Faculty Bibliography

OBJECTIVE:Contemporary commercially available endovascular devices for the treatment of abdominal aortic aneurysm (AAA) include standard endovascular aortic repair (sEVAR) or fenestrated EVAR (fEVAR) endografts. However, aortic neck dilatation (AND) can occur in nearly 25% of patients following EVAR, resulting in loss of proximal seal with risk of aortic rupture. AND has not been well characterized in fEVAR, and direct comparisons studying AND between fEVAR and sEVAR have not been performed. This study aims to analyze AND in the infrarenal and suprarenal aortic segments, including seal zone, and quantify sac regression following fEVAR implantation compared to sEVAR. METHOD/METHODS:A retrospective review of prospectively collected data on 20 consecutive fEVAR patients (Cook Zenith® Fenestrated) and 20 sEVAR (Cook Zenith®) patients was performed. Demographic data, anatomic characteristics, procedural details, and clinical outcome were analyzed. Pre-operative, post-operative (1 month), and longest follow-up CT scan at an average of 29.3 months for fEVAR and 29.8 months for sEVAR were analyzed using a dedicated 3D workstation (iNtuition, TeraRecon Inc, Foster City, California). Abdominal aortic aneurysm neck diameter was measured in 5 mm increments, ranging from 20 mm above to 20 mm below the lowest renal artery. Sub-analysis comparing the fEVAR to the sEVAR group at 12 months and at greater than 30 months was performed. Standard statistical analysis was done. RESULTS:Demographic characteristics did not differ significantly between the two cohorts. The fEVAR group had a larger mean aortic diameter at the lowest renal artery, shorter infrarenal aortic neck length, increased prevalence of nonparallel neck shape, and longer AAA length. On follow-up imaging, the suprarenal aortic segment dilated significantly more at all locations in the fEVAR cohort, whereas the infrarenal aortic neck segment dilated significantly less compared to the sEVAR group. Compared to the sEVAR cohort, the fEVAR patients demonstrated significantly greater positive sac remodeling as evident by more sac diameter regression, and elongation of distance measured from the celiac axis to the most cephalad margin of the sac. Device migration, endoleak occurrence, re-intervention rate, and mortalities were similar in both groups. CONCLUSION/CONCLUSIONS:Compared to sEVAR, patients undergoing fEVAR had greater extent of suprarenal AND, consistent with a more diseased native proximal aorta. However, the infrarenal neck, which is shorter and also more diseased in fEVAR patients, appears more stable in the post-operative period as compared to sEVAR. Moreover, the fEVAR cohort had significantly greater sac shrinkage and improved aortic remodeling. The suprarenal seal zone in fEVAR may result in a previously undescribed increased level of protection against infrarenal neck dilatation. We hypothesize that the resultant decreased endotension conferred by better seal zone may be responsible for a more dramatic sac shrinkage in fEVAR.

Arteriovenous fistula is a rare and often unrecognized complication of aneurysms, with a varied and frequently inconsistent presentation. We present the case of an ilio-iliac arteriovenous fistula formation in a 71-year-old man associated with a type III endoleak after endovascular iliac branch repair. Because of rapidly progressing congestive heart failure and hepatorenal syndrome, we performed urgent endovascular repair with successful endoleak exclusion. After the procedure, the patient demonstrated a remarkably rapid and complete recovery.

OBJECTIVE:There is a lack of evidence regarding the effect of anticoagulation and antiplatelet medications on aortic remodeling for aortic dissection after endovascular repair. We investigated whether anticoagulation and antiplatelet medications affect aortic remodeling after thoracic endovascular aortic repair (TEVAR) for Type B aortic dissection (TBAD). METHODS:Records of the Vascular Quality Initiative TEVAR registry (2012-2020) were reviewed. Procedures performed for TBAD were included. Aortic reintervention, false lumen thrombosis of the treated aorta and all-cause mortality at follow-up were compared between patients treated with and without anticoagulation medications. A secondary analysis was performed to assess the effect of antiplatelet therapy in patients not on anticoagulation. Cox proportional hazards models were used to estimate the effect of anticoagulation and antiplatelet therapies on outcomes. RESULTS:1,210 patients (mean age, 60.7±12.2 years; 825 (68%) males) were identified with a mean follow-up of 21.2±15.7 months (range 1-94 months). 166 (14%) patients were on anticoagulation medications at discharge and at follow-up. Patients on anticoagulation were more likely to be older (mean age, 65.5 vs 60 years; P<.001) and Caucasian (69% vs 55%; P=.003), with higher proportions of coronary artery disease (10% vs 3%; P<.001), congestive heart failure (10% vs 2%; P<.001) and chronic obstructive pulmonary disease (15% vs 9%; P=.017). There were no differences in the mean preoperative thoracic aortic diameter or the number of endografts used. At 18-month, the rates of aortic reinterventions (8% vs 9% log-rank P=.873), complete false lumen thrombosis (52% vs 45%; P=.175) and mortality (2.5% vs 2.7%; P=.209) were similar in patients with and without anticoagulation, respectively. Controlling for covariates with the Cox regression method, anticoagulation use was not independently associated with a decreased rates of complete false lumen thrombosis (hazard ratio (HR) 0.74; 95% confidence interval (CI), 0.5-1.1; P=.132), increased need for aortic reinterventions (HR 1.02; 95% CI, 0.62-1.68; P=.934), and mortality (HR 1.25; 95% CI, 0.64-2.47; P=.514). On a secondary analysis, antiplatelet medications did not affect the rates of aortic reintervention, complete false lumen thrombosis and mortality. CONCLUSIONS:Anticoagulation and antiplatelet medications do not appear to negatively influence the midterm endpoints of aortic reintervention or death in patients undergoing TEVAR for TBAD. Moreover, it did not impair complete false lumen thrombosis. Anticoagulation and antiplatelet medications do not adversely affect aortic remodeling and survival in this population at midterm.

