Faculty Bibliography

OBJECTIVE:While bovine aortic arch (BAA) is the most common aortic arch variant and has been associated with an increased risk of stroke in the general population, limited data exist on the impact of BAA on outcomes following carotid artery stenting (CAS). This study evaluates the association between BAA and post-operative outcomes in patients undergoing CAS. METHODS:A retrospective analysis of the multi-institutional Vascular Quality Initiative database identified all patients undergoing CAS for atherosclerotic carotid stenosis from January 2017 to February 2024. Patients were stratified by the presence of BAA. Procedures included transcarotid artery revascularisation (TCAR) with flow reversal, transfemoral CAS (TF-CAS), and transbrachial/transradial CAS (TB/TR-CAS) using distal embolic protection. The primary outcome was in hospital stroke or death. Secondary outcomes included stroke, death, myocardial infarction (MI), access-related complications, and stroke/transient ischaemic attack (TIA). Baseline characteristics were compared, and multivariable logistic regression was performed to adjust for potential confounders. RESULTS:Among 18 254 patients undergoing CAS, 2 037 (11.1%) had BAA. Patients with BAA were more likely to present with symptomatic and left sided carotid stenosis. After adjustment, BAA was not associated with increased odds of post-operative stroke, death, MI, or composite adverse events. Within the BAA cohort, peri-operative outcomes were comparable across TCAR, TF-CAS, and TB/TR-CAS, regardless of symptomatic status. Independent predictors of in hospital stroke or death included history of congestive heart failure and advanced age. Outcomes did not differ by lesion laterality in patients with BAA. CONCLUSION/CONCLUSIONS:In this large, contemporary, multicentre study, BAA was not independently associated with increased peri-operative risk following CAS. In current practice, where access selection is guided by pre-operative imaging and clinical judgement, CAS can be performed with comparable post-operative outcomes in select patients with BAA.

OBJECTIVE:Non-pneumatic compression devices (NPCDs) have demonstrated their clinical efficacy and safety in treating lymphedema (LED) in multiple studies, including two recent multi-centered, randomized head-to-head comparative studies with advanced pneumatic compression devices (APCD). In the most recent study, TEAYS (ClinicalTrials.gov Identifier: NCT05507346), NPCDs demonstrated better clinical utility as well as greater efficacy and adherence than APCDs in the treatment of lower extremity swelling. This current sub analysis of TEAYS focuses on the outcomes for patients whose secondary lymphedema is associated with underlying venous etiology or phlebolymphedema (PLED). METHODS:This trial was a randomized, crossover head-to-head study was performed across nine sites in the US in 2023. Patients were subjected to an initial 4-week washout period and then randomized to either the NPCD or a commercially available APCD. Patients used the randomly assigned initial device for 90 days followed by a second 4-week washout period before a 90-day use of the second device. The current study focuses specifically on the sub-analysis of the cohort of PLED patients. Primary efficacy outcomes assessed in this study included change in affected limb volume between baseline (day 0) and end of treatment (day 90), change in Lymphedema Quality of Life Questionnaire (LYMQOL), and treatment adherence. RESULTS:Analysis included a total of 71 patients with lower extremity lymphedema; 35 of whom were diagnosed with PLED and this subset comprises the study cohort for the current study. In the PLED cohort 13 (37%) were male, Average BMI was 36.2 +/- 1.68, and 19 had bilateral limbs affected (54%). Most patients had clinical stage II lymphedema: I (n=6), II (n=20) and III (n=9). These PLED patients achieved statistically greater mean limb volume reduction (424.49±100.9mL) while on NPCD vs (50.8± 112.1mL) for APCD (p=.0085). NPCD also showed significantly better improvement in overall Quality of Life (1.39±0.39) vs. APCD (0.18±0.29); (p=0.01). Statistically significant improvement in adherence was also observed while on NPCD 81% vs APCD 49% (p ≤ .001). No device-related adverse events were reported. CONCLUSION/CONCLUSIONS:The NPCD is a clinically effective treatment for decreasing limb volume in patients with lower extremity LED. The NPCD was more effective than an APCD and resulted in superior limb volume decrease, greater improved quality of life, adherence, mobility, and patient satisfaction. The outcomes for the subset of patients diagnosed with PLED corroborates the improvements seen in the overall LED study patient population previously reported. Additionally, results suggest that PLED patients may potentially benefit even more from NPCD than non-PLED patients.

