Faculty Bibliography

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: Beta-blockers are first-line anti-impulse therapy for patients presenting with type B aortic dissection (TBAD); however, little is understood about their impact after aortic repair. The aim of this study was to evaluate the role of postoperative beta-blocker use on the outcomes of thoracic endovascular aortic repair (TEVAR) for TBAD.
Method(s): The Vascular Quality Initiative database was queried for all patients undergoing TEVAR for TBAD from 2012 to 2020. Aortic-related reintervention, all-cause mortality, and success of TEVAR measured by complete false lumen thrombosis of the treated aortic segment were assessed and compared between patients treated with and without beta-blocker use postoperatively. Cox proportional hazards models were used to estimate the effect of beta-blocker therapy on outcomes.
Result(s): A total of 1147 patients undergoing TEVAR for TBAD were identified, with a mean follow-up of 18 +/- 12 months (median, 14 months). The mean age was 61.3 +/- 11.8 years, and 791 (71%) were men. Of the 1147 patients, 935 (84%) continued beta-blocker therapy at discharge and follow-up. Patients receiving beta-blocker therapy were more likely to have an entry tear originating in zones 1 to 2 (22% vs 13%; P =.022). The prevalence of acute, elective, and symptomatic TBAD, concurrent aneurysms, number of endografts used, distribution of the proximal and distal zones of dissection, and operative time were comparable between the two groups. At 18 months, significantly more complete false lumen thrombosis (58.4% vs 47.4%; P =.018; Fig) was observed in the patients with beta-blocker use. However, the rates of aortic-related reintervention (12.8% vs 8.8%; log-rank P =.396) and mortality (0.7% vs 0.1%; log-rank P =.401) were similar in those with and without beta-blocker therapy. Even after adjusting for clinical and operative factors, continuous postoperative beta-blocker use was associated with increased complete false lumen thrombosis (hazard ratio, 1.56; 95% confidence interval, 1.10-2.21; P =.012) but did not affect all-cause mortality or aortic-related reintervention (Table). When analyzed separately, postoperative angiotensin-converting enzyme inhibitor use did not affect the rates of aortic-related reintervention, complete false lumen thrombosis, or mortality.
Conclusion(s): Beta-blocker use was associated with the promotion of complete false lumen in patients undergoing TEVAR for TBAD. In addition to its role in acute TBAD, anti-impulse control appears to confer favorable aortic remodeling after TEVAR. Beta-blocker therapy might improve the outcomes after TEVAR for TBAD. [Formula presented] [Formula presented]
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OBJECTIVE:Data on the efficacy of non-reversed and reversed great saphenous vein bypass (NRGSV and RGSV) techniques are lacking. The aim of the study was to compare the outcomes of patients undergoing open infrainguinal revascularisation using NRGSV and RGSV from a multi-institutional database. METHODS:The Vascular Quality Initiative database was queried for patients undergoing infrainguinal bypasses using NRGSV and RGSV for symptomatic occlusive disease from January 2003 to February 2021. The primary outcome measures included primary and secondary patency at discharge and one year. Secondary outcomes were re-interventions at discharge and one year. Cox proportional hazards models were used to evaluate the impact of graft configuration on outcomes of interest. RESULTS:Of 7 123 patients, 4 662 and 2 461 patients underwent RGSV and NRGSV, respectively. At one year, the rates of primary patency (78% vs. 78%; p = .83), secondary patency (90% vs. 89%; p = .26), and re-intervention (16% vs. 16%; p = .95) were similar between the RGSV and NRGSV cohorts, respectively. Subgroup analysis based on outflow bypass target and indication for revascularisation did not show differences in primary and secondary outcomes between the two groups. Multivariable analysis confirmed that RGSV (NRGSV as the reference) configuration was not independently associated with increased risk of primary patency loss (hazard ratio [HR] 1.01; 95% confidence interval [CI] 0.91 - 1.13; p = .80), secondary patency loss (HR 0.94; 95% CI 0.81 - 1.10; p = .44), and re-intervention (HR 1.03; 95% CI 0.91 - 1.16; p = .67) at follow up. CONCLUSION/CONCLUSIONS:The study shows that RGSV and NRGSV grafting techniques have comparable peri-operative and one year primary and secondary patency and re-intervention rates. This effect persisted when stratified by outflow targets and indication for revascularisation. Therefore, optimal selection of vein grafting technique should be guided by the patient's anatomy, vein conduit availability, and surgeon's experience.

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: 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: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.

Myocardial injury after non-cardiac surgery (MINS) is common. We investigated the incidence and outcomes of MINS, and mechanistic underpinnings using pre-operative whole blood gene expression profiling in a prospective cohort study of individuals undergoing lower extremity revascularization (LER) for peripheral artery disease (PAD). Major adverse cardiovascular and limb events (MACLE) were defined as a composite of death, myocardial infarction, stroke, major lower extremity amputation or reoperation. Among 226 participants undergoing LER, MINS occurred in 53 (23.5%). Patients with MINS had a greater incidence of major adverse cardiovascular events (49.1% vs. 22.0%, adjusted HR 1.87, 95% CI 1.07-3.26) and MACLE (67.9% vs. 44.5%; adjusted HR 1.66, 95% CI 1.08-2.55) at median 20-month follow-up. Pre-operative whole blood transcriptome profiling of a nested matched MINS case-control cohort (n = 41) identified upregulation of pathways related to platelet alpha granules and coagulation in patients who subsequently developed MINS. Thrombospondin 1 (THBS1) mRNA expression was 60% higher at baseline in patients who later developed MINS, and was independently associated with long-term cardiovascular events in the Duke Catheterization Genetics biorepository cohort. In conclusion, pre-operative THBS1 mRNA expression is higher in patients who subsequently develop MINS and is associated with incident cardiovascular events. Pathways related to platelet activity and coagulation associated with MINS provide novel insights into mechanisms of myocardial injury.

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.

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.