Association between socioeconomic deprivation and presentation with a ruptured abdominal aortic aneurysm.

OBJECTIVE: Given the ongoing nature of research in the social determinants space and urges to improve United States Preventive Services Task Force screening efforts for abdominal aortic aneurysms (AAAs), this project aims to characterize the association between the level of socioeconomic deprivation, rurality, and ruptured AAA (rAAA) presentation across the United States. METHODS: We queried the Vascular Quality Initiative registry (2010-2019) for patients with AAAs. The area deprivation index (ADI) is an index from 1 to 100 used to capture socioeconomic status. ADI was grouped into quintiles, with the most deprived regions being quintile 5 and having the highest ADI index. Multivariable logistic regression assessed the association between ADI, rurality, and rAAA presentation overall and before age 65. RESULTS: Of the 82,909 patients included, 11,458 patients (14%) resided in the most socioeconomically deprived regions, and 18,083 patients (22%) lived in rural regions. Overall, 6831 patients (8.2%) experienced an rAAA, with 4696 patients (69%) residing in the three most deprived quintiles. Most patients underwent endovascular repair (n = 67,933; 82%), followed by open repair (n = 14,976; 18%). On multivariable analysis, residence in the most socioeconomically deprived region was associated with a near 1.5-fold increased odds of presenting with an rAAA compared with a residence in the least deprived regions (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.31-1.63; P < .001), whereas urban residence was associated with a decreased odds to present with an rAAA compared with rural residence (OR, 0.84; 95% CI, 0.79-0.89; P < .001). When stratifying the study population by the United States Preventive Services Task Force recommended age for AAA screening (65 years old), 14,147 patients (17%) were under 65. Of those under 65, 1381 patients (9.8%) experienced a rAAA, and 9955 patients (71%) resided in the three most deprived quintiles. Residence in the most socioeconomically deprived region was associated with an increased odds of presenting with an rAAA compared with residence in the least deprived region (OR, 1.31; 95% CI, 1.01-1.69; P = .042). However, there were no significant associations between rural residence and increased rAAA presentation among individuals under 65 (OR, 1.07; 95% CI, 0.93-1.23; P = .36). CONCLUSIONS: Among all patients in this study, patients residing in highly socioeconomically deprived or rural regions were more likely to present with an rAAA, but among those under 65, only residence in a socioeconomically deprived area was associated with increased odds of rAAA presentation. Understanding the effects of socioeconomic deprivation on rAAA presentation can identify at-risk populations for early AAA screening before rupture.

Natural history of superior mesenteric artery in-stent restenosis.

OBJECTIVE: Superior mesenteric artery (SMA) stenting is the preferred approach for patients with symptomatic SMA-associated chronic mesenteric ischemia (CMI). The durability of this modality is impacted by in-stent restenosis (ISR). Duplex ultrasound (DUS) and computed tomographic angiography (CTA)-measured ISR may be weakly correlated and not uniformly associated with recurrence of presenting symptoms. This study aims to analyze the association between the degree of ISR for patients with CMI and to develop a predictive model for symptom recurrence. METHODS: Single center, retrospective study included all patients with CMI with SMA stents from the period of 2003 to 2020. Follow-up period analysis included patients' symptoms recurrence, DUS, CTA, and angiography. A receiver operating characteristic (ROC) analysis was used to evaluate whether peak systolic velocity (PSV) was predictive of symptom recurrence. A subgroup analysis of patients (asymptomatic and symptomatic) with SMA ISR was identified; restenosis defined by DUS with peak systolic velocity (PSV) ≥350. RESULTS: The study included 186 patients with the ROC analysis obtained from 503 postoperative visits. PSV was not a predictor of symptoms return with area under the curve (AUC) = 0.49 (95% confidence interval [CI], 0.40-0.57). Agreement analysis between imaging modalities showed higher agreement between CTA and angiogram (AUC, 0.769; 95% CI, 0.688-0.849) vs CTA and DUS (AUC, 0.650; 95% CI, 0.589-0.711). The subgroup analysis of patients with ISR included 99 patients (asymptomatic n = 67; symptomatic n = 32). There was no statistical difference between median time (months) to ISR between both groups: 4.5 (asymptomatic group) and 7.6 (symptomatic group). The use of preoperative antiplatelet (86% vs 65%; P = .015) and P2Y12 receptor blockers (36% vs 13%; P = .016) was more prevalent in the asymptomatic group. There was no difference between the type or number of stents placed, stent diameter, or concomitant celiac artery intervention between both groups. CONCLUSIONS: The natural history of SMA and multimodality defined ISR in CMI has not previously been described. Elevated PSV was a poor predictor of symptoms recurrence. Both asymptomatic and symptomatic patients with ISR did not differ in type of stent placed, time to ISR, or involvement of celiac artery. Antiplatelet use pre- and postoperatively appears protective against symptoms recurrence. Our findings underscore the need for long-term surveillance integrating clinical evaluation and multimodality imaging when indicated.

