A national census for the off-label treatment of complex aortic aneurysms.

OBJECTIVE: Despite regulatory challenges, device availability, and rapidly expanding techniques, off-label endovascular repair of complex aortic aneurysms (cAAs) has expanded in the past decade. Given the lack of United States Food and Drug Administration-approved endovascular technology to treat cAAs, we performed a national census to better understand volume and current practice patterns in the United States. METHODS: Targeted sampling identified vascular surgeons with experience in off-label endovascular repair of cAAs. An electronic survey was distributed with institutional review board approval from the University of Rochester to 261 individuals with a response rate of 38% (n = 98). RESULTS: A total of 93 respondents (95%) reported off-label endovascular repair of cAAs. Mean age was 45.7 ± 8.3 years, and 84% were male. Most respondents (59%) were within the first 10 years of practice, and 69% trained at institutions with a high-volume of off-label endovascular procedures for complex aortic aneurysms with or without a physician-sponsored investigational device exemption (PS-IDE). Twelve respondents from 11 institutions reported institutional PS-IDEs for physician-modified endografts (PMEGs), in-situ laser fenestration (ISLF), or parallel grafting technique (PGT), including sites with PS-IDEs for custom-manufactured devices. Eighty-nine unique institutions reported elective off-label endovascular repair with a mean of 20.2 ± 16.5 cases/year and ∼1757 total cases/year nationally. Eighty reported urgent/emergent off-label endovascular repair with a mean of 5.7 ± 5.4 cases/year and ∼499 total cases/year nationally. There was no correlation between high-volume endovascular institutions (>15 cases/year) and institutions with high volumes of open surgical repair for cAAs (>15 cases/year; odds ratio, 0.7; 95% confidence interval, 0.3-1.5; P = .34). Elective techniques included PMEG (70%), ISLF (30%), hybrid PMEG/ISLF (18%), and PGT (14%), with PMEG being the preferred technique for 63% of respondents. Techniques for emergent endovascular treatment of complex aortic disease included PMEG (52%), ISLF (40%), PGT (20%), and hybrid-PMEG/ISLF (14%), with PMEG being the preferred technique for 41% of respondents. Thirty-nine percent of respondents always or frequently offer referrals to institutions with PS-IDEs for custom-manufactured devices. The most common barrier for referral to PS-IDE centers included geographic distance (48%), longitudinal relationship with patient (45%), and costs associated with travel (33%). Only 61% of respondents participate in the Vascular Quality Initiative for complex endovascular aneurysm repair, and only 57% maintain a prospective institutional database. Eighty-six percent reported interest in a national collaborative database for off-label endovascular repair of cAA. CONCLUSIONS: Estimates of off-label endovascular repair of cAAs are likely underrepresented in the literature based on this national census. PMEG was the most common technique for elective and emergent procedures. Under-reported off-label endovascular repair of cAA outcomes data appears to be limited by non-standardized PS-IDE reporting to the United States Food and Drug Administration, and the lack of Vascular Quality Initiative participation and prospective institutional data collection. Most participants are interested in a national collaborative database for endovascular repair of cAAs.

Early Financial Outcomes of Physician Modified Endograft Programs Are Dictated by Device Cost.

INTRODUCTION: Physician-modified endografts (PMEGs) have been used for repair of thoracoabdominal aortic aneurysms (TAAAs) for 2 decades with good outcomes but limited financial data. This study compared the financial and clinical outcomes of PMEGs to the Cook Zenith-Fenestrated (ZFEN) graft and open surgical repair (OSR). METHODS: A retrospective review of financial and clinical data was performed for all patients who underwent endovascular or OSR of juxtarenal aortic aneurysms and TAAAs from January 2018 to December 2022 at an academic medical center. Clinical presentation, demographics, operative details, and outcomes were reviewed. Financial data was obtained through the institution's finance department. The primary end point was contribution margin (CM). RESULTS: Thirty patients met inclusion criteria, consisting of twelve PMEG, seven ZFEN, and eleven open repairs. PMEG repairs had a total CM of -$110,000 compared to $18,000 for ZFEN and $290,000 for OSR. Aortic and branch artery implants were major cost-drivers for endovascular procedures. Extent II TAAA repairs were the costliest PMEG procedure, with a total device cost of $59,000 per case. PMEG repairs had 30-d and 1-y mortality rates of 8.3% which was not significantly different from ZFEN (0.0%, P = 0.46; 0.0%, P = 0.46) or OSR (9.1%, P = 0.95; 18%, P = 0.51). Average intensive care unit and hospital stay after PMEG repairs were comparable to ZFEN and shorter than OSR. CONCLUSIONS: Our study suggests that PMEG repairs yield a negative CM. To make these cases financially viable for hospital systems, device costs will need to be reduced or reimbursement rates increased by approximately $8800.

