Faculty Bibliography

OBJECTIVE:The objective of this study was to examine the effect of corona virus 2019 (COVID-19) vaccination on perioperative outcomes after major vascular surgery. BACKGROUND DATA/BACKGROUND:COVID-19 vaccination is associated with decreased mortality in patients undergoing various surgical procedures. However, the effect of vaccination on perioperative mortality after major vascular surgery is unknown. METHODS:This is a multicenter retrospective study of patients who underwent major vascular surgery between December 2021 through August 2023. The primary outcome was all-cause mortality within 30 days of index operation or prior to hospital discharge. Multivariable models were used to examine the association between vaccination status and the primary outcome. RESULTS:Of the total 85,424 patients included, 19161 (22.4%) were unvaccinated. Unvaccinated patients were younger compared to vaccinated patients (mean age 68.44 +/- 10.37 y vs 72.11 +/- 9.20 y, P <0.001) and less likely to have comorbid conditions, including hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dialysis. After risk factor adjustment, vaccination was associated with decreased mortality (OR 0.7, 95% CI 0.62 - 0.81, P <0.0001). Stratification by procedure type demonstrated that vaccinated patients had decreased odds of mortality after open AAA (OR 0.6, 95% CI 0.42-0.97, P =0.03), EVAR (OR 0.6, 95% CI 0.43-0.83, p 0.002), CAS (OR 0.7, 95% CI 0.51-0.88, P =0.004) and infra-inguinal lower extremity bypass (OR 0.7, 95% CI 0.48-0.96, P =0.03). CONCLUSIONS:COVID-19 vaccination is associated with reduced perioperative mortality in patients undergoing vascular surgery. This association is most pronounced for patients undergoing aortic aneurysm repair, carotid stenting and infrainguinal bypass.

OBJECTIVES/OBJECTIVE:In April 2022, the Society for Vascular Surgery (SVS) published the Appropriate Use Criteria (AUC) for the management of intermittent claudication (IC). Our goal was to compare practice patterns before and after publication of the AUC to identify changes. METHODS:The Vascular Quality Initiative (VQI) peripheral vascular intervention (PVI), and suprainguinal, and infrainguinal bypass registries were analyzed for interventions for IC. Relevant patient and intervention characteristics pre-AUC (2018-2019) and post-AUC (May 2022-December 2023) were compared. Key points of the AUC that are analyzable from the VQI include claudication severity, use of optimal medical therapy (OMT), smoking status, high-risk comorbid conditions (as indicators of operative risk), operative management of complex aortoiliac and femoropopliteal disease (TASC II C/D), common femoral artery (CFA) PVIs, and infrapopliteal procedures. RESULTS:There were 15,892 PVI, 2352 suprainguinal bypass, and 3480 infrainguinal bypass procedures analyzed. Changes consistent with the appropriateness ratings for PVI included more interventions for severe symptoms (72% vs 66.6%, P<.001), improvement in post-operative OMT (83% vs 79.7%, P<.001), fewer patients on dialysis undergoing PVI (2% vs 2.7%, P<.002), and less interventions on complex (TASC II C/D) aortoiliac (6.3% vs 9.5%, P<.001) and femoropopliteal (4.5% vs 5.8%, P <.001) anatomy. No changes were seen in the rates of pre-operative smoking and pre-operative OMT use, interventions on octogenarians, or in the use of extra-anatomic suprainguinal bypass, infrapopliteal bypass, or prosthetic conduit. Inconsistent with appropriateness ratings were more patients with congestive heart failure (15.1% vs 12.8%, P<.001) undergoing PVIs, and more PVIs for CFA (5.2% vs 3.4%, P<.001) and isolated infrapopliteal disease (5.7% vs 3.5%, P<.001). CONCLUSION/CONCLUSIONS:Since the publication of the AUC, there have been improvements with better OMT on discharge, fewer patients with ESRD undergoing interventions, and less endovascular treatment of complex disease. However, further work is needed to improve pre-operative medical optimization in patients with IC undergoing an invasive intervention and decrease the use of endovascular interventions for CFA and infrapopliteal disease, extra-anatomic aortoiliac revascularizations, and prosthetic conduit use.

