Faculty Bibliography

OBJECTIVE:Type II endoleaks (T2Es), often identified after endovascular aneurysm repair (EVAR), have been associated with late endograft failure and secondary rupture. The number and size of the patent aortic aneurysm sac outflow vessels (ie, the inferior mesenteric, lumbar, and accessory renal arteries) have been implicated as known risk factors for persistent T2Es. Given the technical challenges associated with post-EVAR embolization, prophylactic embolization of aortic aneurysm sac outflow vessels has been advocated to prevent T2Es; however, the evidence available at present is limited. We sought to examine the effects of concomitant prophylactic aortic aneurysm sac outflow vessel embolization in patients undergoing EVAR. METHODS:Patients aged ≥18 years included in the Society for Vascular Surgery Vascular Quality Initiative database who had undergone elective EVAR for intact aneurysms between January 2009 and November 2020 were included in the present study. Patients with a history of prior aortic repair and those without available follow-up data were excluded. The patient demographics, operative characteristics, and outcomes were analyzed by group: EVAR alone vs EVAR with prophylactic sac outflow vessel embolization (emboEVAR). The outcomes of interest were the in-hospital postoperative complication rates, incidence of aneurysmal sac regression (≥5 mm) and T2Es, and reintervention rates during follow-up. RESULTS:A total of 15,060 patients were included. Of these patients, 272 had undergone emboEVAR and 14,788 had undergone EVAR alone. No significant differences were found between the two groups in age, comorbidities, or anatomic characteristics, including the mean maximum preoperative aortic diameter (5.5 vs 5.6 cm; P = .48). emboEVAR was associated with significantly longer procedural times (148 vs 124 minutes; P < .0001), prolonged fluoroscopy times (32 vs 23 minutes; P < .0001), increased contrast use (105 vs 91 mL; P < .0001), without a significant reduction in T2Es at case completion (17.7% vs 16.3%; P = .54). The incidence of postoperative complications (3.7% vs 4.6%; P = .56), index hospitalization reintervention rates (0.7% vs 1.3%; P = .59), length of stay (1.8 vs 2 days; P = .75), and 30-day mortality (0% vs 0%; P = 1.00) were similar between the two groups. At mid-term follow-up (14.6 ± 6.2 months), the emboEVAR group had a significantly greater mean reduction in the maximum aortic diameter (0.69 vs 0.54 cm; P = .006), with a greater proportion experiencing sac regression of ≥5 mm (53.5% vs 48.7%). The reintervention rates were similar between the two groups. On multivariable analysis, prophylactic aortic aneurysm sac outflow vessel embolization (odds ratio, 1.34; 95% confidence interval, 1.04-1.74; P = .024) was a significant independent predictor of sac regression. CONCLUSIONS:Prophylactic sac outflow vessel embolization can be performed safely for patients with intact aortic aneurysms undergoing elective EVAR without significant associated perioperative morbidity or mortality. emboEVAR was associated with significant sac regression compared with EVAR alone at mid-term follow-up. Although no decrease was found in the incidence of T2Es, this technique shows promise, and future efforts should focus on identifying a subset of aneurysm and outflow branch characteristics that will benefit from concomitant selective vs complete prophylactic sac outflow vessel embolization.

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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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: 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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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: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: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.

OBJECTIVE:In 2014, in addition to male smokers aged 65-75 years, the U.S. Preventive Services Task Force (USPSTF) recommended abdominal aortic aneurysm (AAA) screening for male never-smokers aged 65-75 years with cardiovascular risk factors (Grade C). The USPSTF evolved from a negative to neutral position on screening for female smokers aged 65-75 years (Grade I). We sought to determine whether 2014 guidelines resulted in more AAA repairs in these populations. METHODS:We queried the Vascular Quality Initiative national database (2013-2018) for elective endovascular aortic repairs and open aortic repairs. We implemented difference-in-differences (DID) analysis, a causal inference technique that adjusts for secular time trends, to isolate changes in repair numbers due to the 2014 USPSTF guidelines. Our DID models compared changes in repair numbers in patient groups targeted by the USPSTF updates (intervention group) to those in unaffected, older patient groups (control), before and after 2014. The first model compared changes in repair numbers between male never-smokers aged 65-75 years (intervention group) and 76-85 years (control). The second model compared repair numbers between female smokers aged 65-75 years (intervention group) and 76-85 years (control). RESULTS:There was no significant change in male never-smokers (n = 1,295) aged 65-75 (42%) vs. 76-85 (58%) undergoing AAA repairs after guideline updates, averaged over 4.5 years (+2.4 percentage points; 95% Confidence Interval [CI] -.56-5.26). However, when their primary insurer was Medicare, male never-smokers aged 65-75 years compared with 76-85 years underwent significantly more repairs over 4.5 years (+3.69 percentage points; 95% CI.16-7.22; representing a 10.4% relative increase from baseline in the proportion of male never-smokers on Medicare undergoing AAA repair). Comparing female smokers (n = 2,312) aged 65-75 (54%) vs. 76-85 (46%), there was no significant change in repairs over 4.5 years (-.66 percentage points; 95% CI -4.57-3.26). CONCLUSIONS:The USPSTF 2014 AAA guidelines were associated with modestly increased repairs in male never-smokers aged 65-75 years only on Medicare. There was no impact among female smokers. Higher-grade recommendations and improved guideline adherence may be requisites for change.