Aneurysms of the superior mesenteric artery and its branches.

OBJECTIVE: Aneurysms of the superior mesenteric artery (SMA) and its branches are rare and account for only 6% to 15% of all visceral artery aneurysms. In the present report, we have described our 30-year experience with the management of aneurysms of the SMA and its branches at a high-volume referral center. METHODS: A retrospective review of all patients with a diagnosis of an aneurysm of the SMA or one of its branches from 1988 to 2018 was performed. Pseudoaneurysms and mycotic aneurysms were excluded. The clinical presentation, etiology, aneurysm shape and size, treatment modalities, and outcomes were analyzed. The growth rate of the aneurysms was estimated using linear regression. RESULTS: A total of 131 patients with 144 aneurysms were reviewed. The patients were primarily men (64%), with a median age of 60 years. Of the 144 aneurysms, 57 were fusiform, 30 were saccular, and 57 were dissection-associated aneurysms. Of the 131 patients, 41 had had an isolated SMA branch aneurysm. Degenerative aneurysms were the most common etiology (66%). A total of 35 patients (27%) were symptomatic at presentation. Of the 144 aneurysms, 111 had multiple computed tomography angiograms available, with a median follow-up of 43.6 months (interquartile range, 10.6-87.2 months). Only 18 aneurysms (16%) had had an estimated growth rate of ≥1.0 mm/y. The initial aneurysm size was significantly associated with the growth rate for the fusiform aneurysms (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.0-1.3]; P = .02) but not for the saccular (OR, 0.91; 95% CI, 0.76-1.1; P = 1.1) or dissection-associated (OR, 1.2; 95% CI, 0.91-1.5; P = .20) aneurysms. Acute abdominal pain (OR, 5.9; 95% CI, 1.6-22; P = .01) and chronic abdominal pain (OR, 3.7; 95% CI, 1.1-13; P = .04) were associated with aneurysm growth. Only two patients had a ruptured aneurysm, both of whom presented with rupture with no prior imaging studies. These two patients had a diagnosis of fibromuscular dysplasia and systemic lupus erythematosus, respectively. Of the 131 patients, 46 (34%) had undergone operative repair, including 36 open revascularizations and 8 endovascular procedures. The average aneurysm size for these 46 patients was 24.0 ± 8.6 mm. One patient died perioperatively, and nine patients experienced perioperative complications (25%). Of the 144 aneurysms, 91 were <20 mm, with an average size of 13.4 ± 3.1 mm. These 91 aneurysms had been followed up for a median of 120.8 months (interquartile range, 30.5-232.2 months), with no ruptures within this cohort during the follow-up period. CONCLUSIONS: The present study represents one of the largest series on aneurysms of the SMA and its branches. Our results showed that aneurysms of the SMA are relatively stable. Patients with symptomatic and fusiform aneurysms had a greater risk of growth. Aneurysms <20 mm with a degenerative etiology can be safely monitored without treatment.

Thirty-year single-center experience with arterial thoracic outlet syndrome.