Renal Artery Reimplantation Versus Bypass in Elective Open Aneurysm Repair.

BACKGROUND: Complex open abdominal aortic aneurysm (AAA) repair often necessitates revascularization of renal arteries by either renal artery reimplantation or bypass. This study aims to evaluate the perioperative and short term outcomes between these 2 strategies of renal artery revascularization. METHODS: We performed a retrospective review of patients who underwent open AAA repair from 2004 to 2020 at our own institution. Patients who underwent elective suprarenal, juxtarenal, or type 4 thoracoabdominal aneurysm repair were identified using current procedural terminology (CPT) codes and a retrospectively maintained database of AAA patients. Patients who had symptomatic aneurysm or significant renal artery stenosis before AAA repair were excluded. Patient demographics, intraoperative conditions, renal function, bypass patency, and perioperative and postoperative outcomes at 30 days and 1 year were compared. RESULTS: One hundred and forty-three patients underwent either renal artery reimplantation (n = 86) or bypass (n = 57) during this time period. The mean age was 69.7 years and 76.2% of the patients were male. Median preoperative creatinine was 1.2 mg/dL for the renal bypass group versus 1.06 mg/dL for reimplantation (P = 0.088). Both groups had similar median preoperative glomerular filtration rate (GFR) of >60 mL/min (P = 0.13). Bypass and reimplantation groups had similar perioperative complications including acute kidney injury (51.8% vs. 49.4% P = 0.78), inpatient dialysis (3.6% vs. 1.2% P = 0.56), myocardial infarction (1.8% vs. 2.4% P = 0.99), and death (3.5% vs. 4.7% P = 0.99), respectively. During the 30-day follow-up period, renal artery stenosis was identified in 9.8% of bypasses and 6.7% of reimplantations (P = 0.71). Six point one percent of patients in the bypass group had renal failure requiring dialysis (both acute and permanent) compared to 1.3% in reimplantation group (P = 0.3). For those who had 1-year follow-up, the reimplantation group had higher new incidence of renal artery stenosis compared to bypass group (6 vs. 0 P = 0.16). CONCLUSIONS: Given that there is no significant difference in outcomes between renal artery reimplantation and bypass within 30 days or at 1-year follow-up, both bypass and reimplantation are acceptable means for renal artery revascularization during elective AAA repair.

Concomitant Carotid and Coronary Artery Disease Management: A Review of the Literature.

This review examines current evidence regarding management of patients with both coronary and carotid artery disease. It highlights the elevated stroke risk after surgery for this cohort and scrutinizes approaches to minimize this risk. Various revascularization methods are outlined, including carotid endarterectomy (CEA), carotid artery stenting (CAS), and staged versus simultaneous surgical approaches. The importance of judiciously screening coronary artery bypass grafting (CABG) candidates for carotid stenosis is emphasized, suggesting risk factor-based targeted screening is noninferior to indiscriminate screening. Efficacy comparisons are made between revascularization strategies such as staged versus synchronous CEA/CABG, CAS, and hybrid techniques. Controversies surrounding necessity and optimal timing of carotid revascularization in asymptomatic patients are addressed, indicating a need for rigorous randomized controlled trials to establish definitive treatment algorithms.

Late Referral and Patient Transfer is Associated with Worse Outcomes for Patients Presenting with Initially Uncomplicated Type B Aortic Dissections.

