Faculty Bibliography

BACKGROUND:The impact of pulmonary embolism response teams (PERTs) on treatment choice and outcomes of patients with acute pulmonary embolism (PE) is still uncertain. OBJECTIVE:To determine the effect of PERTs in the management and outcomes of patients with PE. METHODS:PubMed, Embase, Web of Science, CINAHL, WorldWideScience and MedRxiv were searched for original articles reporting PERT patient outcomes from 2009. Data were analysed using a random effects model. RESULTS:16 studies comprising 3827 PERT patients and 3967 controls met inclusion criteria. The PERT group had more patients with intermediate and high-risk PE (66.2%) compared to the control group (48.5%). Meta-analysis demonstrated an increased risk of catheter-directed interventions, systemic thrombolysis and surgical embolectomy (odds ratio (OR) 2.10, 95% confidence interval (CI) 1.74-2.53; p<0.01), similar bleeding complications (OR 1.10, 95% CI 0.88-1.37) and decreased utilisation of inferior vena cava (IVC) filters (OR 0.71, 95% CI 0.58-0.88; p<0.01) in the PERT group. Furthermore, there was a nonsignificant trend towards decreased mortality (OR 0.87, 95% CI 0.71-1.07; p=0.19) with PERTs. CONCLUSIONS:The PERT group showed an increased use of advanced therapies and a decreased utilisation of IVC filters. This was not associated with increased bleeding. Despite comprising more severe PE patients, there was a trend towards lower mortality in the PERT group.

OBJECTIVE/UNASSIGNED:The aim of this multicentric registry was to assess the outcomes of "anteRior versus posteRior divisional bRanches Of the hYpogastric artery as distAl landing zone for iLiac branch devices (R3OYAL)." METHODS/UNASSIGNED:The main exposure of interest for the purpose of this study was the internal iliac artery (IIA) divisional branch (anterior vs posterior) that was used as distal landing zone. Early endpoints included technical success and adverse events. Late endpoints included survival, primary/secondary IIA patency, and IIA branch instability. RESULTS/UNASSIGNED:= 1.0). The overall rate of freedom from the composite IBD branch instability did not show significant differences between patients receiving distal landing in the anterior or posterior division of the IIA at 3 years (79% vs 87%, log-rank test = .215). The 3-year estimates of IBD patency were significantly lower in patients who received distal landing in the anterior divisional branch than those who received distal landing in the posterior divisional branch (primary patency: 81% vs 96%, log-rank test = .009; secondary patency: 81% vs 97%, log-rank test < .001). CONCLUSIONS/UNASSIGNED:The use of the anterior or posterior divisional branches of the IIA as distal landing zone for IBD implantation shows comparable profiles in terms of immediate technical success, perioperative safety, and side-branch instability up to 3 years. However, IBD patency at 3 years was higher when the distal landing zone was achieved within the posterior divisional branch of the IIA. CLINICAL IMPACT/CONCLUSIONS:The results from this large multicentric registry confirm that use of the anterior or posterior divisional branches of the internal iliac artery (IIA) as distal landing zone for implantation of iliac branch devices (IBD) shows comparable profiles of safety and feasibility, thereby allowing to extend the indications for endovascular repair of aorto-iliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Although mid-term rates of device durability and branch instability seem to be similar, the rates of primary and secondary IBD patency at three years was favored when the distal landing zone was achieved in the posterior divisional branch of the IIA.