OBJECTIVES/OBJECTIVE:Presence of an endoleak can compromise aneurysm exclusion after endovascular abdominal aortic aneurysm repair(EVAR). Type II endoleaks(T2Es) are most common and may cause sac expansion. We report outcomes of translumbar embolization(TLE) of T2Es following EVAR. METHODS:We conducted a retrospective chart review of patients with T2E after EVAR treated with TLE from 2011-2018 at a single academic institution. Treatment indications were the presence of persistent T2E and aneurysm growth ≥5mm. Sac stabilization was defined as growth ≤5mm throughout the follow-up period. RESULTS:Thirty consecutive patients were identified. The majority were men (n=24) with a mean age of 74.3 years (70.9-77.6, 95% CI). The most common comorbidities were hypertension (83.3%) and coronary artery disease (54.0%). The mean maximal sac diameter at T2E discovery was 5.8 cm (5.4-6.2, 95% CI). The mean time to intervention from endoleak discovery was 33.7±28 months with a mean growth of 0.84 cm (0.48-1.2, 95% CI) during that time period. The mean follow-up time after TLE was 19.1 months (11.1-27.2, 95% CI). Twenty-eight patients were treated with cyanoacrylate glue(CyG) alone, and 2 were treated with CyG plus coil embolization(CE). There was immediate complete endoleak resolution as assessed intraoperatively, and sac stabilization in 15 cases (50.0%). Eleven (36.7%) patients had evidence of persistent T2E on initial imaging after the embolization procedure; additional follow-up revealed eventual sac stabilization at a mean of 21.3±7.2 months and therefore these patients did not require further intervention. In the remaining four cases (13.3%) there was persistent T2E after the initial TLE requiring a second intervention. Repeat TLE stabilized growth in three of these four patients after a mean of 17.6±12.9 months. One patient required open sacotomy and ligation of lumbar vessels due to continued persistence of the T2E and continued aneurysm growth. There were no ischemic complications related to the embolization procedures. Factors associated with persistent endoleak after initial embolization were: larger aneurysm diameter at the time of initial endoleak identification (p<0.001), and the use of antiplatelet agents (p<0.02). The use of anticoagulation was not a significant risk factor for endoleak recurrence or aneurysm growth after TLE. CONCLUSIONS:TLE of T2E is a safe and effective treatment option for T2E with aneurysm growth following EVAR. Patients taking antiplatelet medication and those with larger aneurysms at the time of endoleak identification appear to be at increased risk for persistent endoleak and need for subsequent procedures following initial TLE. These patients may require more intensive monitoring and follow-up.

