Faculty Bibliography

Background: Endovascular aortic aneurysm repair (EVAR) for aortoiliac aneurysms may require sacrifice of the hypogastric artery (HA) or use of iliac branch devices (IBD) to salvage antegrade flow through the HA.
Method(s): We identified all patients who underwent elective EVAR for aortoiliac aneurysms in the Society for Vascular Surgery-Vascular Quality Initiative (2014-2021). Patients were categorized as unilateral/bilateral IBD, bilateral HA sacrifice, or mixed (unilateral HA sacrifice or one-sided IBD/one-sided HA sacrifice). HA sacrifice was defined as coil embolization, Amplatzer plug, or coverage of HA. We compared postoperative outcomes, aneurysm sac remodeling, and late survival across the three groups. Logistic regression and Cox regression were used to identify independent effect of HA patency on outcomes of interest.
Result(s): Among 2822 patients undergoing EVAR for aortoiliac aneurysms, after EVAR 29% had bilateral HA patency, 64% had mixed repair, 7% had bilateral HA sacrifice. Patients with bilateral HA patency had smaller aortic diameter (bilateral patency 5.0 cm vs mixed repair 5.2 cm vs bilateral sacrifice 5.2 cm; P <.001) and fewer concomitant iliac artery and HA aneurysms (14% vs 16% vs 23%; P <.001). Unilateral and bilateral HA patency was associated with lower odds of major adverse cardiac events and postoperative renal complications (Table). There was no association between HA patency and postoperative mortality (0.6% vs 1.2% vs 1.1%; P =.35), leg ischemia (1.0% vs 1.0% vs 1.1%; P =.98), or mesenteric ischemia (0.2% vs 0.3% vs 0.5%; P =.80). There were no differences in 1-year sac shrinkage (>=5 mm decrease) (39% vs 40% vs 45%; P =.580) or 5-year survival (92% vs 94% vs 89%; P =.435).
Conclusion(s): In patients with aortoiliac aneurysms, bilateral HA patency was associated with lower postoperative major adverse cardiac events and renal complications. Salvage of the HA is important for quality of life and functional capacity, but future studies with larger sample sizes are needed. [Formula presented]
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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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Background: Preoperative renal function is a predictor of morbidity and mortality after endovascular repair of juxtarenal aortic aneurysms. However, the impact of postoperative renal complication on outcomes after repair are poorly understood. Therefore, our objective was to assess the impact of postoperative renal dysfunction on midterm outcomes following endovascular repair of juxtarenal aortic aneurysms.
Method(s): We identified all endovascular repairs of juxtarenal aortic aneurysms in the Vascular Quality Initiative from 2011 to 2018 with linkage to Medicare claims data. Juxtarenal aortic aneurysm repair was defined as repair with at least one scallop, fenestration, branch, or parallel grafting into a renal vessel. Postoperative renal complication was defined as acute kidney injury (AKI; >=0.5 mg/dL serum creatinine increase) or new renal replacement therapy (RRT). We excluded any patients on preoperative hemodialysis. Kaplan-Meier estimates and Cox regression were used to determine the effect of AKI/RRT on midterm mortality, rupture, and reintervention.
Result(s): Of 931 endovascular repairs, 17% experienced postoperative AKI/RRT. Repairs with postoperative AKI/RRT more often had coverage/occlusion of renal vessels (AKI/RRT: 17% vs stable function: 4.5%; P <.001) or parallel grafting of renal vessels (24% vs 16%; P <.001). Furthermore, repairs with postoperative AKI/RRT had higher rates of postoperative mortality (18% vs 1.2%; P <.001). Postoperative AKI/RRT was independently associated with a higher risk of 5-year mortality (42% vs 16%; adjusted hazard ratio [aHR] 2.4; 95% confidence interval [CI], 1.5-3.8; P <.001) (Figure) and 3-year late rupture (17% vs 5.1%; adjusted hazard ratio, 4.0; 95% CI, 1.8-8.8; P =.001). Meanwhile, postoperative AKI/RRT trended toward a higher risk of 3-year reinterventions (28% vs 20%; adjusted hazard ratio, 1.5; 95% CI, 0.9-2.5; P =.105).