OBJECTIVE:This study compared outcomes in patients with and without preoperative stress testing undergoing carotid revascularization including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid revascularization (TCAR). METHODS:Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network (VQI VISION) database who underwent elective carotid revascularization 2016-2020 were included. Patients were analyzed by group based upon whether they underwent cardiac stress testing within two years preceding revascularization without subsequent coronary intervention. Subset analysis was performed comparing outcomes between those with negative and positive results (evidence of ischemia or MI). Outcomes of interest were postoperative MI/neurologic events, 90-day re-admission rates, as well as long-term mortality. RESULTS:We analyzed 18,364 patients (78.8% CEA, 9.3% TF-CAS, 11.9% TCAR). Of these, 35.8% underwent preoperative stress testing (37.4% of CEA patients, 27.5% of TF-CAS patients, and 31.9% of TCAR patients). While comorbidities were significantly higher amongst patients undergoing CEA with preoperative stress test compared to those without stress testing, the overall prevalence of co-morbidities was higher amongst patients undergoing TF-CAS or TCAR irrespective of preoperative stress test status. Compared to patients with a negative stress test, patients with positive stress test undergoing any form of carotid revascularization had a significant increase in 90-day re-admission rates (CEA 19.6% vs 15.8%, p=0.003; CAS 33.3% vs. 18.6%, p<0.001; TCAR 25% vs. 17.5%, p=0.04). No group demonstrated a difference in the incidence of in-hospital postoperative neurologic events or CHF, but those undergoing CEA (but not CAS or TCAR) experienced a significant increase in-hospital post-operative MI (1.7% vs 0.6%, p<0.001). In 3-year follow-up, those with a positive compared to negative stress test were more likely to undergo CABG/PCI in the CEA (adjusted HR 1.87 [1.42-2.27], p<0.0001) and CAS groups (adjusted HR 3.89 [1.77-8.57], p<0.01), but not the TCAR cohort. Notably those undergoing CEA with a positive compared to negative stress test, but not CAS or TCAR, exhibited a 28% increase in mortality (adjusted HR 1.28 [1.03-1.58], p=0.03) at 3 years. Conversely, those patients with a negative stress test compared to no stress test undergoing CEA experienced a 14% reduction in mortality at 3 years (adjusted HR 0.86 [0.76-0.98], p=0.02); this mortality difference was not observed in similar stress test cohort undergoing TF-CAS or TCAR. CONCLUSIONS:Our study highlights that a positive stress test in appropriately selected, asymptomatic patients undergoing elective carotid revascularization can predict select perioperative and long-term cardiovascular outcomes. However, given the high follow-up mortality associated with those undergoing CEA for elective carotid revascularization, our findings call into question whether these patients should be preferentially offered optimal medical management and/or stenting.

OBJECTIVE:The objective of this study was to characterize the natural history of incidentally identified asymptomatic mesenteric artery stenosis and to identify clinical and radiographic predictors that differentiate patients with asymptomatic mesenteric artery occlusive disease (MAOD) and patients with symptomatic chronic mesenteric ischemia (CMI) diagnosed at index study. METHODS:This single-institution retrospective analysis included patients diagnosed with >70% stenosis of the celiac or superior mesenteric artery (SMA) on axial imaging or duplex ultrasound in an institutional radiology database. Patients were grouped into asymptomatic MAOD and symptomatic CMI cohorts according to their clinical presentation at index study. The primary endpoint was progression of disease from asymptomatic stenosis to CMI. Demographic, clinical, and imaging features at index study were also compared between asymptomatic and symptomatic cohorts. RESULTS:79 patients met the inclusion criteria, with 43 in the asymptomatic group and 36 in the symptomatic group. Patients in the asymptomatic group were followed for mean 32.7 ± 30.2 months; 60.5% (n=26) were referred to and followed by a vascular surgeon for 21.5 ± 27.8 months. No asymptomatic patients developed symptoms during the follow-up period. All patients in the symptomatic group were evaluated by a vascular surgeon and underwent procedural intervention for CMI within six months of diagnosis. Patients with CMI were more likely to have a history of smoking (p=0.02) and less likely to be anticoagulated (p<0.01) than patients with asymptomatic MAOD. Symptomatic patients trended towards a higher prevalence of coronary artery disease (p=0.06) and a lower prevalence of arrhythmia (p=0.08). On imaging, the symptomatic cohort was more likely to have severe SMA stenosis (p<0.001), multivessel mesenteric disease (p=0.001), calcified aortic plaque (p=0.01), and severe stenosis in one or both internal iliac arteries (p<0.001). On multivariable analysis, a lack of anticoagulation use (p<0.01) and severe SMA stenosis (p<0.001) were independently associated with higher odds of symptomatic mesenteric stenosis. While statistically insignificant, calcified aortic plaque (p=0.08) and smoking history (p=0.06) trended toward higher odds of symptomatic index presentation. CONCLUSIONS:The rate of progression from asymptomatic MAOD to CMI appears exceedingly low in the first two to three years after diagnosis, suggesting that prophylactic revascularization is mostly unnecessary. Surveillance of asymptomatic MAOD may be personalized based on clinical and radiographic features of disease. SMA stenosis severity, anticoagulation use, and possibly smoking history and the presence of aortic plaque calcification may be promising markers to stratify the risk of ischemic progression.