BACKGROUND: Acute type B aortic dissections (TBADs) can become complicated at any time point, necessitating surgical repair. We sought to investigate the effect of interhospital transfer on the development of delayed complications in acute type B aortic dissection (dcTBAD). METHODS: All patients who presented with acute TBAD to a tertiary aortic center from 2015 to 2019 were analyzed. Patients were divided into initially complicated type B aortic dissection (icTBAD) (0-24 hours from symptom onset), dcTBAD (25 hours to 14 days), and uncomplicated type B aortic dissection (ucTBAD) groups. Criteria for complicated dissection were aortic rupture, malperfusion, or rapid aortic growth. Demographics, patient history, the timing of presentation, imaging findings, and clinical outcomes were compared between groups. RESULTS: Of 120 acute TBADs included, 27 (22%) were initially complicated (aortic rupture, n = 9; malperfusion, n = 18). Twenty-one (18%) developed delayed complications (aortic rupture, n = 3; malperfusion, n = 14; rapid growth, n = 4) at a median of 7.0 [4.0, 9.0] days from symptom onset. Seventy-two (60%) remained uncomplicated. Overall, 111 (93%) presented as transfers from outside hospitals (icTBAD, n = 25; dcTBAD, n = 21; ucTBAD, n = 65). Of those, dcTBADs were more likely to have a prolonged delay between presentation to the outside hospital and referral to the tertiary center compared to ucTBADs (median = 1.00 [0.0, 5.0] days delayed vs. 0.00 [0.0, 0.0] days delayed; P < 0.001). Initially uncomplicated patients referred for transfer ≥24 hours from presentation went on to develop dcTBAD more often than those transferred in <24 hours (73% vs 13%; P < 0.001). Of dcTBADs, 38% had no high-risk features on initial imaging. Patients with dcTBAD had significantly longer length of stay (median = 12 vs 7 days; P = 0.006). In-hospital mortality was significantly higher in dcTBADs than ucTBADs (9.5% vs 0%; P = 0.047). In-hospital mortality was not significantly different between dcTBADs and icTBADs (9.5% vs. 11%; P > 0.05). CONCLUSIONS: The incidence and consequence of dcTBADsare not insignificant. Late referral and transfer to a tertiary aortic center (≥24 hours from initial presentation) was associated with dcTBADsrequiring surgical intervention. The development of dcTBADwas associated with increased length of stay and increased in-hospital mortality.

Endovascular and Hybrid Interventions for Aortoiliac Occlusive Disease in Patients with Intermittent Claudication.

INTRODUCTION: Significant practice variability exists regarding the management of intermittent claudication (IC) across anatomic segments. We sought to answer the question of whether the safety, efficacy, and durability outcomes of an endovascular approach with or without common femoral endarterectomy for complex aortoiliac occlusive disease (AIOD) justify a surgical approach in patients presenting with IC. METHODS: A retrospective single-center review of all patients who were treated using an endovascular approach for AIOD with or without CFE from 2010 to 2020 was conducted. The review was limited to those with symptoms of IC. Patient- and limb-level preoperative presentations were reviewed. The outcomes were postoperative complications and patency rates in addition to freedom from re-intervention. Subgroup analyses were conducted to compare patients who underwent endovascular and hybrid procedures. RESULTS: A total of 245 limbs in 180 consecutive patients were analyzed. The mean age was 65 years and 61% were males. Of 176 patients, 101 (57%) had TASC class D and 18 (10%) had Class C. Eleven limbs (7.4%) had access site complications, 12 (7.9%) had surgical wound complications, and below-the-knee amputation was observed in 2 limbs (0.82%) (2 patients). Two (1.0%) patients had perioperative MI, 1(0.5%) stroke, 1(0.5%) AKI that progressed to dialysis, and no 30-day mortality. Rutherford's classification was improved during the follow-up period. The 1-, 2- and 5-year primary patency rates were 94%, 77%, and 58%; primary-assisted patency rates were 98%,91%, and 79%, respectively; and secondary patency rates were 100% for all follow-up periods. Patients who had concurrent CFE were likely to have hypertension, hyperlipidemia, and anatomically more diffuse disease. No significant differences in patency or reintervention-free survival were observed, though event rates were low in both outcomes and trended toward a protective effect with CFE. CONCLUSION: Endovascular management for complex AIOD with or without CFE for IC patients is safe, effective, and durable. These results justify an active, patient-centered approach for this advanced anatomic disease pattern. The morbidity of a hybrid approach in the CFE subset is low and treatment vessel patency is excellent. The presence of anatomically advanced AIOD is not prohibitive for the treatment of patients with IC, however careful patient selection is essential.

