Faculty Bibliography

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.

BACKGROUND:While preoperative anemia is prevalent among surgical patients, its impact on patients undergoing transcarotid artery revascularization (TCAR) remains poorly understood. This study aims to assess the relationship between the severity of preoperative anemia and outcomes following TCAR. METHODS:A retrospective analysis of the Vascular Quality Initiative database (2016-2021) was performed to identify patients who underwent TCAR for carotid stenosis. Anemia was defined according to World Health Organization guidelines as a hemoglobin (Hb) level <12 g/dL in females and <13 g/dL in males. The severity of anemia was further classified as mild (Hb: 10-11.9 g/dL in females and 11-12.9 g/dL in males) or moderate to severe (Hb < 10 g/dL in females and <11 g/dL in males). Patients were stratified into three cohorts as follows, based on the presence and severity of preoperative anemia: no anemia, mild anemia, and moderate-to-severe anemia. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital stroke, in-hospital death, myocardial infarction (MI), and prolonged postoperative hospitalization (>1 day). Univariable and multivariable logistic regression analyses were conducted to evaluate the association between the severity of preoperative anemia and clinical outcomes. RESULTS:Among 21,648 patients who underwent TCAR, 4,240 (19.8%) had mild anemia, and 3,401 (15.8%) had moderate-to-severe anemia preoperatively. After adjusting for relevant clinical factors and confounders, moderate-to-severe preoperative anemia was associated with significantly increased odds of in-hospital MI (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI]: 1.53-3.74; P < 0.001), in-hospital death (aOR, 2.65; 95% CI: 1.62-4.34; P < 0.001), and 30-day mortality (aOR, 1.89; 95% CI: 1.32-2.72; P < 0.001) compared to nonanemic patients. Among patients with moderate-to-severe anemia, factors such as a history of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), urgent or emergent procedures, and symptomatic carotid stenosis were the strongest predictors of 30-day mortality. In contrast, mild anemia was not associated with increased odds of adverse postoperative outcomes compared to the nonanemic cohort. Preoperative anemia, regardless of severity, was not associated with an increased risk of postoperative stroke following TCAR. However, the severity of preoperative anemia was associated with a stepwise increase in the adjusted odds of prolonged hospitalization (aOR, 1.19 [mild anemia] and 1.57 [moderate-to-severe anemia]). CONCLUSION/CONCLUSIONS:In this multi-institutional retrospective study of patients undergoing TCAR, moderate-to-severe preoperative anemia was independently associated with higher adjusted odds of in-hospital MI, in-hospital death, and 30-day mortality, without an increased risk of postoperative stroke. These findings highlight moderate-to-severe preoperative anemia as a potential independent prognostic marker for identifying high-risk patients. Furthermore, incorporating the severity of anemia into preoperative risk stratification may aid in tailoring perioperative cardiac assessment and optimization strategies, potentially mitigating the risk of adverse outcomes following TCAR.

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.

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.

BACKGROUND AND AIMS/OBJECTIVE:Low functional capacity is an independent risk factor for cardiovascular (CV) events. Regular physical activity may reduce CV risk through suppression of inflammation and reduced platelet activity. We aimed to investigate the association of functional capacity quantified by the validated Duke Activity Status Index (DASI) with platelet activity and incident major adverse CV and limb events (MACLE) in individuals with peripheral artery disease (PAD) undergoing lower extremity revascularization (LER). METHODS:Light transmission aggregometry and platelet RNAseq were performed on specimens isolated from men and women prior to LER. Functional capacity was assessed using DASI. Prospective follow-up occurred at 1, 6, 12, and every 6 months following the LER. Subjects were separated into tertiles of DASI scores and incidence rates for MACLE were calculated using log-rank tests. Mediation analysis using linear regression fit with least squares was performed to test whether DASI exerted its effect on MACLE via platelet aggregation. RESULTS:281 patients completed the DASI questionnaire with scores ranging from 0.0 to 50.2 (bottom tertile: 0.0-9.95). Mean age was 74.4 ± 10.9 years and 32.4 % were female. During a median follow-up of 19 months, 163 (58.0 %) participants experienced a MACLE. After correction for demographics and CV risk factors, individuals in the lowest DASI tertile experienced significantly more MACLE than participants in other tertiles. The association between DASI and MACLE was consistent across multiple subgroups stratified by age, sex, body mass index, antiplatelet therapy, and clinical comorbidities. Mediation analyses suggested higher platelet aggregation to epinephrine in the bottom DASI tertile mediated 24.7 % [5.0 %, 103 %] of increased MACLE risk. Platelet mRNA demonstrated upregulation of inflammation pathways in the most sedentary individuals (lowest DASI tertile). CONCLUSIONS:Patients with PAD and low functional capacity have increased platelet activity and high incidence of MACLE. Our data suggest that elevated platelet aggregation mediates one-quarter of the MACLE risk in persons with low functional capacity undergoing LER. Our findings support a potential platelet-mediated mechanism for improved CV outcomes associated with regular physical activity.