OBJECTIVES/OBJECTIVE:The Best Endovascular versus Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial found that in patients with an adequate (≥ 3.0 mm) single-segment great saphenous vein (GSV), surgical bypass resulted in superior outcomes when compared to endovascular intervention. Thus, the prevalence of an adequate GSV is an essential factor in planning appropriate intervention for patients with chronic limb-threatening ischemia (CLTI). However, the percentage of patients with an adequate GSV remains unknown. The objective of this study was to report the prevalence of an adequate GSV in patients with CLTI. METHODS:This was a single-center retrospective analysis of patients with CLTI, defined as an ankle-brachial index (ABI) ≤ 0.60 with appropriate symptoms (ie, rest pain, arterial ulceration), who underwent bilateral sonographic GSV mapping from May 2023 to November 2023. Ipsilateral GSV was defined as the symptomatic limb with the lowest recorded ABI. GSV diameter measurements were collected in seven locations from the saphenofemoral junction (SFJ) to the distal calf. To be considered an adequate GSV, all unilateral GSV diameter measurements from the SFJ to the mid-calf must have been at least 3.0 mm. Patients who underwent previous lower extremity bypass procedures were excluded. RESULTS:Seventy patients with CLTI were identified during the study period. Only 11.4 % (8/70) of patients had a completely adequate ipsilateral GSV; if the contralateral vein was also included, rates of GSV adequacy increased to 14.3% (10/70). There were no differences in demographics between patients who had adequate GSV and those who did not. Seven patients (10%) were missing an ipsilateral GSV due to a previous coronary bypass, and one patient (1.4%) had superficial venous thrombosis in their GSV. Patients with an inadequate ipsilateral GSV were less likely to have an adequate contralateral GSV (4.8% vs. 50.0%, p<0.001). The rates of GSV diameter ≥ 3 mm decreased as measurements were recorded more distally: 80% of GSVs were adequate at the level of the SFJ, 21% were adequate at the proximal-calf level, and only 9% were adequate at the distal-calf level. CONCLUSIONS:The majority of patients presenting with CLTI at our institution did not have a sonographically adequate ipsilateral nor contralateral GSV available for surgical bypass to the infrageniculate popliteal or tibial arteries. The rates of GSV diameter ≥ 3 mm in the calf were extremely low overall. Despite the improved outcomes in surgical bypass patients demonstrated in BEST-CLI, endovascular intervention will likely remain frequently utilized due to the low prevalence of an adequate GSV.