IntroductionThis study assessed the relationship between venous leg ulcers (VLUs) and overall survival among patients treated for chronic venous insufficiency.MethodsPatients with CEAP C2-C6 disease who underwent superficial venous interventions at a single center from May 2016-April 2024 were identified from the Vascular Quality Initiative Varicose Vein Registry. Demographics, comorbidities, and venous disease severity were recorded at the index database procedure. Mortality was recorded from the electronic health record and Social Security Death Index. Patient characteristics and all-cause mortality were compared between VLU (C5-C6) and non-VLU (C2-C4) cohorts.ResultsAmong 7084 patients, 8.9% (n = 632) had a VLU history. Compared with non-VLU patients, those with a VLU history were older (p < .001) and disproportionately male (p < .001), Black/African American (p < .001), and Medicaid-insured (p = .009). They had greater body mass indices (p < .001), revised venous clinical severity scores (rVCSS) (p < .001), HASTI scores (p = .015), and work/activity limitations (p < .001). Prior venous thromboembolism (p < .001), anticoagulation use (p < .001), previous varicose vein (VV) treatment (p = .042), and deep venous reflux (DVR) (p < .001) were also more common. Mortality was higher among VLU patients than non-VLU patients (3.6% vs 0.7%, p < .001) over a similar mean follow-up (2.8 vs 3.0 years, p = .070). VLU history was associated with worse survival (HR 5.03, 95% CI [2.96-8.53], p < .001), in addition to older age (p < .001), male sex (p = .003), White race (p = .003), no prior VV treatment (p = .026), anticoagulation use (p < .001), higher rVCSS (p < .001), and DVR (p = .016). After adjusting for these latter variables, VLU history remained independently associated with mortality (adjusted HR 2.01, 95% CI [1.00-4.01], p = .049). Compared with C2, only C6 -not C3-C5 -was associated with increased mortality after multivariable adjustment (adjusted HR 3.40, 95% CI [1.08, 10.69], p = .036).ConclusionAmong patients undergoing superficial venous interventions, VLUs were associated with a two-fold hazard of all-cause death. The mechanism driving their increased mortality warrants further study.

OBJECTIVE:Lower-extremity acute limb ischemia (LE-ALI) is a severe form of peripheral artery disease associated with high morbidity and mortality. Thrombus in previously placed stents or grafts may present treatment challenges when compared to treatment of thrombus in native vessels, and data evaluating first-line treatment with mechanical aspiration thrombectomy are lacking. This post hoc analysis of the STRIDE study examines outcomes for first-line mechanical aspiration thrombectomy with the Indigo Aspiration System for LE-ALI in patients with either in-stent or in-graft thrombosis as compared to native-vessel thrombosis. METHODS:STRIDE was a prospective, single-arm study that enrolled 119 adult patients across 16 sites in the United States and Europe who were treated first-line with the Indigo Aspiration System for LE-ALI. The primary outcome was target limb salvage (TLS) at 30 days post-procedure. Secondary outcomes included device-related serious adverse events (SAEs), technical success (post-procedure TIMI flow grades 2/3), and patency at 30 days. Outcomes for the in-stent thrombosis group versus the native-vessel thrombosis group, and for the in-graft thrombosis group versus the native-vessel thrombosis group, were compared. RESULTS:Of the 119 STRIDE patients, 29 had in-stent thrombosis, 19 had in-graft thrombosis, and 71 had native-vessel thrombosis. For both the in-stent vs native-vessel thrombosis and the in-graft vs native-vessel thrombosis group comparisons, there were no significant differences for any of the primary or secondary outcomes. Overnight adjunctive thrombolytics usage was higher for the in-graft vs. native-vessel groups (52.6% (10/19) and 11.3% (8/71), respectively (P< .001). In a combined multivariate Cox model, when adjusted for age and sex among US patients, in-stent thrombosis was associated with time to retreatment within 30 days (HR=3.8,95% CI 1.1-13.3, P = .040). CONCLUSION/CONCLUSIONS:Although in-stent and in-graft thrombosis may represent more challenging treatment settings for LE-ALI, high technical success and high TLS at 30 days were observed for both groups, similar to the favorable results seen in the native-vessel group. Additionally, there were no device-related SAEs in either the in-stent or in-graft groups. In-stent thrombosis is associated with an increased risk of retreatment, which is unrelated to the device or procedure and may be expected due to known complications of stenting. This STRIDE subgroup analysis shows that first-line mechanical aspiration thrombectomy using Indigo is safe and effective for LE-ALI patients in presentations of acute thrombosis in a stent or graft.