OBJECTIVE: Arterial thoracic outlet syndrome (ATOS) is rare. We present our 30-year experience with the management of ATOS at a high-volume referral center. METHODS: A retrospective review of all patients who had undergone primary operative treatment for ATOS from 1988 to 2018 was performed. ATOS was defined as subclavian artery pathology caused by extrinsic compression from a bony abnormality within the thoracic outlet. RESULTS: A total of 41 patients (45 limbs) underwent surgery for ATOS at a median age of 46 years (interquartile range [IQR], 34-58 years). Chronic symptoms (>6 weeks) were present in 31 limbs (69%). Of the 45 limbs, 13 (29%) presented with acute limb ischemia (ALI), requiring urgent brachial artery thromboembolectomy (BAT) in 9 and catheter-directed thrombolysis and thrombectomy (CDT) in 4. All patients underwent thoracic outlet decompression. 31 limbs (69%) required subclavian artery reconstruction. No perioperative deaths and only one major adverse limb event occurred. Patients with ALI underwent staged thoracic outlet decompression after initial BAT or CDT at a median of 23 days (IQR, 11-140 days). Of the 13 limbs with an initial presentation of ALI, 8 (62%) had recurrent thromboembolic events before thoracic outlet decompression subsequently requiring 10 additional BATs and 1 CDT. The cumulative probability of recurrent embolization at 14, 30, and 90 days was 8.33% (95% confidence interval [CI], 1.28%-54.42%), 16.67% (95% CI, 4.70%-59.06%), and 33.33% (95% CI, 14.98-74.20%), respectively. The median follow-up for 32 patients (35 limbs) was 13 months (IQR, 5-36 months). Subclavian artery/graft primary and secondary patency was 87% and 90%, respectively, at 5 years by Kaplan-Meier analysis. Of the 35 limbs, 5 (14%) had chronic upper extremity pain and 5 (14%) had persistent weakness. Preoperative forearm or hand pain and brachial artery occlusion were associated with chronic pain (P = .04 and P = .03) and weakness (P = .03 and P = .02). Of the 13 limbs that presented with ALI, 11 had a median follow-up after thoracic outlet decompression of 6 months (IQR, 5-14 months), including 9 (82%) with oral anticoagulation therapy. Anticoagulation therapy had no effect on subclavian artery patency (P = 1.0) or the presence of chronic symptoms (P = .93). CONCLUSIONS: The presentation of ATOS is diverse, and the diagnosis can be delayed. Preoperative upper extremity pain and brachial artery occlusion in the setting of ALI were associated with chronic pain and weakness after thoracic outlet decompression. Delayed thoracic outlet decompression was associated with an increased risk of recurrent thromboembolic events for patients who presented with ALI. An early and accurate diagnosis of ATOS is necessary to reduce morbidity and optimize outcomes.

Are Vascular Surgery Trainees Satisfied and are They Using the Right Factors to Choose a Training Program?

BACKGROUND: Medical students and residents often evaluate training sites in vascular surgery with minimal exposure to those programs. We sought to identify factors associated with vascular surgery trainee satisfaction in relation to their current work environment and how they made their rank list. METHODS: All integrated residents and fellows currently in United States vascular training programs were queried using an anonymous electronic survey for variables of their current training environment, factors that influenced their rank order list, and satisfaction. Questions were graded on a Likert scale. Continuous, ordinal, and categorical variables were respectively analyzed using the two-sample t-test, Mann-Whitney U-test/Wilcoxon rank sum test, and Fisher's exact test. RESULTS: A total of 166 of 517 (32%) trainees completed the survey with equal distribution across postgraduate years. Respondents reported high rates of satisfaction with their training program overall (84%), including 88% (n = 83) of residents and 78% (n = 56) of fellows. Several work environment variables were associated with both resident and fellow satisfaction including program-funded trips for conferences and presentations (P = 0.027 for residents; P = 0.001 for fellows), diversity of operative cases (P = 0.024; P < 0.001), perception of a strong supportive social network at the hospital (P = 0.006; P = 0.001), and perception of appreciation by attending surgeons (P < 0.001; P < 0.001). Fellows who felt appreciated by nursing staff (P = 0.047), ancillary staff (P = 0.013), and patients were more likely to be satisfied (P = 0.011); however, this was not true for integrated residents. Social outings with nontrainee family and friends were associated with satisfaction for fellows (P = 0.002) but not integrated residents (P = 0.138), whereas social outings with vascular trainees were associated with satisfaction for integrated residents (P = 0.047) but not fellows (P = 0.375). Similarly, satisfied integrated residents were more likely to have close relationships with their vascular cotrainees (P = 0.035) than fellows (P = 0.349). No rank list factors were found to be predictive of current trainee satisfaction for integrated residents. Rank list factors associated with fellow satisfaction included recommendation of the institution from a mentor (P < 0.001), success of program graduates (P = 0.002), faculty (P = 0.014), perceived program prestige (P = 0.040), and amount of early operative exposure (P = 0.042). CONCLUSIONS: Vascular surgery trainees report a high level of satisfaction with their training program. Fellow satisfaction was more dependent on the perception of their workplace peers than integrated residents. Satisfied integrated residents were more likely to have close relationships with their vascular cotrainees than fellows.

Strategies to reduce rates of severe endothermal heat-induced thrombosis following radiofrequency ablation.

