Comparison of anticoagulation vs mechanical thrombectomy for the treatment of iliofemoral deep vein thrombosis.

OBJECTIVE: To compare the comparative effects of treatment with contemporary mechanical thrombectomy (MT) or anticoagulation (AC) on Villalta scores and post-thrombotic syndrome (PTS) incidence through 12 months in iliofemoral deep vein thrombosis (DVT). METHODS: Patients with DVT in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) randomized trial and the ClotTriever Outcomes (CLOUT) registry were included in this analysis. Both studies evaluated the effects of thrombus removal on the incidence of PTS. Patients with bilateral DVT, isolated femoral-popliteal DVT, symptom duration of >4 weeks, or incomplete case data for matching covariates were excluded. Propensity scores were used to match patients 1:1 who received AC (from ATTRACT) with those treated with mechanical thrombectomy (from CLOUT) using nearest neighbor matching on nine baseline covariates, including age, body mass index, leg treated, provoked DVT, prior venous thromboembolism, race, sex, Villalta score, and symptom duration. Clinical outcomes, including Villalta score and PTS, were assessed. Logistic regression was used to estimate the likelihood of developing PTS at 12 months. RESULTS: A total of 164 pairs were matched, with no significant differences in baseline characteristics after matching. There were fewer patients with any PTS at 6 months (19% vs 46%; P < .001) and 12 months (17% vs 38%; P < .001) in the MT treatment group. Modeling revealed that, after adjusting for baseline Villalta scores, patients treated with AC had significantly higher odds of developing any PTS (odds ratio, 3.1; 95% confidence interval, 1.5-6.2; P = .002) or moderate to severe PTS (odds ratio, 3.1; 95% confidence interval, 1.1-8.4; P = .027) at 12 months compared with those treated with MT. Mean Villalta scores were lower through 12 months among those receiving MT vs AC (3.3 vs 6.3 at 30 days, 2.5 vs 5.5 at 6 months, and 2.6 vs 4.9 at 12 months; P < .001 for all). CONCLUSIONS: MT treatment of iliofemoral DVT was associated with significantly lower Villalta scores and a lower incidence of PTS through 12 months compared with treatment using AC. Results from currently enrolling clinical trials will further clarify the role of these therapies in the prevention of PTS after an acute DVT event.

Mechanical Thrombectomy vs. Pharmacomechanical Catheter Directed Thrombolysis for the Treatment of Iliofemoral Deep Vein Thrombosis: A Propensity Score Matched Exploratory Analysis of 12 Month Clinical Outcomes.

OBJECTIVE: To 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 covariables, 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: 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.

Six-Month Outcomes of Mechanical Thrombectomy for Treating Deep Vein Thrombosis: Analysis from the 500-Patient CLOUT Registry.

PURPOSE: Mechanical thrombectomy for the treatment of deep vein thrombosis (DVT) is being increasingly utilized to reduce symptoms and prevent postthrombotic syndrome (PTS), but more data on clinical outcomes are needed. Mechanical thrombectomy was studied in the ClotTriever Outcomes (CLOUT) registry with 6-month full analysis outcomes reported herein. MATERIALS AND METHODS: The CLOUT registry is a prospective, all-comer study that enrolled 500 lower extremity DVT patients across 43 US sites treated with mechanical thrombectomy using the ClotTriever System. Core-lab assessed Marder scores and physician-assessed venous patency by duplex ultrasound, PTS assessment using Villalta score, venous symptom severity, pain, and quality of life scores through 6 months were analyzed. Adverse events were identified and independently adjudicated. RESULTS: All-cause mortality at 30 days was 0.9%, and 8.6% of subjects experienced a serious adverse event (SAE) within the first 30 days, 1 of which (0.2%) was device related. SAE rethrombosis/residual thrombus incidence was 4.8% at 30 days and 8.0% at 6 months. Between baseline and 6 months, venous flow increased from 27.2% to 92.5% of limbs (P < 0.0001), and venous compressibility improved from 28.0% to 91.8% (P < 0.0001), while median Villalta scores improved from 9.0 at baseline to 1.0 at 6 months (P < 0.0001). Significant improvements in venous symptom severity, pain, and quality of life were also demonstrated. Outcomes from iliofemoral and isolated femoral-popliteal segments showed similar improvements. CONCLUSION: Outcomes from the CLOUT study, a large prospective registry for DVT, indicate that mechanical thrombectomy is safe and demonstrates significant improvement in symptoms and health status through 6 months. Level of Evidence 3: Non-randomized controlled cohort/follow-up study.