OBJECTIVE:Carotid artery plaque burden, indirectly measured by the degree of stenosis, quantifies future embolic risk. In natural history studies, patients with moderate degrees of stenosis have a lower stroke risk than those with severe stenosis. However, patients with symptomatic carotid stenosis who have experienced TIA or stroke are found to have both moderate and severe degrees of stenosis. We sought to examine the association carotid artery stenosis severity with outcomes in symptomatic patients undergoing carotid interventions including carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS) and transcervical carotid artery revascularization (TCAR). 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 on the severity of stenosis - non-severe (0 - 69%) and severe (≥ 70%). Primary endpoints were periprocedural neurologic events (strokes and transient ischemic attacks (TIAs)). Secondary endpoints were periprocedural death, myocardial infarction (MI) and composite outcomes of stroke/death and stroke/death/MI per reporting standards for carotid interventions. RESULTS:Of 29,614 symptomatic patients included in the analysis, 5,296 (17.9%) patients underwent TCAR, 7,844 (26.5%) underwent CAS, and 16,474 (55.6%) underwent CEA for symptomatic carotid artery stenosis. In the CEA cohort, the neurologic event rate was similarly significantly lower in patients with severe stenosis when compared to those with non-severe stenosis (2.6% vs. 3.2%, P=.024). In the TCAR cohort, the periprocedural neurologic even rate was lower in patients with severe stenosis when compared to those with non-severe stenosis (3% vs. 4.3%, P=.033). There was no similar difference noted in the CAS cohort, with periprocedural neurologic event rates of 3.8% in the severe group versus 3.5% in the non-severe group (P=.518). On multivariable analysis, severe stenosis was associated with significantly decreased odds of post procedural neurologic events in patients undergoing CEA (odds ratio [OR] 0.75, 95% confidence interval [CI], 0.6 - 0.92; P=.007) and TCAR (OR .83; CI, .69 - 0.99; P=.039), but not CAS. CONCLUSION/CONCLUSIONS:Severe carotid stenosis as opposed to more moderate degrees of stenosis was associated with decreased rates of periprocedural stroke and TIAs in symptomatic patients undergoing TCAR and CEA, but not CAS. The finding of increased rates of periprocedural neurologic events in symptomatic patients with lesser degrees of stenosis undergoing TCAR and CEA warrants further evaluation with a particular focus on plaque morphology and brain physiology, and their inherent risks with carotid revascularization procedures.

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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BACKGROUND:Mannitol is often administered during open juxtarenal or suprarenal aortic surgery to prevent ischemic injury to the kidneys. Prior evidence evaluating the benefits of intraoperative mannitol in reducing ischemia/reperfusion injury is conflicting and largely based on small, retrospective series. The aim of this study was to evaluate the effect of mannitol in preventing postoperative hemodialysis in patients undergoing open abdominal aortic aneurysm (AAA) repair where proximal control involved temporary renal ischemia. METHODS:The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients were included in the current analysis if the proximal aortic clamp was placed above at least one renal artery. Chronic kidney disease (CKD) was defined as Cr > 1.8 mg/dL. Primary end points were 30-day major morbidity (myocardial infarction, respiratory complications, lower extremity or intestinal ischemia, and the need for temporary or permanent hemodialysis) and mortality. Comparisons were made between the mannitol and nonmannitol cohorts and stratified by the presence of preexisting CKD. RESULTS:During the study period, 4,156 patients underwent elective open AAA repair requiring clamp placement more than one (32.7%) or both (67.3%) renal arteries; 182 patients (4.4%) had preexisting CKD. Overall, 69.8% of patients received mannitol during their surgery. Mannitol was more frequently used in cases involving clamp placement above both renal arteries (70.3%) than one renal artery (61.5%). While prolonged ischemia time (more than 40 min) was associated with a higher risk of postoperative dialysis in patients without CKD, it was not significant in patients with baseline CKD. On a univariate analysis, mannitol use in patients with CKD was associated with a lower risk of postoperative dialysis (P = 0.005). This remained significant on a multivariate analysis (P = 0.008). Mannitol use did not appear to confer renal protective effects in patients without baseline CKD. CONCLUSIONS:Mannitol use was associated with a decreased risk of need for postoperative hemodialysis in patients with CKD undergoing suprarenal aortic clamping for open aneurysm repair. In appropriately selected patients, particularly those with underlying renal insufficiency, mannitol may confer a renal protective effect in open repair of pararenal AAA requiring suprarenal clamping.