Explant of an infected, endo-trashed IVC filter in an immunosuppressed patient with chronically occluded iliocaval stents.

BACKGROUND: In the absence of a contiguous bowel perforation or intraabdominal source, infection of a retained vena cava filter in an occluded IVC has never been described. OBJECTIVE: To describe a case of an infected IVC filter in a chronically occluded iliocaval segment. METHODS: Here we present a case of an immunosuppressed 35-year-old female with chronically occluded iliocaval stents and an extensive staphylococcus hominis infection of a previously endo-trashed Bard Eclipse® filter. Particular attention is paid to supportive imaging in establishing the diagnosis and technical aspects of successful device explant and retroperitoneal debridement. RESULTS: At 6 months postoperatively, the patient was doing well without evidence of recurrent infection. Her lower extremity edema was controlled with compression alone. CONCLUSIONS: The main objective of this operation was source control with debridement of the infection and removal of the filter and as much of the iliac vein as safely possible. Superinfection of a previously placed iliocaval stents and inferior vena cava filter remains a concern in patients with retroperitoneal infection and chronic iliocaval occlusion. Operative explant and debridement can be safely performed in patients with favorable cardiopulmonary risk.

No difference in midterm outcomes and complication rate between retroperitoneal and transperitoneal open aortic aneurysm repair in females.

OBJECTIVES: Abdominal Aortic Aneurysms (AAA) in females are less prevalent, have higher expansion rates and experience rupture at smaller diameters than in males. Studies have compared outcomes of the retroperitoneal (RP) and transperitoneal (TP) approach in open aortic aneurysm repair (OAR) with conflicting results. No study to date has compared the two approaches solely in females. In this study we compare midterm outcomes of the RP and TP approach in females undergoing OAR. METHODS: Single-center, retrospective review of all females undergoing OAR from 2010 to 2021. Patients undergoing elective, symptomatic and ruptured OAR were included. The cohort was stratified by surgical approach RP versus TP and midterm outcomes were compared amongst the groups. Outcomes included mortality, graft related, and non-graft related complications. RESULTS: A total of 244 patients (RP n = 133; TP n = 111) were identified. Follow-up period was 28 ± 30.7 months. Baseline perioperative characteristics were similar except that more people in the RP group had ejection fraction ((EF) > 50% (82% vs 68%), p = .037). Patients who underwent RP repair had longer visceral/renal ischemia time (p = .01), larger graft diameter (18 vs 16 mm; p = <0.001), were more likely to have a suprarenal clamp placed(70.5 vs 48.2; p < .001), and had decreased autotransfusion volume (611 vs 861 mL; p < .01) compared to those who underwent TP repair. Number of deaths was higher in the TP group during study follow-up period (36.4 vs 23.8; p = .035), but the difference of the time to event analysis was not significant. There was no difference in all-cause survival at 36 months between RP and TP (77.8 vs 76.8; p = .045). Overall midterm complications were 9.5% in both groups. Any graft related complication was 1.8% in TP versus 3% RP (p = .69). In a multivariable model, after adjusting for age, urgency, smoking, prior aneurysm repair, and ASA level, the hazard ratio decreases with the RP approach, however this did not reach significance (p = .052). CONCLUSION: In a 12-year period of OAR in females, TP and RP results were comparable at midterm analysis. The RP approach appeared to be used more often for OAR requiring suprarenal clamping. Although the TP group had increased mortality, the difference of the time to event analysis was not significant. Midterm postoperative complications in both groups were low. This suggests that both approaches are safe in the female population and decision should be driven by anatomy and surgeon's preference.