Symptomatic Profunda Femoris Artery Aneurysm With Superficial Calf Ulcerations.

Profunda femoris artery aneurysms (PFAA) account for less than 0.5% of peripheral aneurysms. Most PFAA are secondary to trauma, iatrogenic injury, or infection, whereas the incidence of true atherosclerotic aneurysms is especially rare. These aneurysms are typically asymptomatic but can cause nerve compression, deep vein thrombosis, pain, swelling, and even rupture. We present a case of bilateral PFAA in conjunction with bilateral popliteal artery aneurysms in which the patient had rare unilateral symptoms involving calf ulcerations suggestive of geniculate emboli. We explore this unusual presentation and etiology as well as discuss the options for repair of complex PFAA.

Aortic Healing Appears to Occur Rapidly after Successful Endovascular Sealing of Blunt Thoracic Aortic Injury.

BACKGROUND: The traumatic nature of blunt thoracic aortic injury (BTAI) would suggest that healing of the aorta would occur once the injured area is shielded from aortic pressure. This would be in contrast to degenerative aortic diseases which often continue to degenerate despite coverage. We hypothesize that after successful thoracic aortic endografting (TEVAR) that the aorta rapidly heals itself leaving minimal to no trace of the residual injury. METHODS: BTAI that were successfully covered with TEVAR from 2006 to 2019 were collected. Those with failed sealing or a lack of follow-up scans were excluded. Centerline aortic diameters were measured at healthy aorta 1 cm above (D1) and below the injury (D3) and at the widest point of injury (D2) on preoperative and initial postoperative computed tomography (CT) scans. Postoperative CTs were examined for residual signs of aortic injury including residual periaortic hematoma, persistent thrombosed pseudoaneurysm, or thickened aortic wall. Diameter changes in the healthy and injured aortic segments were compared pre and post TEVAR. Aortic diameter changes were analyzed with the Student's t-test. RESULTS: Twenty four patients were identified with sealed BTAI. The mean graft diameter was 24.2 ± 3.2 mm with oversizing of 10.74 ± 6.1 % at D1 and 19.52 ± 10.22 % at D3. Postoperative CTs occurred at 61.25 ± 123.6 days with one outlier at 602 days. Injured aortic segments (D2) had significantly larger diameters compared to D1 (28.94 ± 5.08 mm vs. 22.14 ± 3.08 mm, P < 0.001). After TEVAR, 23/24 (95.8%) had no residual radiographic evidence of aortic injury by 2 months. One patient had a persistent thrombosed pseudoaneurysm likely due to more than 50% disruption of the aortic wall. Post TEVAR, there was a significant diameter reduction at D2 by 13.8% (29.10 ± 5.27 mm vs. 24.8 ± 4.2 mm, P < 0.001) which was within 2.45% of the mean stent graft diameter. The healthy aorta dilated to accommodate the graft by 9% at D1 (21.9 ± 3.0 vs. 23.7 ± 2.5 mm, P < 0.001) and 17% at D3 (20.6 ± 3.4 mm vs. 23.6 ± 3.2 mm, P < 0.001). CONCLUSIONS: TEVAR promotes rapid aortic healing in BTAI with no evidence of residual aortic injury suggesting that a long-term seal is not necessary. The healthy aorta dilates to the stent graft size, as expected, whereas the injured aortic segment heals around the stent graft and assumes its diameter as well. Massive disruption of the aortic wall may preclude early healing.

Interim outcomes of mechanical thrombectomy for deep vein thrombosis from the All-Comer CLOUT Registry.

OBJECTIVES: The multicenter, prospective, single arm CLOUT registry assesses the safety and effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) for the treatment of acute and nonacute lower extremity deep vein thrombosis (DVT) in all-comer patients. Reported here are the outcomes of the first 250 patients. METHODS: All-comer patients with lower extremity DVT were enrolled, including those with bilateral DVT, those with previously failed DVT treatment, and regardless of symptom duration. The primary effectiveness end point is complete or near-complete (≥75%) thrombus removal determined by independent core laboratory-adjudicated Marder scores. Safety outcomes include serious adverse events through 30 days and clinical outcomes include post-thrombotic syndrome severity, symptoms, pain, and quality of life through 6 months. RESULTS: The median age was 62 years and 40% of patients had contraindications to thrombolytics. A range of thrombus chronicity (33% acute, 35% subacute, 32% chronic) was observed. No patients received thrombolytics and 99.6% were treated in a single session. The median thrombectomy time was 28 minutes. The primary effectiveness end point was achieved in 86% of limbs. Through 30 days, one device-related serious adverse event occurred. At 6 months, 24% of patients had post-thrombotic syndrome. Significant and sustained improvements were observed in all clinical outcomes, including the Revised Venous Clinical Severity Score, the numeric pain rating scale, and the EuroQol Group 5-Dimension Self-Report Questionnaire. CONCLUSIONS: The 6-month outcomes from the all-comer CLOUT registry with a range of thrombus chronicities demonstrate favorable effectiveness, safety, and sustained clinical improvements.