OBJECTIVE:Juxtarenal aortic aneurysms present a challenge for endovascular treatment. While renal dysfunction following open repair has been associated with lower short-term survival, the relationship between postoperative kidney function and midterm outcomes such as rupture, reintervention, and mortality remains unclear. This study investigates the association between postoperative renal function and these outcomes. METHODS:We conducted a retrospective cohort study using data from the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) linked to Medicare claims through the Vascular Implant Surveillance and Interventional Outcomes Network (VISION). Patients who underwent elective open repair for juxtarenal aortic aneurysms between January 2003 and December 2018 (N=1925) were included. Patients were stratified based on postoperative renal function: stable renal function; acute kidney injury (AKI), as defined by ≥0.5 mg/dL increase in baseline serum creatinine level; or need for renal replacement therapy (RRT). Primary outcomes included 5-year mortality, rupture, and reintervention, and secondary outcomes were immediate postoperative complications. Multivariable logistic regression, Kaplan-Meier analysis, and Cox regression modeling were used. RESULTS:Among the 1925 patients, 74% had stable postoperative renal function, 21% developed AKI, and 4.9% required RRT. Worse renal outcomes were associated with longer renal ischemia times, higher proximal aortic clamping, and renal artery bypass. Postoperative, 30-day mortality was highest in the RRT group, along with higher rates of cardiac, respiratory, and intestinal ischemic complications (P<.001). Patients requiring RRT had higher risks of subsequent aortic aneurysm-related reintervention (aHR 2.4 [1.1-5.1], P=.03) and midterm (1-,3-,and 5-year follow up) mortality (aHR 2.2 [2.1-5.1], P<.001) compared to those with stable renal function. Patients with AKI also had higher midterm mortality (aHR 1.5 [1.1-2.0], P=.01). No significant differences in aneurysm rupture were observed between groups. CONCLUSION/CONCLUSIONS:Postoperative patients who required RRT were associated with increased midterm aortic reinterventions and mortality after open juxtarenal aneurysm repair. Patients demonstrating any degree of renal impairment were associated with higher midterm mortality risk, though rupture rates and rates of reintervention demonstrated no difference.

BACKGROUND:Antithrombotic therapy (AT) aims to strike a balance between preventing thromboembolic and hemorrhagic complications. However, evidence for AT management after pancreatectomy with vascular reconstruction is lacking. We aimed to provide an overview of the current use of AT for pancreatic surgery with vascular reconstructions. PATIENTS AND METHODS/METHODS:A web-based survey was distributed to 123 surgeons from high-volume pancreas centers (>50 pancreatic resections/year). AT management after different types of vascular reconstruction were investigated. An "aggressive" protocol was defined as the use of any AT protocol other than prophylactic heparin, aspirin, or their combination. RESULTS:The survey was completed by 80 surgeons (59% Europe, 30% USA, 11% Asia). In Europe/Asia, prophylactic heparin was the most commonly reported protocol after partial venous resection/end-to-end anastomosis/human graft (71%/65%/50%, respectively), and an "aggressive" protocol (86%) was the most frequently used after prosthetic graft reconstruction. Conversely, in the USA, prophylactic heparin + aspirin was the most commonly reported protocol after all types of venous reconstruction. Following arterial reconstruction, heparin + aspirin was the most commonly reported protocol, regardless of region. An "aggressive" protocol was more frequently used in Europe/Asia (odds ratio (OR) 1.28; p < 0.001) and following vein reconstruction with either human graft (OR 1.2; p = 0.007) or prosthetic graft (OR 1.56, p <0.001), while ultrasound (OR 1.65; p < 0.001) and arterial reconstruction (OR 1.64; p < 0.001) were significantly associated with antiplatelet use. CONCLUSIONS:In an international cohort of high-volume pancreas surgeons, significant variation in the use of AT following pancreatectomy with vascular reconstruction was observed. This variation was driven by geographical differences and the type of vascular reconstructions performed. In an international cohort of high-volume pancreas surgeons, this Worldwide Snapshot Survey analyzed the current use of antithrombotic therapy for pancreatic surgery with vascular reconstruction. A significant heterogeneity in antithrombotic practice was found and it was mainly driven by geographical differences and the type of vascular reconstructions performed.

