Faculty Bibliography

Objectives: Despite the expanded application of thoracic endovascular aortic repair (TEVAR) to patients with significant cardiac comorbidities deemed too high risk for open repair, the effect of decreased left ventricular ejection fraction (EF) on patient outcomes remains unknown. The aim of this study was to compare the outcomes of patients with normal and abnormal EFs undergoing TEVAR.
Method(s): The Vascular Quality Initiative database (2003-2019) was reviewed to identify patients undergoing TEVAR for aortic dissection. Patients were categorized into those with severely reduced EF (SREF; EF <=30%) reduced EF (REF; EF <=50%), and normal EF (NEF; EF >50%). The baseline characteristics, procedural details, and 18-month outcomes were compared. Multivariable logistic regression was used to identify the factors associated with mortality, aortic-related reintervention, and complete false lumen thrombosis of the treated aortic segment.
Result(s): Of 2455 patients, 54 (1%) and 267 (3%) had had SREF and REF, respectively. Patients with an abnormal EF (SREF and REF) were more likely to be African American and to have more cardiac comorbidities compared with those with a NEF. The use of angiotensin-converting enzyme inhibitor and anticoagulant therapy was higher for patients with an abnormal EF postoperatively and at follow-up. At 18 months, mortality was significantly higher among the patients with SREF (35.2%) than for those with REF (13%) and NEF (13.4%; Fig). The rates of aortic-related reintervention and complete false lumen thrombosis were comparable among the three cohorts. On multivariable analysis, SREF was associated with an increased risk of mortality (hazard ratio, 2.52; 95% confidence interval, 1.28-4.96; P =.008) compared with NEF (Table). However, REF showed a comparable risk of mortality (hazard ratio, 0.90; 95% confidence interval, 0.55-1.46; P =.659) compared with NEF. Neither SREF nor REF was associated with an increased risk of aortic-related reinterventions and complete false lumen thrombosis compared with NEF.
Conclusion(s): SREF was independently associated with an increased risk of mortality compared with NEF at midterm follow-up. However, REF had a similar risk of morbidity and mortality compared with NEF. Furthermore, TEVAR-related complications were similar among the three cohorts. As such, the decision to perform TEVAR in patients with SREF requires balancing a careful estimation of the anticipated benefits and competing risk of death. [Formula presented] [Formula presented]
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Objective: 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.
Method(s): This single-institution retrospective analysis studied patients with CAO diagnosed by duplex ultrasound test between 2010 and 2021. Patients were identified by searching our office-based accredited vascular laboratory database. Imaging and clinical data were obtained via our institutional electronic medical record.
Result(s): A total of 5523 patients underwent carotid artery duplex examination during the study period. The CAO cohort consisted of 140 patients, as characterized in Table I; incidence of CAO was 2.5%. A total of 61.3% (n = 86) of patients were asymptomatic at diagnosis. A total of 27.9% (n = 39) were diagnosed after a stroke or transient ischemic attack, with 16.4% ipsilaterally affected, 7.9% contralaterally affected, and 3.6% with unclear laterality. For 23 patients with prior duplex imaging demonstrating ipsilateral patency, 26.1% had <50% ipsilateral stenosis, 39.1% had 50%-69% stenosis, and 26.1% had >70% stenosis at a mean of 32.8 +/- 26.4 months before CAO diagnosis. At CAO diagnosis, 55.2% of patients had <50% contralateral stenosis, 24.8% had 50%-69% stenosis, and 9.9% had >70% stenosis. Ninety-five patients (67.9%) had duplex imaging follow-up (mean: 42.7 +/- 31.3 months). Six patients (6.3%) developed recanalization with the mean occurrence of 42.9 +/- 32.6 months after diagnosis. Four patients (2.9%) developed subsequent stroke ipsilateral to the CAO with the mean occurrence of 27.8 +/- 39.0 months after diagnosis. Thirteen patients (9.3%) developed other related symptoms, including global hypoperfusion (5.0%), cognitive changes (2.9%), and transient ischemic attack (1.4%). Ten patients (7.1%) underwent eventual ipsilateral intervention, including carotid endarterectomy (n = 6), transfemoral carotid artery stenosis (n = 2), transcarotid artery revascularization (n = 1), and carotid bypass (n = 1), with the mean occurrence of 17.7 +/- 23.7 months after diagnosis. Before intervention, seven occlusions on duplex imaging were recharacterized as severe stenosis per periprocedural CT or MR imaging. Two CAOs were intervened on subsequent to recanalization. One patient with confirmed CAO underwent bypass for symptoms of global cerebral hypoperfusion. Intervention characteristics are shown in Table II. The aggregate rate of developing recanalization, related stroke or symptoms, or undergoing ipsilateral intervention was 19.3%. A total of 16 patients (11.4%) underwent contralateral intervention, including carotid endarterectomy (8.6%), transcarotid artery revascularization (2.1%), and transfemoral carotid artery stenosis (0.7%), with the mean occurrence of 11.5 +/- 18.2 months after diagnosis.
Conclusion(s): In this large, institutional cohort of patients with CAO diagnosed by duplex ultrasound test, a clinically meaningful subset of patients experienced recanalization, stroke, or related symptoms. Most patients with CAO per duplex ultrasound test who underwent intervention were subsequently recharacterized as having severe stenosis. These data suggest that patients with CAO may benefit from aggressive medical management, close follow-up, and confirmatory imaging. [Formula presented] [Formula presented]
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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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OBJECTIVE:The optimal medical management strategy in the periprocedural period for patients undergoing carotid artery interventions is not well described. Renin-angiotensin-system blocking (RASB) agents are considered to be among the first line anti-hypertensive agents; however, their role in the perioperative period is unclear. The objective of this study was to examine the relationship between the use of RASB agents on periprocedural outcomes in patients undergoing carotid interventions-carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). METHOD/METHODS:The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA, and TCAR between 2003 and 2020. Patients were stratified into two groups based upon their use of RASB agents in the periprocedural period. The primary endpoint was periprocedural neurologic events (including both strokes and transient ischemic attacks (TIAs)). The secondary endpoints were peri-procedural mortality and significant cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure. RESULTS:= 0.461). CONCLUSION/CONCLUSIONS:The use of peri-procedural RASB agents was associated with a significantly decreased rate of neurologic events in patients undergoing both CEA and TCAR. This effect was not observed in patients undergoing CAS. As carotid interventions warrant absolute minimization of perioperative complications in order to provide maximum efficacy with regard to stroke protection, the potential neuro-protective effect associated with RASB agents use following CEA and TCAR warrants further examination.

