remodeling and may improve outcomes after TEVAR, particularly for chronic TBAD.

OBJECTIVE:Current guidelines recommend dual antiplatelet therapy (DAPT) in patients undergoing carotid artery stenting. The most common DAPT regimen is aspirin and clopidogrel, a P2Y12 receptor antagonist; however, the prevalence of clopidogrel resistance (CR) in patients undergoing percutaneous coronary interventions may exceed 60%. Few studies have investigated the prevalence and impact of CR in patients undergoing extracranial carotid artery stenting, particularly transcarotid artery revascularization (TCAR). METHODS:Consecutive high-risk patients ≥ 18 years who underwent TCAR for high grade (≥70%) and/or symptomatic (≥50%) carotid stenosis with preoperative P2Y12 testing between August 2019 and December 2021 were identified across five institutions. Preoperative platelet reactivity was measured with the VerifyNow P2Y12 Reaction Unit (PRU) Test (Instrumentation Laboratory, Bedford, MA), with CR defined as PRU ≥ 194 and hyper-response as PRU <70. Patients without preoperative P2Y12 testing within 30 days prior to TCAR or those on a non-clopidogrel P2Y12 inhibitor preoperatively were excluded. The primary outcome of interest was prevalence of CR. Secondary outcomes of interest included the incidence of ischemic and hemorrhagic complications. RESULTS:= 1) between clopidogrel phenotypes. Three (3.3%) patients, one CR (PRU 240) and two responders (PRU 119 and PRU 189), experienced postoperative access site hematomas that required no subsequent intervention. No other index hospitalization hemorrhagic complications occurred. CONCLUSIONS:Using preoperative P2Y12 testing with a threshold PRU ≥ 194 to define CR, we identified a high prevalence of CR in patients undergoing TCAR similar to that in the pre-existing coronary literature. We found no significant differences in postoperative ischemic or hemorrhagic complications by clopidogrel response phenotype, although complication rates in the overall study cohort were low. CR may be a spectrum from responder to partial responder to complete non-responder, and this may account for the differences in our CR cohort compared to the ROADSTER 2 protocol deviation cohort. Further investigation is warranted to determine if a quantitative assessment of CR is sufficient to identify patients at risk of developing secondary cerebrovascular ischemic events in this patient population.