OBJECTIVE:Endothermal ablation is well established for the treatment of the great and small saphenous veins. Data are lacking for treatment of the Anterior Accessory Saphenous Vein (AASV). The purpose of this study is to evaluate the safety and efficacy of AASV treatment using endothermal ablation. METHODS:This was a retrospective review of 314 limbs at a single academic institution from 2016-2018 using the institutional Vascular Quality Initiative database. All limbs had documented AASV reflux. Baseline characteristics were evaluated including age, sex, ethnicity, CEAP (clinical, etiology, anatomy, pathophysiology) classification, Venous Clinical Severity Score (VCSS), and vein diameter. Outcomes relating to procedure safety and efficacy included treatment modality and length, successful ablation on post-operative imaging, post-procedural clinical outcomes, incidence of endothermal heat induced thrombosis (EHIT), and any post-procedural complication. RESULTS:A total of 314 consecutive limbs were identified from 2016-2018. Pre-procedure VCSS scores were available for 312 limbs and averaged 6.13 ± 3.33. History of varicose veins were reported in all limbs with 49.4% (n=155) having previously undergone a procedure. The most common presenting symptom was mild edema in 52.5% (n=165). Vein diameter and assessment of reflux were obtained by venous duplex ultrasound (DUS). The largest AASV diameter was available for 304 limbs, averaging 7.93 ± 2.69 mm. Treatment modalities included radiofrequency ablation (RFA) in 59.2% (n=186), endovenous laser ablation (EVLA) in 37.9% (n=119), and isolated microphlebectomy in 2.9% (n=9). 38.5% (N=121) of limbs underwent concomitant microphlebectomy at the time of EVLA. Total treatment length was obtained in 297 limbs, averaging 23.0 cm ± 12.0. Post-operatively, 94.6% (n=297) of limbs were prescribed compression stockings. Post-operative DUS was performed in 312 limbs, revealing successful ablation in 96.5% (n=303) with 2 limbs (0.6%) developing an EHIT, both treated with therapeutic enoxaparin for one week. Repeat DUS revealed thrombus resolution in one limb, while the other patient was lost to follow-up. VCSS scores post-procedure were available for 145 limbs and averaged 4.45 ± 2.31. This was a statistically significant decrease from pre-procedure VCSS scores (p<0.01). Average duration of follow-up was 2.2 years, with two limbs lost to follow-up. Of the 9 limbs (3.5%) whose initial procedure failed, 5 (56%) were treated using RFA and 4 (44%) were treated using EVLA. There were no other post-operative complications. CONCLUSION/CONCLUSIONS:Our experience over a three-year period for treating the AASV shows it to be safe and effective in a broad range of disease severity with an improvement in VCSS and a low incidence of EHIT. Additionally, RFA and EVLA exhibit similar treatment efficacy. Long-term follow-up data are needed.

OBJECTIVES/OBJECTIVE:Endovascular aortic aneurysm repair (EVAR) has become the standard of care treatment for abdominal aortic aneurysms (AAA) in the modern era. While numerous devices exist for standard infrarenal AAA repair, fenestrated endovascular aneurysm repair (fEVAR) offers a minimally invasive alternative to traditional open repair in patients with short infrarenal necks. Over time, aortic neck dilation can occur leading to loss of proximal seal, endoleaks, and AAA sac growth. This study analyzes aortic remodeling following EVAR versus fEVAR and further evaluates whether fEVAR confers a benefit in terms of sac shrinkage. METHODS:A retrospective review of prospectively collected data on 120 patients undergoing EVAR was performed: 30 patients were treated with fEVAR (Cook Zenith© Fenestrated) and 90 patients were treated with EVAR devices (30 with each Medtronic Endurant ©, Gore Excluder ©, and Cook Zenith ©). Demographic data were recorded, and anatomic measurements were taken for each patient pre-operatively, 30 days post-operatively, and at the longest point of follow-up using three-dimensional reconstruction software. RESULTS:There were no significant differences in demographics data between the 4 groups. fEVAR was used more often in aortas with large necks and irregular morphology (p= 0.004). At the time of longest follow up, the suprarenal aorta encompassing 5, 10, and 15mm above the lowest renal artery (ALRA) dilated the most for fEVAR versus all EVAR groups. Despite this, the infrarenal segment tended to increase by the least, or even regress, for fEVAR compared to all EVAR groups, and was associated with the overall greatest proportion of sac shrinkage for the fEVAR group compared to Medtronic, Gore, and Cook devices, respectively (-13.90% vs. -5.75% vs. -2.31% vs. -4.68%, p=0.025). CONCLUSIONS:Compared to EVAR, patients treated with fEVAR had greater suprarenal dilation over time, consistent with an overall greater burden of disease in the proximal native aorta. However, the infrarenal segment dilated significantly less over time in the fEVAR group compared to all EVAR groups, suggesting that fEVAR may stabilize the infrarenal neck, promoting positive sac remodeling, as evidenced by the greatest degree of decrease in largest AAA diameter in the fEVAR group.