OBJECTIVE:Over the past two decades, the treatment of popliteal artery aneurysms (PAAs) has undergone a transformation. While open surgical repair (OR) remains the gold standard for treatment, endovascular repair (ER) has become an attractive alternative in select patient populations. The objective of this study was to compare the outcomes of open versus endovascular repair of PAAs at a single institution. METHODS:We performed a retrospective chart review of all patients between 1998 and 2017 who underwent repair for PAA. Patient baseline, anatomic, and operative characteristics as well as outcomes were compared between the open and endovascular cohorts. The intervention and treatment were at the discretion of the surgeon. RESULTS:Between 1998 and 2017, a total of 64 patients underwent repair of 73 PAAs at our tertiary care center. Twenty-nine patients with 33 PAAs underwent OR, and 35 patients with 40 PAAs underwent ER. When comparing the 2 cohorts, there were no statistically significant differences in demographic characteristics such as age, gender, or number of run-off vessels. There were significantly more patients in the ER group (21/53%) than the OR group (7/21%) with hyperlipidemia (p=.008) and a prior carotid intervention (6% vs. 0%, p=.029). Overall, the presence of symptoms was similar amongst the two groups; however, patients in the OR group had a significantly higher number of patients presenting with acute ischemia (p=.01). Length of stay (LOS) was significantly shorter in the ER cohort (mean 1.8 days [1-11]) compared to the OR group (5.4 days [2-13]) (p<.0001). There was no significant difference in primary or secondary patency rates between the two groups. In the ER group, good runoff (≥2 vessels) was a positive predictor for primary patency at 1 year (3.36 [1.0-11.25]), however, it was not in the OR group. Post-operative single and/or dual anti-platelet therapy did not affect primary patency in either cohort. CONCLUSIONS:The results of our study demonstrate that ER of PAAs is a safe and durable option with comparable patency rates to OR and a decreased LOS, with good run-off being a positive predictor for primary patency in the ER cohort.

Objective: Autogenous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration has remained a source of debate. We compared the outcomes of patients who had undergone LEB using in situ and reversed configuration.
Method(s): The Vascular Quality Initiative database (January 2003 to February 2021) was queried for patients undergoing LEB with in situ and reversed GSV. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary endpoint was primary patency. The second endpoints included freedom from major adverse limb events (MALE; defined as major lower extremity amputation and reintervention), limb salvage, and freedom from reintervention at 1 year. Multivariable models were created to determine the association between bypass configuration and outcomes of interest.
Result(s): Of the 8234 patients who had undergone LEB, in situ and reversed GSV was used in 3546 and 4688 patients, respectively. Patients with in situ bypass were older with higher rates of cardiopulmonary and renal comorbidities. The patients who had undergone reversed bypass were more likely to have undergone previous LEBs and endovascular interventions. The indication for LEB was similar between the in situ and reversed bypass cohorts. In situ bypass had been performed more frequently from the common femoral artery and to more distal targets (tibial or peroneal). Reversed bypass was associated with higher intraoperative blood loss and a longer operative time. Perioperatively, in situ bypass had resulted in greater rates of reintervention (13.2% vs 11.1%; P =.004) and surgical site infection (4.2% vs 3%; P =.003) and lower primary patency (93.5% vs 95%; P =.004). At 1 year, in situ bypass had a lower rate of MALE (22.6% vs 25.6), mainly driven by a lower rate of reintervention (19.4% vs 21.6%). The primary patency and limb salvage rates were not different. On multivariable analysis, in situ bypass was associated with lower primary patency loss (hazard ratio [HR], 0.9; 95% confidence interval [CI], 0.82-0.98), reintervention (HR, 0.88; 95% CI, 0.8-0.97), and MALE (HR, 0.89; 95% CI, 0.81-0.97) but did not affect the rate of limb salvage compared with reversed bypass.
Conclusion(s): Compared with those with reversed GSV, LEBs with in situ GSV confer improved primary patency and MALE at midterm. Our results have demonstrated that an in situ configuration might be a favorable option for appropriately selected patients with suitable anatomy.
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BACKGROUND:With the exponential increase in the use of endovascular techniques in the treatment of peripheral artery disease, our understanding of factors that affect intervention failures continues to grow. We sought to assess the outcomes of percutaneous transluminal angioplasty for isolated de novo superficial femoral artery (SFA) disease based on balloon diameter. METHODS:The Vascular Quality Initiative database was queried for patients undergoing percutaneous balloon angioplasty for isolated de novo atherosclerotic SFA disease. Based on the diameter of the angioplasty balloon as a surrogate measure of arterial diameter, patients were stratified into two groups: group 1, balloon diameter < 5 mm (354 patients) and group 2, balloon diameter ≥ 5 mm (1,550 patients). The primary patency and major adverse limb event (MALE) were estimated by the Kaplan-Meier method and compared with the log-rank test, based on vessel diameter. multivariable Cox regression analysis was used to determine factors associated with the primary patency. RESULTS:From January 2010 through December 2018, a total of 1,904 patients met criteria for analysis, with a mean follow-up of 13.3 ± 4.5 months. The mean balloon diameters were 3.92 ± 0.26 mm and 5.47 ± 0.55 mm in group 1 and 2, respectively (P<.001). The mean length of treatment and distribution of TASC lesions were not statistically different between the groups. Primary patency at 18 months was significantly lower in group 1, compared with group 2 (55% vs 67%; log-rank P<.001). The MALE rate was higher in group 1 than group 2 (33% vs 26%; log-rank P<.001). Among patients with claudication, there was no significant difference in the primary patency (61% vs 68%; log-rank P=.073) and MALE (27% vs 22%; log-rank P=.176) at 18 months between groups 1 and 2, respectively. However, in patients with CLTI, group 1 had significantly lower 18-month primary patency (47% vs 64%; log-rank P<.014) and higher MALE rates (41% vs 35%; log-rank P=.012) than group 2. Cox proportional hazard analysis confirmed that balloon diameter < 5 mm was independently associated with increased risks of primary patency loss (HR 1.35; 95% CI, 1.04-1.72; P=.021) and MALE (HR 1.29; 95% CI, 1-1.67; P=.048) at 18-months. CONCLUSIONS:In patients undergoing isolated SFA balloon angioplasty for CLTI, smaller SFA (< 5mm) was associated with worse primary patency and MALE. Using balloon size as a surrogate, our findings suggest that patients with a smaller SFA diameter appear to be at increased risk for treatment failure and warrant closer surveillance. Furthermore, these patients may also be considered for alternative approaches, including open revascularization.