Prevalence of intracranial aneurysms in Marfan syndrome.

OBJECTIVE: Aneurysmal pathology of the aorta is well-defined in the Marfan syndrome (MFS) population. Owing in part to the rarity of pathologies, the prevalence of intracranial aneurysms (IA) in MFS is poorly defined. There is debate as to whether or not there is an association between the two. The aim of this study was to evaluate the prevalence of IA in a population of patients with MFS who underwent intracranial imaging. METHODS: This was a single-center retrospective review of patients with MFS. Between 1995 and 2021, 983 patients were reviewed. We identified 198 patients with MFS who had intracranial imaging. Imaging consisted of CTA and/or MRA, and was read by an attending radiologist. Details of the aneurysm, patient demographics, and aortic characteristics were collected. RESULTS: The prevalence of IA was 7.1% (14/198). Age of patients with IA (55.0 ± 15.1 years) was not significantly different than those without IA (52.6 ± 16.0 years) (P = .58). The most common location of IA was the internal carotid artery. The mean diameter of the IA was 7 ± 5.8 mm. No ruptures of the internal carotid artery were identified. One patient (0.5%) underwent intervention for the IA. There were no significant differences found in aortic characteristic including dimensions, history of dissection, or aneurysm. CONCLUSIONS: In a large, single-center experience over 20 years, we identified patients with confirmed MFS who underwent intracranial imaging. The prevalence of IA in our experience was 7.1%. There were no patient or aortic characteristics found to be significantly associated with IA; however, this finding may be due to the small number of aneurysms. Although this number is higher than the historically reported prevalence in the general population, a collection of experiences from multiple institutions will likely be required to truly define the risk of IA in MFS and to determine whether screening is warranted.

Management of patients with chronic mesenteric ischemia across three consecutive eras.

BACKGROUND: Endovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras. METHODS: A retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup. RESULTS: A total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014). CONCLUSIONS: Consistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.

Effects of abdominal aortic aneurysm appropriateness dashboard on clinical practice.

OBJECTIVE: The Society for Vascular Surgery published abdominal aortic aneurysm (AAA) practice guidelines in 2003, 2009, and 2018 to improve the management and treatment of AAAs. In 2014, our vascular surgery department implemented a quarterly AAA dashboard (AAAdb) to record the perioperative outcomes and guideline compliance with a focus on intervention appropriateness and procedural follow-up, which supplemented our Vascular Quality Initiative data. From the available reported evidence and expert consensus opinions, nine additional criteria for the appropriate treatment of AAAs <5 cm in women and <5.5 cm in men were noted, when applicable. The purpose of our study was to assess the effects of AAAdb implementation on adherence to society and institutional guidelines, documentation of treatment rationale, and the quality of follow-up. METHODS: We performed a retrospective review of elective open and endovascular AAA repair at a single institution from 2010 to 2018. The AAAdb was implemented in the middle of this period in 2014. The patient demographics, aortic size, repair indication, repair type, 30-day mortality, and postoperative and 1-year follow-up imaging findings were analyzed. The primary outcome was adherence to intervention appropriateness and the follow-up guidelines. The categorical factors were summarized using frequencies and percentages and compared using the Pearson χ2 test or Fisher exact test. Continuous measures were summarized using the mean ± standard deviation and compared between study periods using two-sample t tests. RESULTS: From 2010 to 2018, 1549 patients had undergone elective AAA repair: 657 before and 892 after AAAdb implementation. No differences were found in AAA size after AAAdb (5.6 ± 1.2 cm vs 5.6 ± 1.1 cm; P = .88). However, the proportion of size-appropriate repairs increased (64.1% vs 71.3%; P = .003). The proportion of small AAA repairs with a documented rationale had increased (64.4% vs 80.5%; P < .001), with rapid disease progression cited most often. No difference was found in 30-day mortality (1.2% vs 1.5%; P = .69). Follow-up imaging after endovascular abdominal aortic aneurysm repair increased at <60 days postoperatively (76% vs 84%; P = .004) and at 1 year of follow-up (78% vs 86%; P = .0005). The proportion of patients with endoleak at <60 days postoperatively had increased in the post-AAAdb cohort (21% vs 29%; P = .012). CONCLUSIONS: The AAAdb served as a centerpiece for improving the appropriateness of care and compliance with national and institutional guidelines, including treatment of small AAAs in special circumstances. Its implementation was associated with higher quality follow-up and surveillance in a high-volume, regional aortic center. Consideration should be given to adding additional criteria to the Society for Vascular Surgery guidelines and Vascular Quality Initiative reporting.