OBJECTIVES/OBJECTIVE:Patients presenting with iliofemoral deep venous thrombosis (DVT) often undergo percutaneous thrombectomy intending to prevent post-thrombotic syndrome (PTS). However, the relationship between the extent of DVT and outcomes after thrombectomy has not been explored. The objective of this study was to compare rates of post-thrombectomy DVT recurrence between patients with isolated iliofemoral DVT and patients with iliofemoral DVT and extension more peripherally. METHODS:We conducted a single-center, retrospective analysis of all patients who underwent thrombectomy for iliofemoral DVT from 2014-2023. Patients were stratified into two cohorts: (1) iliofemoral DVT without popliteal/tibial extension or (2) iliofemoral DVT with popliteal/tibial extension. The primary outcome was acute DVT recurrence and multivariable analysis was performed to identify risk factors for recurrence. Chi-squared and t-tests were calculated for categorical and continuous data, respectively. Kaplan-Meier analysis was used to compare rates of acute DVT and chronic venous changes postoperatively. A P-value <0.05 was considered statistically significant. RESULTS:222 patients were identified during the study period (76 isolated iliofemoral DVT vs. 146 iliofemoral DVT with peripheral extension) with a median follow-up of 19 months. Patients who presented with iliofemoral DVT with peripheral extension were more likely to be older (57 vs. 50 years, p=0.004), have hypertension (64% vs. 41%, p=0.001) or hyperlipidemia (58% vs. 40%, p=0.01), and to have had surgery within the prior 6-months (29% vs. 17%, p=0.04). Amongst female patients, those on hormone therapy were more likely to have isolated iliofemoral DVT (17% vs. 3%, p<0.001). Patients with iliofemoral DVT with peripheral extension had a greater chance of developing recurrent acute DVT (48% vs. 20%, p<0.001) and chronic venous changes (51% vs. 30%, p=0.004) during follow-up. Multivariable analysis showed a significant correlation between iliofemoral DVT with peripheral extension (Odds ratio 3.8 [95% confidence interval 1.7-8.7], p=0.001) and acute DVT recurrence. There were no differences in the rates of reintervention or death. CONCLUSION/CONCLUSIONS:More extensive peripheral thrombus burden was associated with higher rates of follow-up DVT recurrence in patients undergoing thrombectomy for iliofemoral DVT. These findings suggest that such patients may require closer follow-up and more aggressive anticoagulation therapy postoperatively. Moreover, our results provide a framework for further studies to specifically study the role peripheral thrombus may play in venous hemodynamics and the development of recurrent DVT and, ultimately, PTS.

OBJECTIVE:Spontaneous isolated celiac artery dissection (SICAD) is a rare condition with an unclear natural history and no management consensus. This study evaluated mid-to-long-term outcomes of conservatively managed SICAD. METHODS:This single-center, retrospective cohort study identified patients with SICAD from January 2011-December 2022 in the institutional electronic health record. Demographics, comorbidities, radiographic features, management, and outcomes were reviewed. Clinical endpoints were symptomatic remission, significant organ malperfusion, rupture, and secondary intervention. Radiographic endpoints included dissection remodeling (i.e., shortened dissection length or increased true lumen diameter), celiac aneurysm incidence, and aneurysm diameter growth among <1.5 cm, 1.5-1.9 cm, and ≥2.0 cm size categories. Endpoints were stratified by symptomatic vs. incidental presentation. RESULTS:Forty-nine patients with SICAD were identified. Eighty percent were male, and 57% had hypertension. Extra-celiac aneurysms were present in 25%, including 12% with aortic aneurysms. Forty-nine percent of SICADs were symptomatic on presentation, while 51% were incidentally discovered. Patients with incidental SICAD were older than symptomatic patients (62 ± 15 years vs. 54 ± 8 years, p=0.02) but had similar comorbidities. Ninety-two percent of symptomatic patients experienced complete symptom resolution without operative intervention by the earliest follow-up (182 ± 386 days). No incidental cases developed symptoms over a mean of 3.9 ± 3.5 years. No significant organ malperfusion, rupture, or secondary intervention occurred in this series. Symptomatic SICAD was more likely to undergo remodeling than incidental SICAD (p=0.02) over an average of 3.3 ± 3.7 years. Thirty-two percent of symptomatic cases had partial remodeling, and 37% had no residual dissection. Seventy-one percent of incidental dissections remained stable without remodeling. Celiac thrombus on initial imaging predicted remodeling (p=0.003). Baseline antihypertensive (p=0.006) and antiplatelet use (p=0.047) were associated with remodeling in symptomatic patients only. Aneurysmal degeneration was noted in 46% of all presenting lesions; none were ≥2.0 cm in maximal diameter. Incidental cases presented with more aneurysmal dilatation than symptomatic cases (59% vs. 32%, p<0.001). No celiac aneurysms at presentation grew over an average of 4.8 ± 4.0 years. Forty percent and 13% of incidental and symptomatic cases without initial celiac aneurysms, respectively, developed incident aneurysms by a mean follow-up of 2.0 ± 3.0 years (p=0.3). CONCLUSIONS:Conservative management of uncomplicated SICAD yielded excellent clinical outcomes, even with incomplete remodeling and aneurysmal degeneration, which were common, albeit largely benign. Patients may warrant screening for aneurysms beyond the celiac axis. Antihypertensive and antiplatelet therapy for ≥3-6 months may promote remodeling until dissection stabilization.