A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy.

Coronavirus disease 2019 (COVID-19) has been widely reported to be associated with increased risk of Venous Thromboembolism, both deep vein thrombosis (DVT) and pulmonary embolism. A rare and extreme manifestation of DVT is Phlegmasia cerulea dolens, characterized by poor tissue perfusion due to marked limb swelling which can progress to limb and life-threatening venous gangrene. We report the case of a 53-year-old man with severe SARS-CoV2 pneumonia who developed acute iliofemoral DVT leading to acute limb ischemia due to Phlegmasia cerulea dolens. The patient underwent successful emergent fasciotomy and mechanical thrombectomy with removal of extensive thrombus burden and restoration of normal venous circulation. Our case highlights the importance of clinical vigilance and early implementation of therapeutic interventions to avoid adverse outcomes in patients who develop SARS-CoV2 induced Venous Thromboembolism complications.

Vascular Surgeons as Expert Witnesses in Malpractice Litigation.

BACKGROUND: This study investigates the role of vascular surgeons as expert witnesses in United States' malpractice claims. MATERIALS AND METHODS: We reviewed the Westlaw database from 1999 through 2014 using the search terms "vascular" and "surgeon". Case defendant, plaintiff, allegation, and verdict were compiled. Surgeon expert witness demographic data including age, practice duration, scholarly impact (H-index) and practice setting were reviewed using faculty websites, state licensing boards, and Scopus database. RESULTS: A total of 785 cases were identified, Three-hundred seventy-seven with a vascular surgeon as the plaintiff or defense expert witness. Vascular surgeons were defense experts in One-hundred thirty one (34.75%) cases, plaintiff experts in One-hundred eighteen (31.3%), both plaintiff and defense experts in Ninty six (25.46%), or unspecified in Thiry two cases (8.29%). Two-hunder eighty three individual expert witnesses were identified. Vascular surgeon experts who testified 4 or more times were likely to be plaintiff experts (32.5% versus 18.7%, P <0.05). Mean years of practice (23.5 versus 24.2, P = 0.10) between plaintiff and defense experts was comparable. Plaintiff experts were more likely in non-academic practice (64.4% versus 52.5%, P <0.05) with lower scholarly impact (H-index 12.8 versus 16.7, P <0.05). CONCLUSIONS: A small percentage of vascular surgeons were experts in multiple cases, especially as plaintiff witnesses. Vascular surgeons as plaintiff's witnesses have similar years of age, work less in an academics, and have lower scholarly impact than defense witnesses. While national organizations provide guidelines defining expert witness qualifications, the required credentials vary by State. Development of minimum qualifications nationally may improve consistency in expert credentialing and lead to more ethical trial representation.

Use of three-dimensional-three-dimensional digital subtraction angiography spin fusion protocol for complex aortoiliac endovascular interventions.

Complex endovascular aortic interventions in patients with excessive tortuosity or difficult gantry angles can be challenging. Although fusion imaging can help navigate these issues, it is based on preoperative imaging studies, which becomes skewed after introduction of stiff wires and large devices into the aorta. The subtraction spin protocol performs two cone-beam computed tomography scans to create a subtracted image of the contrast-filled vessels after wire and device placement to accommodate vessel distortion. We have reported a complex fenestrated endovascular aneurysm repair case with a highly angulated neck to highlight the advantages of the subtraction spin protocol in anatomically hostile endovascular repairs.

Endovascular Solution to Endoleak Phenomenon After Open Repair of Abdominal Aortic Aneurysm.