Conclusion(s): Postoperative renal complications adversely impacted late mortality, rupture, and reintervention. Future studies with longer follow-up may likely demonstrate even worse outcomes in this cohort. Our study calls for optimization of preoperative renal status and the use of protective adjuncts to reduce the risk of postoperative renal complications and its negative long-term sequala. [Formula presented]
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Background: Thoracic endovascular aortic repair (TEVAR) is increasingly used to treat aortic dissections and aneurysms. Access-related complications remain a common source of morbidity and mortality following TEVAR. Therefore, this study aims to determine major risk factors predicting postoperative access complications and 3-year survival in patients with access complications.
Method(s): We identified all patients undergoing TEVAR in the Vascular Quality Initiative from July 2010 to August 2021, excluding those converted to open repair. We defined access complication as postoperative occlusion, wound infection, hematoma, or unplanned conversion to open cutdown. The primary outcome was 3-year survival and the secondary outcome was postoperative mortality. Mixed effects logistic regression modelling with physician level clustering was used to identify factors associated with access complications and postoperative mortality. Kaplan-Meier estimates and Cox proportional hazards models were used for analysis of three-year survival.
Result(s): Of 18,172 patients, 1584 (8.7%) had access complications. Bilateral percutaneous access was obtained in 68% of patients, one percutaneous and one open in 14%, and bilateral open access in 13%. Patients with access complications were older (70 +/- 0.6 years vs 66 +/- 0.2 years; P <.01) and female (50% vs 34%; P <.01). Patients with access complications experienced higher postoperative mortality (12% vs 4.6%; P <.01), major adverse cardiac event (17% vs 6.6%; P <.01), reintervention (22% vs 10%; P <.01), and spinal ischemia (7.0% vs 2.1%; P <.01). After adjustment, factors associated with access complication include female sex (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.9-2.6; P <.01) and obesity (OR, 1.2; 95% CI, 1.0-1.4; P =.02). Access complication was independently associated with postoperative mortality (OR, 2.5; 95% CI, 2.0-3.0; P <.01). Bilateral cutdown was associated with lower mortality in male patients (OR, 0.55; 95% CI, 0.34-0.90; P =.02), but not in female patients (OR, 2.1; 95% CI, 1.1-4.3; P =.03). Last, access complications were associated with higher 3 -year mortality (hazard ratio, 1.6; 95% CI, 1.3-1.8; P <.01).
Conclusion(s): Access complications when unexpected are associated with adverse postoperative and three-year outcomes. Female sex is associated with higher rates of access complications, suggesting the need for devices tailored to female anatomy.
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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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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.

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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Objectives: Although, post-carotid endarterectomy (CEA) stroke is rare, it can be devastating. The impairment degree and 1-year effects are unclear. Our goal was to assess the postoperative and 1-year outcomes for patients experiencing a stroke after CEA without preoperative disability.
Method(s): The Vascular Quality Initiative CEA registry was used to examine strokes after CEA that were asymptomatic or symptomatic with a preoperative modified Rankin scale (mRS) score of 0 or 1. The mRS score for stroke disability was classified as 0 (none), 1 (not significant), 2 to 3 (moderate), 4 to 5 (severe), and 6 (dead). Patients who had experienced a postoperative ipsilateral stroke with a recorded postoperative mRS score were included. Perioperative disability and long-term outcomes were analyzed.