OBJECTIVE:Adjunctive false lumen embolization (FLE) with thoracic endovascular aortic repair (TEVAR) in patients with chronic aortic dissection is thought to induce FL thrombosis and favorable aortic remodeling. However, these data are derived from small single-institution experiences and the potential benefit of FLE remains unproven. In this study, we examined perioperative and midterm outcomes of patients with aortic dissection undergoing concomitant TEVAR and FLE.* METHODS: Patients 18 or older who underwent TEVAR for chronic aortic dissection with known FLE status in the Society for Vascular Surgery Vascular Quality Initiative database between January 2010 and February 2020 were included. Ruptured patients and emergent procedures were excluded. Patient characteristics, operative details and outcomes were analyzed by group: TEVAR with or without FLE. Primary outcomes were in-hospital post-operative complications and all-cause mortality. Secondary outcomes included follow-up mean maximum aortic diameter change, rates of false lumen thrombosis, re-intervention rates, and mortality. RESULTS:884 patients were included: 46 had TEVAR/FLE and 838 had TEVAR alone. There was no significant difference between groups in terms of age, gender, comorbidities, prior aortic interventions, mean maximum pre-operative aortic diameter (5.1cm vs. 5.0cm, P=0.43), presentation symptomatology, or intervention indication. FLE was associated with significantly longer procedural times (178min vs. 146min, P=0.0002), increased contrast use (134mL vs. 113mL, P=0.02), and prolonged fluoroscopy time (34min vs. 21min, P<0.0001). However, FLE was not associated with a significant difference in post-operative complications (17.4% vs. 13.8%, P=0.51), length of stay (6.5 vs. 5.7 days, P=0.18), or in-hospital all-cause mortality (0% vs. 1.3%, P=1). In mid-term follow-up (median 15.5months, IQR 2.2-36.2 months), all-cause mortality trended lower, but was not significant (2.2% vs. 7.8%); and Kaplan-Meier analysis demonstrated no difference in overall survival between groups (P=0.23). By Cox regression analysis, post-operative complications had the strongest independent association with all-cause mortality (HR 2.65, 95% CI 1.56-4.5, P<0.001). In patients with available follow-up imaging and re-intervention status, mean aortic diameter change (n=337, -0.71cm vs. -0.69cm, P=0.64) and re-intervention rates (n=487, 10% vs. 11.4%, P=1) were similar. CONCLUSIONS:Adjunctive FLE, despite increased procedural times, can be performed safely for patients with chronic dissection without significantly higher overall perioperative morbidity or mortality. TEVAR/FLE demonstrates trends for improved survival and increased rates of FL thrombosis in the treated thoracic segment; however, given the lack of evidence to suggest a significant reduction in re-intervention rates or induction of more favorable aortic remodeling compared to TEVAR alone, the overall utility of this technique in practice remains unclear. Further investigation is needed to determine the most appropriate role for FLE in managing chronic aortic dissections.

Objectives: In patients with carotid stenosis, both the severity of the stenosis as well as the plaque morphology influence the likelihood of future transient ischemic attack or stroke. In general, severely stenotic lesions are presumed to have a higher embolic potential than moderately stenotic lesions. Carotid intervention is indicated in patients with both moderate and severe stenosis with related cerebrovascular symptoms. However, the effect of the degree of carotid stenosis in symptomatic patients upon the outcome of carotid intervention has not been extensively studied.
