Faculty Bibliography

OBJECTIVE:Compare thrombus removal and residual venous symptoms and signs of disease following interventional treatment of iliofemoral deep vein thrombosis (DVT) with mechanical thrombectomy (MT) and pharmacomechanical catheter directed thrombolysis (PCDT). METHODS:Retrospective cohort analysis of propensity score matched subgroups from the multicentre prospective MT ClotTriever Outcomes registry and the PCDT arm of the randomised Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis trial. Patients with bilateral DVT, symptom duration greater than four weeks, isolated femoral-popliteal disease, or incomplete case data were excluded. Patients with iliofemoral DVT were propensity score matched (1:1) on 10 baseline covariates, including race, sex, age, body mass index, leg treated, prior thromboembolism, Marder score, symptom duration, provoked deep vein thrombosis status, and Villalta score. Reduction in post-procedure thrombus burden (i.e., Marder scores), assessment of venous symptoms and signs (i.e., Villalta scores) at 12 months, and healthcare resource utilisation were compared between subgroups. RESULTS:Propensity score matching resulted in 130 patient pairs with no significant differences in baseline characteristics between the MT and PCDT groups. MT was associated with a greater reduction in Marder scores (91.0% vs. 67.7%, p < .001), and a greater proportion of patients at 12 months with no post-thrombotic syndrome (83.1% vs. 63.6%, p = .007) compared with matched patients receiving PCDT. No differences in rates of adjunctive stenting or venoplasty were identified (p = .27). Higher rates of single session treatment were seen with MT (97.7% vs. 26.9%, p < .001), which also showed shorter mean post-procedure hospital stays (1.81 vs. 3.46 overnights, p < .001), and less post-procedure intensive care unit utilisation (2.3% vs. 52.8%, p < .001). CONCLUSION/CONCLUSIONS:Compared with PCDT, MT was associated with greater peri-procedural thrombus reduction, more efficient post-procedure care, and improved symptoms and signs of iliofemoral vein disease at 12 months.

BACKGROUND:Intraoperative dextran infusion has been associated with reduction of an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions, including anaphylaxis, hemorrhage, cardiac, and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of intraoperative dextran infusion using a large multiinstitutional dataset. METHODS:Patients undergoing CEA between 2008 and 2022 from the Vascular Quality Initiative database were reviewed. Patients were categorized by use of intraoperative dextran infusion, and demographics, procedural data, and in-hospital outcomes were compared. Logistic regression analysis was utilized to adjust for differences in patients while assessing the association between postoperative outcomes and intraoperative infusion of dextran. RESULTS:Of 140,893 patients undergoing CEA, 9,935 (7.1%) patients had intraoperative dextran infusion. Patients with intraoperative dextran infusion were older with lower rates of symptomatic stenosis (24.7% vs. 29.3%; P < 0.001) and preoperative use of antiplatelets, anticoagulants and statins. Additionally, they were more likely to have severe carotid stenosis (>80%; 49% vs. 45%; P < 0.001) and undergo CEA under general anesthesia (96.4% vs. 92.3%; P < 0.001), with a more frequent use of shunt (64.4% vs. 49.5%; P < 0.001). After adjustment, multivariable analysis showed that intraoperative dextran infusion was associated with higher odds of in-hospital major adverse cardiac events (MACE), including myocardial infarction [MI] (odds ratio [OR], 1.76, 95% confidence interval [CI]: 1.34-2.3, P < 0.001), congestive heart failure [CHF] (OR, 2.15, 95% CI: 1.67-2.77, P = 0.001), and hemodynamic instability requiring vasoactive agents (OR, 1.08, 95% CI: 1.03-1.13, P = 0.001). However, it was not associated with decreased odds of stroke (OR, 0.92, 95% CI: 0.74-1.16, P = 0.489) or death (OR, 0.88, 95% CI: 0.58-1.35, P = 0.554). These trends persisted even when stratified by symptomatic status and degree of stenosis. CONCLUSIONS:Intraoperative infusion of dextran was associated with increased odds of MACE, including MI, CHF, and persistent hemodynamic instability, without decreasing the risk of stroke perioperatively. Given these results, judicious use of dextran in patients undergoing CEA is recommended. Furthermore, careful perioperative cardiac management is warranted in select patients receiving intraoperative dextran during CEA.

