Faculty Bibliography

OBJECTIVE:Fragmentation of care (FOC) is referred to as receipt of care across multiple unaffiliated health systems (HS). We evaluated whether FOC was associated with outcomes in patients with uncomplicated type B aortic dissection (uTBAD). METHODS:The Healthcare Cost and Utilization Project State Inpatient Databases, for California (2018-2021), New York/Maryland/Florida (2016-2020) were queried using International Classification of Disease-10th (ICD-10) edition to identify patients who underwent medical management for uTBAD. Patient's hospital affiliation and its linkage to a HS during follow up were verified using the American Hospital Association data (AHA). FOC was defined as receipt of care across multiple unaffiliated, AHA defined HS, care delivered among transitions within the same HS was not classified as FOC. Univariate analyses were conducted to compare outcomes between patients with and without FOC, employing Chi-square or Fisher's exact tests as appropriate. Multivariable logistic regression models were constructed to investigate associations between FOC and outcomes. Model validation was performed using Hosmer-Lemeshow test, and receiver operating characteristic curve analysis. RESULTS:Among 5,476 patients included in the analysis, FOC was observed in 3,046 (55.6%). Baseline characteristics between those with and without FOC differed significantly. During follow-up, while mortality rates were similar between groups, FOC group had significantly more computed tomography scans, higher rates of aortic interventions, and elevated complication rates. Furthermore, total costs were markedly higher with FOC. Multivariable analysis also showed that FOC was associated with increased aortic interventions [TEVAR: OR 1.47, 95%CI 1.26-1.74] and complication rates (renal failure [OR 1.3, 95% CI 1.17-1.50], paraplegia [OR 1.60, 95% CI 1.07-2.42], and stroke [OR 1.31, 95%CI 1.09-1.58]) during follow-up. Total costs were 31% higher in the FOC group (p<0.001). CONCLUSIONS:FOC in uTBAD patients is associated with increased likelihood of intervention with higher post-procedural complications and elevated healthcare costs. Coordinated care within a single HS should be prioritized to improve outcomes and reduce healthcare cost.

Pancreatic ductal adenocarcinoma (PDAC) with extensive peripancreatic vessel involvement is classified as locally advanced pancreatic cancer (LAPC). For this group of patients, the current standard of care does not include considering a potentially curative oncologic resection. However, recent advances in multiagent chemotherapy and surgical techniques are challenging this paradigm. Moreover, the current determination of anatomic resectability is vague and unreliable. Here we propose a definition of local resectability, based on pre- and intra-operative assessment. This anatomic definition of resectability assumes careful patient selection based on tumor biology and patient condition. The pre-operative evaluation of vascular anatomy and tumor involvement is conducted using 3D-rendering of pancreas-protocol computed tomography. Identifying a disease-free arterial or venous segment above and below the tumor involvement ("suitable target") is the single critical factor that determines anatomic resectability. Intraoperative isolation of these target vessels confirms the feasibility of vascular reconstruction before resection. This approach, which focuses on identifying target vessels rather than circumferential involvement, offers a more straightforward and clinically relevant method for assessing surgical eligibility in LAPC patients at centers of excellence. In summary, reconstructability-based on surgical expertise and guided by tumor biology-now defines the modern paradigm of resectability in LAPC.

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.

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: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.

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.

OBJECTIVE:Cryopreserved vein grafts serve as alternative conduits for infrainguinal bypass when autogenous vein is unavailable or inadequate. Anticoagulation has been advocated to improve outcomes, but published studies demonstrate conflicting results. We assessed the association of anticoagulation on outcomes after infrainguinal bypass with cryopreserved vein in patients with chronic limb threatening ischemia (CLTI). METHODS:The Vascular Quality Initiative was queried (2003-2022) for infrainguinal bypass performed using cryopreserved vein graft for CLTI. Baseline characteristics, procedural details, and outcomes between those discharged with or without anticoagulation were recorded. Univariable, Kaplan-Meier, and multivariable analyses were performed. RESULTS:There were 2336 patients who underwent an infrainguinal bypass with cryopreserved vein conduit. The average age was 70.6 years and 63.5% were male. Bypass targets were femoral/popliteal (27.5%) and tibial (72.5%). Indication for intervention included rest pain (25.7%) and tissue loss (74.3%). Patients were discharged with aspirin (80.1%), a P2Y12 inhibitor (45.6%), and anticoagulation (47.3%). Patients discharged on postoperative anticoagulation more often were treated for rest pain (28.1% vs. 23.5%), had a tibial bypass target (78.4% vs. 67.2%), and less often underwent endarterectomy (27.8% vs. 34.2%) (all P<.05). Kaplan-Meier analysis at one-year demonstrated that postoperative anticoagulation had similar freedom from loss of primary patency/death (28.9% vs. 34.3%), major amputation/death (62.3% vs. 63.8%), and reintervention/major amputation/death (50.6% vs. 53.8%) (all P>.05), but higher survival (85.1% vs. 81.7%, P=.03). Multivariable analysis at one-year demonstrated that postoperative anticoagulation had a similar likelihood for loss of primary patency/death (HR .95, 95% CI .83.-1.09), major amputation/death (HR .88, 95% CI .74-1.05), and reintervention/major amputation/death (HR .93, 95% CI .79-1.08) (all P>.05), but lower likelihood for death (HR .59, 95% CI .46-.74, P<.001) compared to no anticoagulation. Postoperative aspirin was associated with decreased likelihood for amputation/death (HR .74, 95% CI .61-.91, P=.003) and reintervention/major amputation/death (HR .76, 95% CI .64-.9, P=.002). Postoperative P2Y12 inhibitor was associated with decreased likelihood for amputation/death (HR .75, 95% CI .63-.9, P=.002) and reintervention/major amputation/death (HR .78, 95% CI .67-.91, P=.001). Results were similar when analyzing patients who were not on anticoagulation preoperatively. CONCLUSIONS:Postoperative anticoagulation following infrainguinal bypass using cryopreserved vein did not affect patency or limb salvage. Antiplatelet agents were associated with improved outcomes. Overall patency and limb salvage rates at one year were poor. When cryopreserved vein is used, surgeons should consider antiplatelet therapy for cryopreserved graft patency rather than anticoagulation.