Endovascular aneurysm repair (EVAR) has quickly outpaced open treatment of infrarenal abdominal aortic aneurysm (AAA) and iliac artery aneurysms, relegating most open AAA repair for either young patients with long life expectancy or patients with extreme anatomic constraints. Typically, open repair involves opening the aneurysm sac with suture ligation of back-bleeding vessels. However, in situations where an aortobifemoral repair is performed, proximal and distal ligation can be performed leaving behind a "remnant" aorta and iliac arteries. Usually, major palpable vessels are ligated and small lumbars spontaneously thrombose. However, failure of this to occur can lead to a rare situation in which there is persistent filling of a remnant aorta and aneurysm sac leading to a situation similar to a type II endoleak after EVAR. Typically, this leak has been repaired by open ligation. We present a technique for endovascular coiling and thrombin injection to correct a "type II endoleak" from a back-bleeding lumbar artery after open aortoiliac and femoral aneurysm repair.

Mid-Term Outcomes of Thrombolysis for Acute Lower Extremity Ischemia at a Tertiary Care Center.

BACKGROUND: Acute limb ischemia (ALI) is challenging to treat because of high morbidity and mortality. Endovascular-first options beginning with thrombolysis are technically feasible with similar results to open surgery. We examined our experience with thrombolysis to identify patients and target conduits that are predictive of improved outcomes. METHODS: We performed a retrospective review of our institutional database of thrombolysis cases for arterial lower extremity disease. Thrombolysis was the index procedure, and any subsequent treatment was a reintervention. Conversion to open surgery perioperatively such as thromboembolectomy or bypass was considered a technical failure. Primary outcomes included primary patency, secondary patency, amputation-free survival (AFS), and survival. Secondary outcomes included conversion to open, reintervention <30 days, and amputation <30 days. Descriptive statistics and analysis of variance were performed for preoperative and intraoperative risk factors. Kaplan-Meier estimation and Cox proportional hazard models were used for primary and secondary outcomes. RESULTS: Ninety-nine patients with ALI were treated with thrombolysis from 2007 to 2017. Thrombolysis was attempted on native artery (40%), vein bypass (7%), prosthetic bypass (33%), and stent (19%). Rutherford class distribution was 50% class 1, 41% class 2a, 5% class 2b, and 3% class 3. Technical success was 70%, characterized by an all-endovascular approach, patency at 30 days, and AFS for 30 days. Primary patency at 1- and 2-years was 31% and 22%, respectively. Secondary patency at 1- and 2-years was 39% and 27%, respectively. Overall, 30% required conversion to open surgery at the time of the index procedure, 7% reintervention <30 days, 5% mortality <30 days, and 5% major amputation <30 days. Prosthetic grafts and vein bypasses had the worst primary and secondary patency (P < 0.05). Five out of 7 vein bypasses required open conversion. Thrombolysis of native arteries was most successful maintaining primary patency (P < 0.05), secondary patency (P < 0.05), and AFS (P < 0.05). Patients who had adjunctive procedures at the time of thrombolysis had a significantly greater primary patency (P < 0.05) and secondary patency (P < 0.05) but not greater AFS. CONCLUSION: Outcomes in thrombolysis for ALI have not significantly improved 20 years after the STILE trial. Technical success and mid-term patency rates are modest at best. Thrombolysis of vein bypasses and prosthetic grafts have poor technical success and primary patency compared with native arteries. However, aggressive adjunctive interventions during thrombolysis appear to improve primary and secondary patency.

Endovascular repair of infected carotid pseudoaneurysm: A case report.

BACKGROUND: Pseudoaneurysm (PA) of the carotid artery is a rare but life-threatening complication following carotid endarterectomy (CEA). Management of carotid PAs is challenging due to the increased risk of stroke and nerve injury in an infected and re-operative field. Open surgery has been the mainstay for this complicated pathology however some patients have characteristics which make an endovascular approach more advantageous. Yet endovascular intervention for infected fields is scrutinized and used as a last option. HISTORY AND TREATMENT PLAN: 72 year old female with history of basilar artery aneurysm embolization and right internal carotid artery occlusion presented with a left carotid pseudoaneurysm after a CEA 6 months prior. She presented with 2 days of increasing left neck swelling, erythema, and a small ulcerated area with bloody discharge from incision site. A Computed Tomagraphy scan (CTA) showed hematoma surrounding the left ICA concerning for PA. Wound cultures were obtained which grew coagulase (-) staphylococcus. We elected to perform an endovascular procedure to temporize the bleeding by placing a stent graft (7 mm × 7.5 cm Gore Viabahn) across the left ICA. She remains asymptomatic with no recurrent symptoms 6 months postoperatively. CONCLUSION: Our experience in this patient indicates that endovascular stenting could be feasible and potentially effective intervention for infection-associated post-CEA PA in patients with an excessively high risk for stroke and nerve injury. We suggest each patient should be evaluated individually and all pertinent characteristics should be considered to make the best decision.