Patients with coronavirus disease 2019 (COVID-19) present increased risk for ischemic cardiovascular complications up to 1 year after infection. Although the systemic inflammatory response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely contributes to this increased cardiovascular risk, whether SARS-CoV-2 directly infects the coronary vasculature and attendant atherosclerotic plaques remains unknown. Here we report that SARS-CoV-2 viral RNA is detectable and replicates in coronary lesions taken at autopsy from severe COVID-19 cases. SARS-CoV-2 targeted plaque macrophages and exhibited a stronger tropism for arterial lesions than adjacent perivascular fat, correlating with macrophage infiltration levels. SARS-CoV-2 entry was increased in cholesterol-loaded primary macrophages and dependent, in part, on neuropilin-1. SARS-CoV-2 induced a robust inflammatory response in cultured macrophages and human atherosclerotic vascular explants with secretion of cytokines known to trigger cardiovascular events. Our data establish that SARS-CoV-2 infects coronary vessels, inducing plaque inflammation that could trigger acute cardiovascular complications and increase the long-term cardiovascular risk.

OBJECTIVE:The outcomes of patients with premature cerebrovascular disease (age ≤55 years) who undergo carotid artery stenting are not well-defined. Our study objective was to analyze the outcomes of younger patients undergoing carotid stenting. METHODS:The Society for Vascular Surgery Vascular Quality Initiative was queried for transfemoral carotid artery stenting (TF-CAS) and transcarotid artery revascularization (TCAR) procedures between 2016 and 2020. Patients were stratified based on age ≤55 or >55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction (MI), and composite outcomes. Secondary endpoints included procedural failure (defined as ipsilateral restenosis ≥80% or occlusion) and reintervention rates. RESULTS:Of the 35,802 patients who underwent either TF-CAS or TCAR, 2912 (6.1%) were ≤55 years. Younger patients were less likely than older patients to have coronary disease (30.5% vs 50.2%; P < .001), diabetes (31.5% vs 37.9%; P < .001), and hypertension (71.8% vs 89.8%; P < .001), but were more likely to be female (45% vs 35.4%; P < .001) and active smokers (50.9% vs 24.0%; P < .001) Younger patients were also more likely to have had a prior transient ischemic attack or stroke than older patients (70.7% vs 56.9%; P < .001). TF-CAS was more frequently performed in younger patients (79.7% vs 55.4%; P < .001). In the periprocedural period, younger patients were less likely to have a MI than older patients (0.3% vs 0.7%; P < .001), but there was no significant difference in the rates of periprocedural stroke (1.5% vs 2.0%; P = .173) and composite outcomes of stroke/death (2.6% vs 2.7%; P = .686) and stroke/death/MI (2.9% vs 3.2%; P = .353) between our two cohorts. The mean follow-up was 12 months regardless of age. During follow-up, younger patients were significantly more likely to experience significant (≥80%) restenosis or occlusion (4.7% vs 2.3%; P = .001) and to undergo reintervention (3.3% vs 1.7%; P < .001). However, there was no statistical difference in the frequency of late strokes between younger and older patients (3.8% vs 3.2%; P = .129). CONCLUSIONS:Patients with premature cerebrovascular disease undergoing carotid artery stenting are more likely to be African American, female, and active smokers than their older counterparts. Young patients are also more likely to present symptomatically. Although periprocedural outcomes are similar, younger patients have higher rates of procedural failure (significant restenosis or occlusion) and reintervention at 1-year follow-up. However, the clinical implication of late procedural failure is unknown, given that we found no significant difference in the rate of stroke at follow-up. Until further longitudinal studies are completed, clinicians should carefully consider the indications for carotid stenting in patients with premature cerebrovascular disease, and those who do undergo stenting may require close follow-up.

BACKGROUND:Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch. METHODS:Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions. RESULTS:288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change. CONCLUSIONS:In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.