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

OBJECTIVE:Transcarotid artery revascularization (TCAR) with dynamic flow reversal is a hybrid technique for operative management of carotid artery stenosis. Dual antiplatelet therapy is recommended for patients undergoing TCAR; however, nonresponders to these medications may be predisposed to perioperative thromboembolic complications. Prevalent in up to 44-66% of patients taking clopidogrel, high on-treatment platelet reactivity (HTPR) may thus be responsible for a portion of adverse cerebrovascular events in TCAR. A previous single-institution study has demonstrated the use of ticagrelor as a viable alternative to clopidogrel for antiplatelet therapy in patients undergoing TCAR; however, large-scale comparisons between clopidogrel and ticagrelor are needed to confirm the safety of ticagrelor outside of highly selected patients and providers. METHODS:Data from patients enrolled in the Society for Vascular Surgery Vascular Quality Initiative undergoing TCAR with a perioperative antiplatelet therapy regimen including either clopidogrel or ticagrelor from January 2015 to March 2021 were analyzed and compared. Multivariable logistic regression and propensity score matching were used to evaluate the primary 30-day outcomes of stroke, major bleeding event, and combined stroke/myocardial infarction (MI)/death rate while adjusting for baseline characteristics of the patients. RESULTS:A total of 11973 patients underwent TCAR with a dual antiplatelet therapy regimen that included clopidogrel versus 426 patients with ticagrelor. Compared to clopidogrel, patients on ticagrelor were significantly more likely to have coronary artery disease (51% vs 66% [P = <.001]), particularly unstable angina or MI within 6 months (3% vs 9% [P = <.001]), and more likely to have insulin-dependent diabetes mellitus (14% vs 19% [P = <.001]). The unadjusted 30-day rates of stroke, major bleeding, and combined stroke/MI/death were not statistically significant among both groups (1.3% vs 0.5% [P = .14], 2.4% vs 1.4% [P = .18], and 1.9% vs 1.6% [P = .71], respectively). After multivariable adjustment and propensity matching, these remained statistically insignificant. CONCLUSIONS:Despite a substantially higher medical risk in patients undergoing TCAR with ticagrelor, 30-day rates of stroke, major bleeding events, and combined stroke/MI/death were similar between patients on ticagrelor and clopidogrel as part of adjunctive antiplatelet therapy. Randomized prospective trials, and studies with larger sample sizes and longer follow-up will be needed to better examine the outcome differences in TCAR between these two medications.

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

BACKGROUND:Isolated iliac artery aneurysms (IAAs), accounting for 2% to 7% of all abdominal aneurysms, are often treated with the use of iliac branched endografts. Although outside the manufacturer's instructions for use, iliac branched devices can be used solely, without the adjunctive placement of an endovascular aneurysm repair device, for the treatment of an isolated IAA. In the present study, we have described the outcomes of the use of the Gore iliac branched endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, Ariz), without the support of an infrarenal endovascular aneurysm repair device, for the exclusion of an isolated IAA. The present study was an international multicenter retrospective cohort analysis. METHODS:All the patients who had undergone treatment with a solitary IBE for IAA exclusion from January 11, 2013 to December 31, 2018 were retrospectively reviewed. The primary outcome was technical success. The secondary outcomes included mortality, intraoperative and postoperative complications, and reintervention. RESULTS:A total of 18 European and American centers participated, with a total of 51 patients in whom 54 IAAs were excluded. The technical success rate was 94.1%, with an assisted technical success rate of 96.1%. No 30-day mortality occurred, with 98.1% patency of the internal and external iliac artery found at 24 months of follow-up. At 24 months of follow-up, 81.5% of the patients were free of complications and 90% were free of a secondary intervention. CONCLUSIONS:Treatment with a solitary IBE is a safe and, at midterm, an effective treatment strategy for selected patients with a solitary IAA.

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

BACKGROUND:Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology. METHODS:In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved. RESULTS:The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment. CONCLUSION/CONCLUSIONS:This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.