Endovascular Repair of the Ascending Aorta for an Anastomotic Saphenous Vein Graft Aneurysm.

The ascending aorta is the final segment of the aorta to be explored with endovascular stent grafts. With a patient population of increasingly advanced age and disease, there are situations where traditional open repair for ascending aneurysms or dissections may be prohibitive. However, the ascending aorta has multiple hostile characteristics that make endovascular treatment challenging. There is also a lack of approved specialized devices in the United States for this aortic territory. We demonstrate the feasibility of adapting an abdominal aortic graft to the ascending aorta for the treatment of a saphenous vein graft aneurysm with a discussion of the technical considerations for the operation.

Endovascular Thoracic Aortic Repair for Catheter Associated Aortic Injury During Thoracostomy Tube Placement.

BACKGROUND: Aortic injuries during non-aortic related procedures are rare but potentially catastrophic. Endovascular aortic repair has been described as a viable option in similar circumstances. However, most reports involve aortic injury from orthopaedic hardware after spine surgery or trocar injury during abdominal surgery. REPORT: This is a report of a thoracic aortic injury during thoracostomy tube placement and summary of the management paradigm. The patient was treated with a thoracic stent graft and was seen at four-month follow up, with imaging showing the endograft in stable position. CONCLUSION: Endovascular stenting can increase the treatment scope for management of emergent thoracic aortic pathology.

Intimomedial mucoid degeneration of the peripheral arteries.

Intimomedial mucoid degeneration, a rare vascular disorder characterized by mucinous deposition in the intima and media layers, causes aneurysmal degeneration of the vessel wall in young patients. Because of the potential for involvement of multiple vessels, these patients may require full body imaging and long-term follow-up. We describe three patients with intimomedial mucoid degeneration and variable clinical presentations. One patient presented emergently with a spontaneously ruptured nonaneurysmal subclavian artery; one patient presented with a known posterior tibial artery aneurysm and new onset of focal pain and paresthesias over the aneurysm; and one patient presented with a self-discovered dorsalis pedis artery aneurysm.

Parallel Stent Graft Technique for Hypogastric Aneurysm Repair With Flow Preservation of Distal Pelvic Circulation.

Hypogastric artery aneurysms (HAA) necessitate repair due to significant morbidity and potential mortality associated with rupture. Coverage or coiling of HAA are not always possible, as the risk of pelvic and spinal cord ischemia become especially significant in bilateral hypogastric disease as well as with prior extensive aortic coverage. We report 2 cases of endovascular HAA exclusion using parallel stent grafts for preservation of flow through the distal hypogastric artery branches and external iliac artery in patients with prior thoracic and abdominal aortic repairs, contralateral hypogastric disease, and significant anatomic constraints.

Why Do Vascular Surgeons Get Sued? Analysis of Claims and Outcomes in Malpractice Litigation.

BACKGROUND: The objective of the study was to analyze causes and outcomes of malpractice claims against vascular surgeons in the United States. METHODS: Cases entered into the Westlaw database from January 1, 1999 to December 31, 2014 were reviewed. Search terms "vascular" and "surgeon" were used. Data were compiled on the allegation, subject matter, and outcome of each case. Additional data including demographics of the defendant were obtained from the U.S. News Health reports on practicing physicians. RESULTS: Of a total of 785 cases identified from the Westlaw database using the search terms "vascular" and "surgeon", 485 (61.8%) were identified where a vascular surgeon was the defendant or expert witness. Of these, 135 (27.8%) had a vascular surgeon identified as a defendant. Among these 135 cases, 88 (65.2%) were found for the defendant with 31 (23%) and 15 (11.1%) being found for the plaintiff or settled, respectively. Of the 31 cases found for the plaintiff, the median award was $750,000 and mean award was $1,830,000. Mean time from incident to verdict was 4.8 years. The most common procedures which led to litigation were open or endovascular peripheral revascularization (PR) (14.8%), carotid interventions (CIs) (11.85%), aortic interventions (AI) (11.1%), vascular trauma (9.63%), dialysis access (8.15%), and venous surgery (5.93%). The most common allegation was "failure to diagnose and treat" (48.9%), followed by complication of open surgery (31.85%) and negligent procedure (25.19%). The most common injuries reported were death (31.85%), major amputation (23.7%), neurovascular injury (14.8%), and bleeding (5.9%). CONCLUSIONS: Analysis of vascular surgery malpractice litigation in the Westlaw database revealed details regarding the subject matter and outcomes of these cases. Through this closed claims analysis, the most common procedures leading to litigation were found to be PR, CI, and AI and not thoracic outlet syndrome procedures as commonly believed. Furthermore, the most common allegations were a "failure to diagnose and treat" and "open surgical complication". Analysis of the salient features and outcomes in these cases can provide a framework for heightened awareness of issues which lead to malpractice claims and can ultimately improve patient care and safety.