OBJECTIVE:Venous duplex ultrasound (VDUS) is the accepted initial imaging study to rule out lower extremity deep venous thrombosis (DVT). In accordance with the Intersocietal Accreditation Commission (IAC) vascular laboratory policies, many institutions require technicians to additionally assess the asymptomatic contralateral common femoral vein. There is conflicting literature on whether this policy is needed. Therefore, the aim of this study was to investigate the utility of examining the asymptomatic contralateral common femoral vein in patients undergoing a unilateral lower extremity VDUS to rule out DVT by (1) defining the prevalence of DVT in the contralateral asymptomatic limb and (2) identifying risk factors that predispose patients to develop a DVT in the asymptomatic limb. METHODS:and Student's t-tests, respectively. For all tests, a P-value of <0.05 was considered statistically significant. RESULTS:371 patients (170 inpatient vs. 201 outpatient) with unilateral DVT symptoms who underwent VDUS during the study period were identified. Right leg symptoms were present in 186 (50%) patients and left leg symptoms were present in 185 (50%) patients. The overall incidence of acute DVT in the symptomatic limb was 17% (17.4% outpatient vs. 16.5% inpatient, p=NS). Outpatients were more likely to have superficial venous thrombosis (7.0% vs. 0.6%, p=0.002) and chronic venous changes (25.4% vs. 1.2%, p<0.001) in the symptomatic limb. 59% of DVTs in the symptomatic limb were documented in the calf veins, 25% in the proximal veins, and 16% in both the proximal and calf veins. There were no incidences of bilateral DVT in our cohort. Moreover, none of the patients had a DVT isolated to the contralateral common femoral vein. CONCLUSIONS:Scanning the asymptomatic contralateral common femoral vein may not be necessary for patients undergoing unilateral VDUS for symptomatic DVT, regardless of thrombotic risk factors. A single-extremity study will suffice in most cases, and if implemented, it will improve vascular laboratory efficiency and decrease costs without a decline in DVT detection.

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.

OBJECTIVES/OBJECTIVE:While the use of endovascular intervention for peripheral artery disease (PAD) has expanded in recent years, there remains relatively few studies focused on the endovascular treatment of isolated popliteal artery occlusive disease. The popliteal artery presents a particular challenge for endovascular intervention due to the constant flexion at the knee. We sought to assess the outcomes for endovascular management of isolated popliteal artery occlusive disease based on type of intervention performed. METHODS:The Vascular Qualitative Initiative (VQI) database was queried for patients with isolated popliteal artery occlusive disease who underwent endovascular intervention from January 2011 to December 2019. Patients were excluded from analysis if they did not have Medicare FFS entitlement, had a history of prior intervention in the ipsilateral limb, or had vessels treated in addition to the popliteal artery. Patients were stratified into groups based on their initial presenting symptom (claudication vs. chronic limb threatening ischemia (CLTI)) and were analyzed by endovascular procedure performed (plain old balloon angioplasty (POBA) vs. adjunctive stent/atherectomy). The POBA group underwent only plain balloon angioplasty whereas the adjunctive stent/atherectomy group underwent any type of balloon angioplasty and adjunctive stenting or atherectomy or both. The primary outcome was amputation-free survival, a composite outcome of freedom from major amputation and/or death. RESULTS:A total of 1,740 patients met criteria for analysis who underwent endovascular intervention for isolated popliteal artery occlusive disease. Among patients with claudication, the amputation-free survival rate was significantly higher at 1 year and 3 years for patients treated with adjunctive stent/atherectomy compared to POBA (1 year: 94.2% vs. 88.9%, p = 0.03; 3 years: 83.0% vs. 76.6%, p = 0.04). This difference appeared to be driven by mortality, as mortality was significantly better for adjunctive stent/atherectomy compared to POBA (1 year: 4.6% vs. 10.2%, p = 0.01; 3 years: 15.4% vs. 23.3%, p = 0.02), whereas major amputation rates were not significantly different. However, multivariable analysis showed that use of adjunctive stent/atherectomy was not independently associated with improved amputation-free survival (adjusted HR 0.74, 95% CI 0.48-1.16, p = 0.19). In the CLTI group, amputation-free survival rates were not significantly different for patients treated with adjunctive stent/atherectomy compared to POBA (1 year: 65% vs. 64.6%, p = 0.78; 3 years: 47.1% vs. 42.6%, p = 0.30). Re-intervention rates were not statistically different when stratified by use of adjunctive therapies in either the claudication or CLTI groups. CONCLUSION/CONCLUSIONS:Our results suggest that across all patients with isolated popliteal artery occlusive disease, amputation-free survival rates were comparable regardless of endovascular treatment modality. As expected, amputation-free survival for patients presenting with claudication was favorable compared to those with CLTI, and was driven primarily by mortality. Re-intervention rates were similar across all patients regardless of treatment modality. This study underscores the clinical challenge of treating isolated popliteal artery occlusive disease and stresses the need for further study of adjunctive modalities in treating complex lesions.