Result(s): Of 149,285 patients, 1178 without a preoperative disability had had a postoperative ipsilateral stroke with a mRS score recorded. The average age was 71 years, and 59.6% were men. Preoperatively, most (98.8%) had lived at home and were independently ambulatory (90%). The preoperative symptoms were none (83.5%), transient ischemic attack (7.3%), and stroke (9.2%). All preoperative patients with stroke had had a mRS score of 0 or 1. Of these patients, 11.6% had required reexploration. The mRS score for all patients with a postoperative stroke with disability was classified as none for 11.6%, not significant for 19.5%, moderate for 29.4%, severe for 26.9%, and dead for 8%. The 1-year survival stratified by postoperative disability was 91.4% for none, 95.6% for not significant, 92.1% for moderate, and 81.5% for severe (P <.001). Multivariable analysis showed that severe postoperative disability was associated with death at 1 year (hazard ratio [HR], 2.97; 95% confidence interval [CI], 1.5-5.9; P <.001) but moderate postoperative disability was not (HR, 0.95; 95% CI, 0.45-2; P =.88). Other factors associated with death at 1 year were end-stage renal disease (HR, 8.1; 95% CI, 2.97-23; P <.001) and previous contralateral stroke (HR, 2.15; 95% CI, 1.13-4.07; P =.019), with postoperative reexploration associated less with death at 1 year (HR, 0.33; 95% CI, 0.15-0.77; P =.01). The 1-year freedom from ipsilateral neurologic events or death stratified by postoperative disability was 87.8% for none, 93.3% for not significant, 88.5% for moderate, and 77.9% for severe (P <.001). Multivariable analysis showed that severe disability was associated with subsequent ipsilateral neurologic events or death at 1 year (HR, 2.34; 95% CI, 1.25-4.4; P =.008) but moderate postoperative disability was not (HR, 0.2; 95% CI, 0.46-1.82; P =.8).
Conclusion(s): Most patients without preoperative disability who experienced a stroke after CEA had a significant disability. Severe disability was associated with higher 1-year mortality and subsequent neurologic events. These data can help aid in the informed consent process and expectations after a postoperative stroke.
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Objectives: Thoracic endovascular aortic repair (TEVAR) has been increasingly used to treat aortic dissection and aneurysms. Access-related complications remain a common source of morbidity and mortality following TEVAR. Therefore, this study aimed to determine the major risk factors predicting for access complications and the 5-year mortality for patients with access complications.
Method(s): We identified all patients undergoing TEVAR in the Vascular Quality Initiative from July 2010 to August 2021, excluding those who had required conversion to open repair. We defined access complication as postoperative occlusion, wound infection, hematoma, and unplanned conversion to open cut down. The primary outcome was 5-year mortality, and the secondary outcome was perioperative mortality. Mixed effects logistic regression modeling with physician-level clustering was used to identify the factors associated with access complications and perioperative mortality. Kaplan-Meier estimates and Cox proportional hazards models were used for the analysis of 5-year mortality.
Result(s): Overall, 16,588 cases were included, with access site complications in 1584 (9.5%). Bilateral percutaneous access was obtained in 68% of patients, one percutaneous and one open in 14%, and bilateral open access in 13%. The patients with access complications were older (age, 70 +/- 0.6 years vs 66 +/- 0.2 years; P <.01) and more likely to be women (50% vs 34%; P <.01). Patients with access complications experienced increased perioperative mortality (12% vs 4.6%; P <.01), major adverse cardiovascular events (17% vs 6.6%; P <.01), reintervention (22% vs 10%; P <.01), and spinal ischemia (7.0% vs 2.1%; P <.01). On adjusted analysis, the factors associated with access complication included female sex (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.9-2.9]; P <.01) and body mass index (OR, 0.84; 95% CI, 0.76-0.93; P <.01). The occurrence of an access complication was independently associated with perioperative mortality (OR, 2.1; 95% CI, 1.6-2.8; P <.01). Bilateral cut down was associated with decreased mortality for male patients (OR, 0.40; 95% CI, 0.24-0.68; P <.01) but not for female patients (OR, 2.3; 95% CI, 1.1-4.8; P =.02). Finally, access complications were associated with increased 5-year mortality (hazard ratio, 1.3; 95% CI, 1.1-1.5; P <.01; Fig).
Conclusion(s): Access complications, when unexpected, were associated with adverse perioperative and 5-year outcomes. Female sex was associated with increased rates of access complications, suggesting the need for devices tailored to the female anatomy. [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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