OBJECTIVES/OBJECTIVE:There is a paucity of data regarding outcomes of patients with premature cerebrovascular disease (age ≤ 55 years) who undergo carotid endarterectomy (CEA). The objective of this study was to analyze the demographics, presentation, perioperative and later outcomes of younger patients undergoing CEA. METHODS:The Society for Vascular Surgery Vascular Quality Initiative was queried for CEA cases between 2012-2022. Patients were stratified based on age ≤ 55 or age > 55 years. Primary endpoints were periprocedural stroke, death, myocardial infarction and composite outcomes. Secondary endpoints included restenosis (≥80%) or occlusion, late neurologic events and re-intervention. RESULTS:Of 120,549 patients undergoing CEA, 7,009 (5.5%) were ≤ 55 years old (mean age of 51.3 years). Younger patients were more likely to be African American (7.7% vs 4.5%, p < .001), female (45.2% vs 38.9%, p < .001) and active smokers (57.3% vs 24.1%, p < .001). They were less likely than older patients to have hypertension (82.5% vs 89.7%, p < .001), coronary artery disease (25% vs 27.3%, p < .001) and CHF (7.8% vs 11.4%, p<.001). Younger patients were significantly less likely than older patients to be on aspirin, anti-coagulation, statins, or beta-blockers but were more likely to be taking P2Y12 inhibitors (37.2 vs 33.7%, p <.001). Younger patients were more likely to present with symptomatic disease (35.1% vs 27.6%, p<.001) and were more likely to undergo non-elective CEA (19.2% vs 12.8%; P < .001). Younger and older patients had similar rates of perioperative stroke/death (2% vs 2%, p= NS) and post-operative neurologic events (1.9% vs 1.8%, p = NS). However, younger patients had lower rates of overall postoperative complications compared to their older counterparts (3.7% vs 4.7%, p<.001). 72.6% of patients had recorded follow-up (mean 13 months). During follow-up, younger patients were significantly more likely than older patients to experience a late failure, defined as significant (≥80%) restenosis or complete occlusion of the operated artery (2.4% vs 1.5%, p <.001) and were more likely to experience any neurologic event (3.1% vs 2.3%, p<.001). Re-intervention rates did not significantly differ between the two cohorts. After controlling for co-variates using a logistic regression model, age ≤ 55 years was independently associated with increased odds of late re-stenosis/occlusion (OR 1.591, 95% CI 1.221-2.073, p<.001) as well as late neurologic events (OR 1.304, 95% CI 1.079-1.576, p = 0.006). CONCLUSIONS:Young patients undergoing CEA are more likely to be African American, female, and active smokers. They are more likely to present symptomatically and undergo non-elective CEA. Although perioperative outcomes are similar, younger patients are more likely to experience carotid occlusion or restenosis as well as subsequent neurological events, during relatively short follow-up. These data suggest that younger CEA patients may require more diligent follow-up, and a continued aggressive approach to medical management of atherosclerosis to prevent future events related to the operated artery, given the particularly aggressive nature of premature atherosclerosis.

OBJECTIVE:Much attention has been given to the influence of anatomic and technical factors, such as maximum abdominal aortic aneurysm diameter and proximal clamp position, in open abdominal aortic aneurysm repair (OSR). However, no studies have rigorously examined the correlation between site of distal anastomosis and OSR outcomes despite conventional wisdom that more proximal sites of anastomosis are preferrable when technically feasible. This study aimed to test the association between sites of distal anastomosis and clinical outcomes for patients undergoing primary elective OSR. METHODS:Our study included 5683 patients undergoing primary elective OSR at 233 centers from 2014 to 2020. Using a variety of statistical methods to account for potential confounders, including multivariable logistic regression and Cox proportional hazards modeling, as well as subgroup analysis, we examined the association between site of distal anastomosis and clinical outcomes in elective OSR. Primary outcomes were major in-hospital complication rate, 30-day mortality, and long-term survival. RESULTS:Patients undergoing elective aortobifemoral reconstruction (n = 672) exhibited significantly increased rates of smoking, chronic obstructive pulmonary disease, and peripheral artery disease in comparison to patients undergoing elective OSR with distal anastomosis to the aorta (n = 2298), common iliac artery (n = 2163), or external iliac artery (n = 550). Patients undergoing aorto-aortic tube grafting were significantly less likely to exhibit iliac aneurysmal disease and significantly more likely to be undergoing elective OSR with a suprarenal or supraceliac proximal clamp position. Using multivariable logistic regression and Cox proportional hazards analysis to control for important confounders, such as age, smoking status, and medical history, we found that distal anastomosis to the common femoral artery was associated with increased odds of major in-hospital complications (adjusted odds ratio, 1.79; 95% confidence interval, 1.46-2.18; P < .001) and reduced long-term survival (adjusted hazard ratio, 1.44; 95% confidence interval, 1.09-1.89; P = .010). We observed no significant differences in 30-day mortality across sites of distal anastomosis in our study population. CONCLUSIONS:It is generally accepted that more proximal sites of distal anastomosis should be selected in OSR when technically feasible. Our findings support this hypothesis by demonstrating that distal anastomosis to the common femoral artery is associated with increased perioperative morbidity and reduced long-term survival. Careful diligence regarding optimization of preoperative health status, perioperative care, and long-term follow-up should be applied to mitigate major complications in this patient population.

Extracranial carotid artery aneurysms (ECAA) are rare vascular anomalies defined as any aneurysmal dilatation of the common, external, or internal carotid artery leading up to the skull base. Operative management is indicated due to the high incidence of morbidity and mortality if left untreated. Endovascular techniques include aneurysm stent-graft exclusions, coil embolization, and transcarotid artery revascularization (TCAR). In-stent restenosis is a rare complication without established guidelines for re-intervention. We successfully treated a patient with in-stent restenosis of a covered stent graft placed to exclude an ECAA utilizing a common carotid artery to internal carotid artery bypass.