OBJECTIVE: Endothermal heat-induced thrombosis (EHIT) is a potential complication of radiofrequency ablation (RFA). Data on effective prophylaxis of EHIT are limited. In 2018, a high-volume, single institution implemented strategies to decrease the incidence of EHIT, including a single periprocedural prophylactic dose of low-molecular-weight heparin to patients with a great saphenous vein (GSV) diameter of ≥8 mm or saphenofemoral junction (SFJ) diameter of ≥10 mm and limiting treatment to one vein per procedure. The size threshold was derived from existing literature. The study objective was to evaluate the effects of these institutional changes on thrombotic complication rates after RFA. METHODS: A retrospective cohort control study was conducted using the Vascular Quality Initiative database. Data were collected for patients who underwent RFA with a GSV diameter of ≥8 mm or SFJ diameter of ≥10 mm from January 2015 to July 2022. The clinical end points were thrombotic complications (ie, thrombophlebitis, EHIT, deep vein thrombosis) and bleeding complications. Patient demographic and procedural variables were included in the analysis, and significant variables after univariable logistic regression were included in a multivariable logistic regression. RESULTS: After the policy change, the overall vein center EHIT rate decreased from 2.6% to 1.5%, with a trend toward significance (P = .096). The inclusion criterion of a GSV diameter of ≥8 mm or an SFJ diameter of ≥10 mm yielded 845 patients, of whom 298 were treated before the policy change and 547 after. There was a significant reduction in the rate of EHIT classified as class ≥III (2.34 vs 0.366; P = .020) after the institutional changes. Treatment of two or more veins and an increased vein diameter were associated with an increased risk of EHIT (P = .049 and P < .001, respectively). No significant association was found between periprocedural anticoagulation and all-cause thrombotic complications or EHIT (P = .563 and P = .885, respectively). CONCLUSIONS: The institutional policy changes have led to lower rates of EHIT, with a reduction in severe EHIT rates in patients with an ≥8-mm diameter GSV or a ≥10-mm diameter SFJ treated with RFA. Of the changes implemented, restricting treatment to one vein was associated with a reduction in severe EHIT. No association was found with periprocedural low-molecular-weight heparin, although a type 2 error might have occurred. Alternative strategies to prevent thrombotic complications should be explored, such as increasing the dosage and duration of periprocedural anticoagulation, antiplatelet use, and nonpharmacologic strategies.

Gore TAG thoracic branch endograft for treatment of a subacute type B aortic dissection complicated by rupture.

An 80-year-old man presented with a subacute zone 3-5 type B aortic dissection complicated by rupture and visceral and lower extremity malperfusion. He underwent emergent zone 2 repair with a Gore TAG thoracic branch endograft with inclusion of the left subclavian artery for a dominant left vertebral artery. The patient's postoperative course was uncomplicated. Type B aortic dissections can be anatomically complex, and rupture is a rare complication in the subacute phase. We report the novel use of a Gore TAG thoracic branch endograft for the management of type B aortic dissection complicated by rupture and demonstrate its feasibility for patients with type B aortic dissection complicated by rupture.

Common Femoral Artery Access on YouTube: What Practices are Being Shown and Who is Delivering the Message?

OBJECTIVES: Novice learners are increasingly turning to YouTube as a learning resource for surgical procedures. One example of such a procedure is common femoral artery puncture and sheath placement. Practitioners in several specialties perform this procedure to access the arterial system for angiography and intervention. We set forth to compare the techniques demonstrated on YouTube by the various specialists, as well as compare each specialty׳s prevalence on this website. METHODS: YouTube (www.youtube.com) was accessed in December 2015 at multiple time points with a cleared-cache web browser for the keyword search categories: "femoral artery access," "femoral access," and "angiography access." The top 500 videos from each of these keyword searches were analyzed. Videos were categorized by practitioner specialty, technique, duration of video, age of video, and total views. Videos with clear demonstration of femoral artery access were included in the analysis. All industry videos were excluded from the analysis. Categorical variables were compared using Fisher׳s exact test, and continuous variables were compared with the Student׳s t-test. RESULTS: A total of 2460, 4680 and 1800 videos were found for each keyword search, respectively. Of these, 33 videos clearly demonstrated femoral artery access technique. Vascular specialists, compared to interventional cardiology and radiology, had fewer videos (n = 4 vs. 14) and older videos (3.5 ± 2.1y vs. 2.25 ± 0.5y, p < 0.05). The vascular specialists demonstrated ultrasound-guided access, while interventional cardiology predominantly demonstrated landmark-guided access (p < 0.05). CONCLUSIONS: Although YouTube and other online resources are being used by novice learners, vascular specialists are underrepresented for femoral artery access, a foundational vascular procedure. Other practitioners demonstrate videos with landmark-guided access and rarely demonstrate ultrasound use. As recognized vascular experts, vascular surgeons should improve their visibility in online learning resources.