Method(s): The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing transfemoral carotid stenting (CAS), carotid endarterectomy (CEA), and transcervical carotid stenting (TCAR) between 2003 and 2020. Patients undergoing interventions for symptomatic disease were included in the analysis. Patients were stratified into two cohorts based on the severity of stenosis-moderate (0%-69%) and severe (greater than or equal to 70%). Primary endpoints were perioperative neurologic events (strokes and transient ischemic attacks [TIAs]). Secondary endpoints were perioperative mortality and postoperative complications.
Result(s): Over 50,000 patients were included in the analysis: 5296 patients (8.9%) underwent TCAR, 7844 (13.3%) underwent CAS, and 45,853 (77.8%) underwent CEA for symptomatic carotid artery disease. In the TCAR and CEA cohorts, patients with moderate stenosis had a significantly higher rate of perioperative neurologic events than patients with severe stenosis (TCAR 4.3% vs 3.0%; P =.033; CEA 3.0% vs 2.3%; P <.001). In contrast, in patients undergoing CAS, there was no significant difference noted in the perioperative neurologic event rate (3.5% in moderate stenosis group vs 3.8% in severe stenosis group; P =.518). There were no differences in perioperative myocardial infarction or mortality (Table). On multivariable analysis, moderate stenosis was significantly and independently associated with an increased rate of neurologic events in the TCAR (odds ratio [OR], 0.833; 95% confidence interval, 0.693-1.000; P =.05), and CEA (odds ratio, 0.901; 95% confidence interval, 0.861-0.944; P <.001) cohorts.
Conclusion(s): Moderate carotid stenosis was associated with increased perioperative neurologic events in patients undergoing TCAR and CEA, but not CAS. Therefore, this effect was noted only in the cohorts that require direct open surgical manipulation of the cervical carotid artery (TCAR and CEA). Moderately stenotic lesions that become symptomatic likely have worse intrinsic plaque morphology than severely stenotic lesions, producing cerebrovascular symptoms at a lower degree of stenosis. The mechanism of such events warrants further evaluation with a particular focus on plaque morphology and brain physiology. [Formula presented]
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Objective: Data regarding the effect of bilateral internal iliac artery (IIA) occlusion during endovascular abdominal aortic aneurysm repair (EVAR) are conflicting, with reported varied risks of pelvic and gastrointestinal ischemia. The aim of our study was to report the perioperative and long-term outcomes of IIA occlusion with origin graft coverage in patients undergoing elective EVAR.
Method(s): Using the Vascular Quality Initiative database (2010-2020), we retrospectively identified patients who had undergone EVAR for infrarenal abdominal aortic aneurysms and aortoiliac aneurysms with or without IIA occlusion by graft coverage or coils. The patients were stratified into three groups according to IIA occlusion status (none, unilateral, bilateral). The baseline characteristics, procedural details, in-hospital outcomes, and overall survival at 5 years were reviewed. The primary outcomes were in-hospital mortality and complications. The secondary outcomes included 5-year mortality. Cox proportional hazards models were used to determine the predictive factors of perioperative and 2-year mortality.
Result(s): A total of 26,690 patients were identified (mean age, 73.5 years; 82% male) who had undergone elective EVAR with bifurcated endografts. Of the 26,690 patients, 2195 (8.2%) had undergone adjunctive unilateral IIA origin graft occlusion, 523 (2%) had undergone bilateral IIA origin graft occlusion, and 23,970 (89.8%) had not undergone any IIA graft occlusion. Perioperatively, no statistically significant differences were found in the incidence of death (0.4% vs 0.6% vs 0.4%; P =.2), gastrointestinal ischemia (0.1% vs 0.1% vs 0.2%; P =.888), unplanned reoperation (1.5% vs 1.8% vs 2.3%; P =.181), or cardiopulmonary complications (2.5% vs 2.8% vs 3.4%; P =.247) among those with no, unilateral, and bilateral IIA origin graft occlusion, respectively (Table). The Kaplan-Meier estimate demonstrated comparable overall survival at 5 years (none, 86.7%; unilateral, 85.2%; bilateral, 89.4%; P =.133; Fig). On multivariable analysis, the status of IIA origin graft coverage was not associated with increased perioperative mortality or complications.
Conclusion(s): EVAR with bilateral IIA interruption was associated with favorable perioperative outcomes with a low rate of major complications. At the time of EVAR, unilateral and bilateral IIA occlusion with a stent-graft did not appear to confer additional risks of perioperative complications and mortality. Our results showed the safety of bilateral IIA interruption in patients undergoing elective EVAR for abdominal aortic aneurysms and aortoiliac aneurysms. [Formula presented] [Formula presented]
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