Objectives: This study compared outcomes in patients with and without preoperative cardiac stress testing undergoing carotid endarterectomy (CEA).
Method(s): Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database who underwent elective carotid revascularization between 2016 and 2019 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, defined as evidence of ischemia or myocardial infarction (MI). Outcomes of interest were periprocedural MI/stroke, 90-day readmission rates, as well as late-term mortality.
Result(s): We analyzed 14,470 patients who underwent elective CEA. Of these, 5411 (37.4%) underwent preoperative stress testing and 1231 (29.4%) were positive. Comorbidities were significantly higher among patients undergoing CEA with preoperative stress test compared to those without stress testing. For patients with positive stress test undergoing CEA, there was a significant increase in postoperative MI (1.7% vs 0.6%; P <.001) and 90-day readmission rates (19.6% vs 15.8%; P =.003), but no significant change in postoperative stroke or congestive heart failure incidence. In 3-year follow-up after CEA, those with a positive stress test were more likely to undergo coronary artery bypass graft/percutaneous coronary intervention (adjusted hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.42-2.27; P <.0001) and also exhibited a 28% increase in mortality (adjusted HR, 1.28; 95% CI, 1.03-1.58; P =.03) in follow-up compared to those patients with a negative preoperative stress test (Figure). Conversely, those patients with a negative stress test compared to no stress test undergoing CEA experienced a 14% reduction in follow-up mortality (adjusted HR, 0.86; 95% CI, 0.76-0.98; P =.02) despite no difference in in-hospital MI/stroke or follow-up coronary artery bypass graft/percutaneous coronary intervention (adjusted HR, 0.94; 95% CI, 0.78-1.14; P =.53).
Conclusion(s): Our study highlights that cardiac stress testing in appropriately selected patients can facilitate risk stratification and identify patients at higher risk of postoperative adverse cardiac events. Furthermore, judicious patient selection for elective CEA is warranted in patients with a positive preoperative stress test given the increased late mortality. [Formula presented]
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Objectives: Though splenic artery aneurysms (SAAs) are the most common visceral aneurysm, there is a paucity of literature on the natural history of SAAs. The objective of this study was to review the natural history of patients with SAA.
Method(s): This single-institution retrospective analysis studied all patients with SAA diagnosed by computed tomography imaging between 2015 and 2019, identified by our radiology database. Imaging, demographic, and clinical data was obtained via the electronic medical record.
Result(s): The cohort consists of 853 patients with 894 SAA; 693 were female (81.2%), with 37 (5.3%) of them of childbearing age (15-50 years). Mean age at diagnosis was 70.9 years (range, 28-100 years). Medical comorbidities included hypertension (70.2%), prior smoking (32.2%), and hypercholesterolemia (54.7%) (Table I). Imaging indications included abdominal pain (37.3%), unrelated follow-up (28.0%) and follow-up of a previously noted visceral artery aneurysm (8.6%). Mean diameter at diagnosis was 13.3 +/- 6.3 mm. Eighty-one patients (9.0%) had more than one SAA. Anatomical locations included the splenic hilum (36.0%), distal splenic artery (30.3%), mid splenic artery (23.9%), and proximal splenic artery (9.7%). Radiographically, the majority were saccular aneurysms (72.4%). Additional characteristics included calcification (88.5%) and thrombus (13.9%). Associated imaging findings included aortic atherosclerosis (58.7%), abdominal aortic aneurysms (7.0%), and additional visceral aneurysms (4.1%). One patient (a 38-year-old female) was initially diagnosed at the time of rupture of a 25-mm aneurysm; this patient underwent immediate endovascular intervention with no complications. Mean clinical follow-up among 812 patients was 4.1 +/- 4.0 years. Mean radiological follow-up among 514 patients was 3.8 +/- 6.8 years. Of these, 122 patients (23.7%) experienced growth, with mean growth of 2.5mm. Aneurysm growth rates for initial sizes <10 mm (n = 123), 10 to 19 mm (n = 353), 20 to 29 mm (n = 34), and >30 mm (n = 4) were 0.166 mm/y, 0.172 mm/y, 0.383 mm/y, and 0.246 mm/y, respectively. Of the entire cohort, 27 patients (3.2%) eventually underwent intervention (81.5% endovascular), with the most common indications including size/growth criteria (70.4%) and symptom development (18.5%). On multivariate analysis, only prior tobacco use (P =.028) was significantly associated with aneurysm growth. Data stratified by sex and childbearing age are presented in Table II.
Conclusion(s): The majority of SAAs in this cohort remained stable in size, with few patients requiring intervention over mean follow-up of 4 years. Current guidelines recommending treatment of asymptomatic aneurysms >30 mm appear appropriate given their slow progression. Despite societal recommendations for intervention for all SAAs among women of childbearing age, only a minority underwent intervention in this series, indicating that these recommendations may not be well known in the general medical community. [Formula presented] [Formula presented]
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