OBJECTIVE:Chronic venous insufficiency (CVI) resulting in venous hypertension can cause lifestyle-limiting debilitation. Studies have identified racial and ethnic disparities in CVI presentation and clinical severity; however, there is limited literature examining disparities in CVI management and procedural outcomes among different racial and ethnic groups. The aim of this study was to characterize differences in endovenous treatment paradigms between racial and ethnic groups and to assess how this affected patient outcomes. METHODS:The national Vascular Quality Initiative (VQI) Varicose Vein Registry (VVR) database was queried for superficial venous interventions, including endovenous radiofrequency ablation, endovenous laser ablation, high ligation, stripping, and microphlebectomy, performed from April 2014-March 2024. We categorized patients as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic/Latino, Asian, and Other (including American Indian, Alaskan Native, Native Hawaiian, other Pacific Islander, more than one race, and unknown/other). Baseline demographics, clinical and treatment characteristics, complication rates, and changes in quality-of-life endpoints (i.e., revised Venous Clinical Severity Score (rVCSS) and HASTI (Heaviness, Achiness, Swelling, Throbbing, Itching) score)) were compared between racial/ethnic groups with NHW as the reference category. Linear regression and logistic regression/chi-squared tests were used to compare continuous/ordinal and categorical variables, respectively. RESULTS:65,090 superficial venous procedures encompassing endovenous thermal ablations, stripping/high ligation, and microphlebectomy were included. NHW patients underwent interventions for less severe baseline CVI based on CEAP class and had more superficial venous interventions (2.45±1.95, p<0.001) and repeat thermal ablations (1.66±1.14, p<0.001) than other groups. NHB had more severe baseline CVI based on higher prevalence of severe CEAP, i.e. C5, C6, and C6r disease (5.8%, 11.8%, 0.9%, respectively, p<0.05). NHB patients were less likely to have concomitant microphlebectomy than NHW (OR: 0.79[ 95% CI 0.73, 0.87] p<0.001). NHB had the highest rVCSS score preoperatively (8.17±4.02, p<0.001) with the largest improvement at <3 (-4.40±5.23, p<0.001) and >3 months (-7.00±5.00, p<0.001) following intervention. Hispanic/Latinos had the highest preoperative HASTI score (10.34±5.40, p<0.001) and the largest score reduction at <3 months (-6.62±6.51, p<0.001). Post procedure, Hispanics and Other study groups were more likely to experience blistering and medication induced ulcer (p<0.05). Other group was less likely to experience hematoma postoperatively (p<0.05). CONCLUSIONS:This study highlights significant differences across racial/ethnic groups in the presentation, treatment and outcomes of patients with treated for CVI . Black patients undergo fewer ablations and superficial venous procedures overall, however once treated, they exhibit significant symptomatic improvement.

