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.

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.

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.

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.

OBJECTIVE:Patients with peripheral artery disease (PAD) undergo lower extremity revascularization (LER) for symptomatic relief or limb salvage. Despite LER, patients remain at increased risk of platelet-mediated complications, such as major adverse cardiac and limb events (MACLEs). Platelet activity is associated with cardiovascular events, yet little is known about the dynamic nature of platelet activity over time. We, therefore, investigated the change in platelet activity over time and its association with long-term cardiovascular risk. METHODS:Patients with PAD undergoing LER were enrolled into the multicenter, prospective Platelet Activity and Cardiovascular Events study. Platelet aggregation was assessed by light transmission aggregometry to submaximal epinephrine (0.4 μmol/L) immediately before LER, and on postoperative day 1 or 2 (POD1 or POD2) and 30 (POD30). A hyperreactive platelet phenotype was defined as >60% aggregation. Patients were followed longitudinally for MACLEs, defined as the composite of death, myocardial infarction, stroke, major lower extremity amputation, or acute limb ischemia leading to reintervention. RESULTS:Among 287 patients undergoing LER, the mean age was 70 ± 11 years, 33% were female, 61% were White, and 89% were on baseline antiplatelet therapy. Platelet aggregation to submaximal epinephrine induced a bimodal response; 15.5%, 16.8%, and 16.4% of patients demonstrated a hyperreactive platelet phenotype at baseline, POD1, and POD30, respectively. Platelet aggregation increased by 18.5% (P = .001) from baseline to POD1, which subsequently returned to baseline at POD30. After a median follow-up of 19 months, MACLEs occurred in 165 patients (57%). After adjustment for demographics, clinical risk factors, procedure type, and antiplatelet therapy, platelet hyperreactivity at POD1 was associated with a significant hazard of long-term MACLE (adjusted hazard ratio, 4.61; 95% confidence interval, 2.08-10.20; P < .001). CONCLUSIONS:Among patients with severe PAD, platelet activity increases after LER. Platelet hyperreactivity to submaximal epinephrine on POD1 is associated with long-term MACLE. Platelet activity after LER may represent a modifiable biomarker associated with excess cardiovascular risk.

OBJECTIVES/OBJECTIVE:Total contact casting (TCC) is used to promote wound closure in diabetic foot ulcers (DFUs); however, this technique is underused today. This study aims to further evaluate the efficacy of TCC in a large cohort, including patients with peripheral artery disease (PAD). METHODS:This was a retrospective analysis of patients with DFUs who underwent TCC from 2017 to 2021. PAD was defined as absence of pedal pulse or ABI <0.9. Demographic data, DFU characteristics, and peripheral arterial intervention were evaluated. Outcomes included complete healing, healing time, and rate of major amputation. Subgroup analysis was performed on patients undergoing peripheral intervention. RESULTS:= .0008) compared to patients without intervention. CONCLUSIONS:TCC remains an effective option for treatment of DFUs, as most were completely healed. Patients with PAD may benefit from TCC and revascularization, however, healing rates are lower in this cohort, necessitating the need for close observation.

OBJECTIVE:Vascular surgeons are often called upon to provide emergent surgical assistance to other specialties for iatrogenic complications, both intraoperatively and in the inpatient setting. The management of iatrogenic vascular injury remains a critical role of the vascular surgeon, especially in the context of the increasing adoption of percutaneous procedures by other specialties. This study aims to characterize consultation timing, management, and outcomes for iatrogenic vascular injuries. METHODS:This study identified patients for whom vascular surgery was consulted for iatrogenic vascular complications from February 1, 2022, to May 12, 2023. Patient information, including demographic information, injury details, and details of any operative intervention, was retrospectively collected from February 1, 2022, to October 13, 2022, and prospectively collected for the remainder of the study period. Analyses were performed with R (version 2022.02.03). RESULTS:There were 87 patients with consultations related to iatrogenic vascular injury. Of these, 42 (46%) were female and the mean age was 59 years (±18 years). The most common consulting services were cardiology (32%), cardiothoracic surgery (26%), general surgery (8%), and neurointerventional radiology (10%). Reasons for consultation included hemorrhage (36%), limb ischemia (36%), and treatment of pseudoaneurysm (23%). A total of 24% of consults were intraoperative, 20% of consults related to extracorporeal membrane oxygenation cannulation, and 16% of consults related to ventricular assist devices including left ventricular assist device and intra-aortic balloon pump. The majority of these consult requests (60%) occurred during evening and night hours (5 PM to 7 AM). Emergent intervention was required in 62% of cases and consisted of primary open surgical repair of arterial injury (54%), endovascular intervention (21%), and open thromboembolectomy (15%). Overall, in-hospital mortality for the patient cohort was 20% and the reintervention rate was 23%, reflecting the underlying complexity of the illness and nature of the vascular injury in this patient group. CONCLUSIONS:Vascular surgeons play an essential role in managing emergent life-threatening hemorrhagic and ischemic iatrogenic vascular complications in the hospitalized setting. The complications require immediate bedside or intraoperative consult and often emergent open surgical or endovascular intervention. Furthermore, many of these require urgent management in the evening or overnight hours, and therefore the high frequency of these events represents a potential significant resource utilization and workforce issue to the vascular surgery workforce.

OBJECTIVE:The objective of this study was to investigate the administrative and clinical impacts of prior authorization (PA) processes in the Office-Based Laboratory (OBL) setting. METHODS:This single-institution retrospective analysis studied all OBL PAs pursued between January 2018 and March 2022. Case, PA, and coding information was obtained from the practice's scheduling database. RESULTS:Over the study period, 1,854 OBL cases were scheduled; 8% (n=146) required PA. Of these, 75% (n=110) were for lower extremity arterial interventions, 19% (n=27) were for deep venous interventions, and 6% (n=9) were for other interventions. Of 146 PAs, 19% (n=27) were initially denied but 74.1% (n=7) of these were overturned on appeal. Deep venous procedures were initially denied, at 43.8% (n=14) more often than were arterial procedures, at 11.8% (n=13). Of 146 requested procedures, 4% (n=6) were delayed due to pending prior authorization determination by a mean 14.2±18.3 working days. An additional 6% (n=8) of procedures were performed in the interest of time prior to final determination. Of the 7 terminally denied procedures, 57% (n=4) were performed at cost to the practice based on clinical judgment. CONCLUSIONS:Utilizing prior authorization appeals mechanisms, while administratively onerous, resulted in the overturning of most initial denials.