Short-term results of left subclavian artery salvage in blunt thoracic aortic injury with short proximal landing zones.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is the standard treatment of blunt thoracic aortic injury (BTAI). The concept of seal was derived from the treatment of aneurysms and has been adopted for BTAI. Given the location of injury in BTAI, left subclavian artery (LSA) coverage is sometimes necessary. In these often healthier aortas, a shorter proximal landing zone may be acceptable and beneficial in avoiding some complications. Current practice patterns vary, and long-term effects of LSA coverage remain unknown. METHODS: A single-institution experience with BTAI for TEVAR was examined from 2006 to 2017. The primary outcome was failure of sealing, endoleak, or persistent aortic injury on follow-up imaging. A centerline was used to measure the length of the landing zone, aortic diameter, and other parameters. Post-TEVAR computed tomography scans were examined for evidence of residual aortic injury. RESULTS: A total of 30 TEVARs were performed for BTAI. The mean age of the patients was 38.7 years (standard deviation [SD], 19.8 years), and 70% were male. The mean injury severity score was 36.75 (SD, 13.1). Treated patients had grade 2 (36.7%) or grade 3 (63.3%) BTAI. The LSA was salvaged in 23 cases and covered in seven cases. The mean landing zone in LSA uncovered cases was 16 mm (SD, 10.4 mm). There were 15 patients (65%) who had a landing zone <20 mm, and eight (35%) patients had a landing zone >20 mm. The mean landing zone in the seven covered cases was 1.8 mm (SD, 2.4 mm). Procedural success was 96% for the uncovered group and 100% for the covered group. On follow-up imaging, there was only one residual endoleak in all surviving patients (n = 25). Five patients did not have postoperative imaging, two (7%) of whom died of nonaorta-related issues. CONCLUSIONS: TEVAR for BTAI in patients with short proximal landing zones of 10 to 20 mm as well as in select patients with landing zones of 5 to 10 mm appears to be safe and efficacious. The aorta demonstrates no residual injury after TEVAR, with the graft acting potentially more as a bridge to allow healing. Long-term issues regarding LSA coverage have been difficult to ascertain and to evaluate because of historically poor follow-up in this population of patients. However, potential issues with LSA coverage and revascularization may be avoided by preserving the subclavian artery even with shorter proximal landing zones.

Fifty years of hemodialysis access literature: The fifty most cited publications in the medical literature.

Objectives The modern era of hemodialysis access surgery began with the publication in 1966 by Brescia et al. describing the use of a surgically created arteriovenous fistula. Since then, the number of patients on chronic hemodialysis and the number of publications dealing with hemodialysis access have steadily increased. We have chronicled the increase in publications in the medical literature dealing with hemodialysis access by evaluating the characteristics of the 50 most cited articles. Methods We queried the Science Citation Index from the years 1960-2014. Articles were selected based on a subject search and were ranked according to the number of times they were cited in the medical literature. Results The 50 most frequently cited articles were selected for further analysis and the number of annual publications was tracked. The landmark publication by Dr Brescia et al. was unequivocally the most cited article dealing with hemodialysis access (1109 citations). The subject matter of the papers included AV fistula and graft (9), hemodialysis catheter (9), complications and outcomes (24), and other topics (8). Most articles were published in nephrology journals (33), with fewer in surgery (7), medicine (7), and radiology (3) journals. Of the 17 journals represented, Kidney International was the clear leader, publishing 18 articles. There has been an exponential rise in the frequency of publications regarding dialysis access with 42 of 50 analyzed papers being authored after 1990. Conclusion As the number of patients on hemodialysis has increased dramatically over the past five decades, there has been a commensurate increase in the overall number of publications related to hemodialysis access.