BACKGROUND/UNASSIGNED:Electronic cigarettes (e-cigarettes) are the most used tobacco product among youth, and adults who smoke combustible cigarettes favor e-cigarettes over approved cessation aids. Despite the lower perceived harm of vaping compared with smoking, acute inhalation of e-cigarette aerosol elicits cardiovascular responses that may lead to persistent damage when repeated over time. METHODS/UNASSIGNED:We exposed female hypercholesterolemic mice to either pod-mod e-cigarette aerosol or filtered air daily for 24 weeks. We assessed the long-term effects of vaping on aortic stiffness and vasoreactivity while investigating the underlying cellular and molecular mechanisms of injury. RESULTS/UNASSIGNED:Chronic inhalation of e-cigarette aerosol triggered the accumulation of inflammatory signals systemically and within aortic tissues, as well as T-lymphocyte accrual in the aortic wall. Limited eNOS (endothelial nitric oxide synthase) expression and enhanced superoxide radical production curbed NO bioavailability in the aorta of mice exposed to e-cigarette aerosol despite iNOS (inducible nitric oxide synthase) induction, impairing the endothelium-dependent vasodilation that regulates blood flow distribution. Inhalation of e-cigarette aerosol thickened and stiffened aortic tissues via collagen deposition and remodeling, hindering the storage of elastic energy and limiting the cyclic distensibility that enables the aorta to function as a pressure reservoir. These effects combined contributed to raising systolic and pulse pressure above control levels. CONCLUSIONS/UNASSIGNED:Chronic inhalation of aerosol from pod-mod e-cigarettes promotes oxidative stress, inflammation, and fibrosis within aortic tissues, significantly impairing passive and vasoactive aortic functions. This evidence provides new insights into the biological processes that increase the risk of adverse cardiovascular events as a result of pod-mod e-cigarette vaping.

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.

BACKGROUND:Patients with intermediate-risk pulmonary embolism (PE) have outcomes worse than uncomplicated ST elevation myocardial infarction. Yet, no large-scale study has compared the outcomes of large-bore mechanical thrombectomy (LBMT) with anticoagulation alone (AC). The aim of this study was to compare the clinical outcomes among patients receiving LBMT vs AC alone. METHODS:This was a two-center retrospective study that included patients with intermediate-risk PE from October 2016 - October 2023 from the institution's Pulmonary Embolism Response Team (PERT) database. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest or hemodynamic decompensation. Inverse probability of treatment weighting (IPTW) was used to balance covariates; Kaplan Meir curves and IPTW multivariable Cox regression were used to assess the relationship between treatment groups and outcomes. RESULTS:Of the 273 patients included in the analysis, 192 (70 %) patients received AC alone and 81 (30 %) patients received LBMT and AC. A total of 30 (10.9 %) patients experienced the primary composite outcome over a median follow-up of 30 days. The primary composite outcome was significantly lower in the group that received LBMT compared to those on AC alone (1.2 % vs 15.1 %, log-rank p < 0.001; adjusted HR: 0.02; 95 % CI: 0.002-0.17, p < 0.001) driven by a lower rate of 30-day all-cause mortality (0 % vs 7.3 %, log-rank p = 0.01), resuscitated cardiac arrest (0 % vs 6.8 %, log-rank p = 0.016) and new or worsening hemodynamic instability (4 % vs 11.1 %, log-rank p = 0.007). CONCLUSION/CONCLUSIONS:In this largest cohort to date comparing LBMT versus AC alone in acute intermediate-risk PE, LBMT had a significantly lower rate of the primary composite outcome including a lower rate of all-cause mortality when compared to AC alone. Ongoing randomized trials will test these associations.