BACKGROUND:In patients with intermediate-risk pulmonary embolism (PE), guidelines recommend further risk stratification (Class 1 indication). However, head-to-head comparison of different risk stratification tools are lacking. Our objective was to compare the performance of 4 scores in predicting adverse clinical events in intermediate-risk PE. METHODS:This was a retrospective study of 192 intermediate-risk PE patients spanning October 2016 to July 2019. Receiver operator characteristic curves were used to compare the predictive performance of the composite PE shock (CPES) score, Bova, simplified PE shock index (sPESI), National Early Warning Score (NEWS) and ESC intermediate-risk subcategory types for the primary outcome, which was a composite of PE-related in-hospital mortality, resuscitated cardiac arrest, or hemodynamic decompensation and its individual components. RESULTS:A total of 28 patients (14.6%) experienced the primary composite outcome. CPES demonstrated the highest discriminatory power for predicting the primary composite outcome (AUC: 0.74; 95% CI: 0.66-0.83) as well as its individual components compared to the other risk scores (p = 0.008). The AUCs for the other scores were as follows: Bova, 0.66 (95% CI: 0.56-0.76); sPESI, 0.67 (95% CI: 0.57-0.77); NEWS, 0.71 (95% CI: 0.63-0.82) and ESC intermediate-risk subcategory, AUC of 0.59 (95% CI: 0.51-0.68). The ESC intermediate-risk subcategory exhibited the lowest performance for the primary composite outcome and across all individual components. CONCLUSION/CONCLUSIONS:CPES score outperformed other commonly used risk stratification tools for PE-related morbidity and mortality in intermediate-risk PE patients. The findings support the integration of CPES into clinical practice to enhance patient selection for escalated care and timely interventions.

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: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.

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.

BACKGROUND:Endovascular aortic aneurysm repair (EVAR) is utilized to treat abdominal aortic aneurysms, while patients with short infrarenal necks can undergo fenestrated EVAR (FEVAR). Previous studies have demonstrated decreased aortic neck dilation for FEVAR compared to EVAR. Sac regression is a marker of success after EVAR; however, little is known regarding changes in sac volumetrics. This study compares aortic sac regression after EVAR versus FEVAR using volumetric analysis. METHODS:A retrospective review of prospectively collected data from 120 patients who underwent EVAR was performed. Thirty patients underwent FEVAR (Cook Medical Inc, Bloomington, IN) and 90 patients underwent EVAR (30 each with Endurant [Medtronic, Dublin, Ireland], Excluder [Gore, Flagstaff, AZ], and Zenith [Cook]). Demographic data were analyzed. Using 3-dimensional reconstruction software, preoperative and postoperative aneurysm sac volumes were measured, in addition to aneurysm characteristics. RESULTS:, P = 0.005). EVAR patients had greater number of lumbar arteries (7.26 ± 1.68 vs. 5.31 ± 1.93, P < 0.000001). On postoperative follow-up, FEVAR cases had greater sac regression compared to standard EVAR (-22.75 ± 25.7% vs. -5.98 ± 19.66%, P = 0.00031). The percentage of sac regression was greater when measured by volume compared to maximum diameter for FEVAR (-22.75 ± 25.7% vs. -13.90 ± 15.4%, P = 0.01) but not EVAR (-5.98 ± 19.7% vs. -4.51 ± 15.2%, P = 0.246). Those in the top tertile of percent volume of thrombus (>48.5%) were more likely to experience greater than 10% sac regression by volume (55% vs. 33.3%, P = 0.015). On multivariate analysis, FEVAR was associated with sac regression greater than 10% by volume (odds ratio [OR] 4.325, 95% confidence interval [CI] 1.346-13.901, P = 0.014), while endoleak (OR 0.162, 95% CI 0.055-0.479, P < 0.001) and 2 patent hypogastric arteries (OR 0.066, 95% CI 0.005-0.904, P = 0.042) were predictive against. CONCLUSIONS:Fenestrated EVAR is associated with greater sac regression compared to EVAR on volumetric analysis. This difference may be attributable to decreased endotension within the aneurysm resulting from less aortic neck dilatation, while the greater proportion of thrombus may be a protective factor from growth. Patients being evaluated for EVAR with borderline neck anatomy should be considered for FEVAR given increased sac regression.