OBJECTIVES/OBJECTIVE:The multicenter, prospective, single arm CLOUT registry assesses the safety and effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) for the treatment of acute and non-acute lower extremity deep vein thrombosis (DVT) in all-comer patients. Reported here are the outcomes of the first 250 patients. METHODS:All-comer patients with lower extremity DVT were enrolled, including those with bilateral DVT, those with previously failed DVT treatment, and regardless of symptom duration. The primary effectiveness endpoint is complete, or near-complete (≥75%) thrombus removal determined by independent core laboratory-adjudicated Marder scores. Safety outcomes include serious adverse events (SAEs) through 30 days and clinical outcomes include PTS severity, symptoms, pain, and quality of life through 6 months. RESULTS:The median age was 62 years and 40% of patients had contraindications to thrombolytics. A range of thrombus chronicity (33% acute, 35% subacute, 32% chronic) was observed. No patients received thrombolytics and 99.6% were treated in a single session. Median thrombectomy time was 28 minutes. The primary effectiveness endpoint was achieved in 86% of limbs. Through 30 days, one device-related SAE occurred. At 6 months, 24% of patients had PTS. Significant and sustained improvements were observed in all clinical outcomes including rVCSS, NPRS, and EQ-5D. CONCLUSIONS:6-month outcomes from the all-comer CLOUT registry with a range of thrombus chronicity demonstrate favorable effectiveness, safety, and sustained clinical improvements.

Superior vena cava (SVC) syndrome is commonly caused by malignancy but is rarely associated with breast cancer. The following case series describes three female breast cancer patients who were found to have disease recurrence years after initial diagnosis, presenting as facial swelling, collateral vessel formation, and shortness of breath consistent with SVC syndrome. All patients were treated with radiation therapy, and one patient required stenting due to tumor thrombus in the SVC. These cases highlight a rare complication of breast cancer that clinicians should recognize in patients who have undergone treatment particularly for right sided breast cancer with lymph node involvement.

Objectives: The impact of preoperative anemia in patients undergoing transcarotid artery revascularization (TCAR) is not well established. This study compared the perioperative outcomes of patients with and without preoperative anemia after TCAR.
Method(s): The Vascular Quality Initiative database (2016-2021) was queried for all patients undergoing TCAR for carotid stenosis. Anemia was defined as a hemoglobin level of <12 g/dL in women and <13 g/dL in men. The primary outcome was a composite of in-hospital major adverse cardiovascular events (MACE; defined as stroke, death, myocardial infarction [MI]). The secondary end points included prolonged postoperative length of stay (>2 days), death, stroke, and MI. Anemia was further stratified by hemoglobin level (mild, 10-11.9 g/dL for women or 12.9 g/dL for men; moderate, 8-9.9 g/dL; severe, 6.5-7.9 g/dL). Multivariable logistic regression and case-controlled matching were conducted to assess the association between anemia and the outcomes of interest.
Result(s): Of 21,468 patients, 7641 (36%) were anemic and 8932 (42%) had symptomatic stenosis. The anemic patients tended to be older and more symptomatic (44% vs 41%), with more comorbidities (Table I). They had a higher rate of in-hospital MACE (2.8% vs 1.9%; P <.001), primarily driven by more deaths (0.7% vs 0.3%; P <.001) and MIs (0.9% vs 0.4%; P <.001). The rate of stroke was not different between the two cohorts (1.5% vs 1.5%). Multivariable logistic regression and case-control matching demonstrated that preoperative anemia was not associated with increased odds of MACE, death, stroke, MI, or stroke or death (Table II). This trend persisted in the subgroup analysis of patients with symptomatic stenosis. However, preoperative anemia was independently associated with an increased postoperative length of stay on multivariable analysis in both the unmatched (odds ratio, 1.34; 95% confidence interval, 1.18-1.70; P <.001) and case-control matched (odds ratio, 1.42; 95% confidence interval, 1.18-1.71; P <.001) cohorts. Finally, the severity of anemia did not appear to affect the perioperative outcomes after TCAR on multivariable analysis.
Conclusion(s): Preoperative anemia was not associated with increased perioperative MACE in patients undergoing TCAR. However, anemic patients had had longer postoperative hospital stays following TCAR, which might potentially implicate increased resource usage. Given the recent study showing an association between preoperative anemia and MACE after carotid endarterectomy and transfemoral carotid stenting, TCAR could be considered for appropriately selected anemic patients with high-risk features. [Formula presented] [Formula presented]
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