A Novel Technique and Outcomes for Transcaval Endoleak Embolization.

BACKGROUND: Strategies for embolization of type 2 endoleaks include translumbar, transgraft, transarterial, and transcaval approaches. The transcaval approach is limited by an inconsistent ability to access the aortic sac and the risk of puncturing and damaging the endograft or adjacent structures. We describe a novel technique for caval to aortic aneurysm sac access and report early outcomes. METHODS: A retrospective review of all patients who underwent transcaval embolization (TCE) at a tertiary referral center. From March 2019 to June 2021, 12 patients were identified to have undergone a novel approach to transcaval aortic sac access using a 0.014″ heavy weight tip wire guide and continuous current electrocautery to create the connection between the inferior vena cava and aortic aneurysm sac. The endoleak outflow vessel is then selectively embolized with coils or liquid embolic agents. When selective embolization was not possible, the aneurysm sac was instilled with liquid embolic agents to induce thrombosis. RESULTS: Twelve patients underwent transcaval embolization using this method over the 3-year period. The average patient age was 79.2 ± 6.2 years and 10/12 (83.3%) were male. A high rate of comorbidities was noted in the cohort. Transcaval access into the aortic sac was achieved in all patients, while selective cannulation of outflow vessels was accomplished in 2/12 (16%) target vessels. Of these, both cases had vessels embolized using detachable coils and liquid embolic agents. Nonselective embolization was performed using liquid embolic and thrombotic agents in the other 10/12 cases. There was one perioperative complication of minor bleeding (1/12, 8.3%). Two patients were observed in intensive care unit for back pain. A persistent endoleak was identified on postoperative imaging performed at 30 days in 4/12 (33.3%) patients. Sac enlargement > 5 mm following TCE was observed in 3/12 (25%) patients. Three patients underwent open conversion with endovascular aneurysm repair explant. One patient was explanted at 1 month after failure to embolize the endoleak flow channel using TCE. A second was explanted for persistent endoleak found to be a Type IIIb with aortic diameter growth > 5 mm at 15-month follow-up. The third explant was performed for aortic sac infection at 4 months postprocedure without endoleak. CONCLUSIONS: TCE is an adjunctive technique to treat endoleaks in patients who have either failed transarterial or translumbar access. An electrified 0.014″ chronic total occlusion wire technique for transcaval access to the aortic sac for endoleak embolization can be successful in all cases without significant acute morbidity or mortality. The transcaval approach is still limited by ability to steer catheters and microcatheters into the outflow vessels with a resultant persistent endoleak and eventual need for explant.

Value of Routine Troponin Measurement in Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Cardiovascular complications are a major cause of morbidity and mortality in the postoperative period after major vascular surgery. Depending on the study population, up to 25% of patients have troponin elevation after noncardiac surgery, yet many do not meet the diagnosis of myocardial infarction (MI). Although outcomes of routine troponin elevation in patients undergoing mixed major vascular surgery have been evaluated, this has not been studied exclusively in elective, open abdominal aortic aneurysm repair (oAAA), especially regarding perioperative and overall mortality. METHODS: We conducted a single-center, retrospective review of routine troponin surveillance for consecutive, oAAA from 2014 to 2019. A total of 319 patients were identified and analyzed for management patterns and interventions. The cohort was stratified into groups for comparison based on those in whom troponin was routinely checked (RC) as part of a care strategy during the study period, not routinely checked (NRC), elevated troponin (ET) >0.001 ng/mL, and not elevated. The median follow-up was 21.5 ± 23.8 months. Groups were compared on demographic data, cardiac comorbidities, 30-day and 3-year outcomes for MI and death using two-sample t-tests, Wilcoxon rank sum tests, Pearson chi-square tests, and Fisher exact tests when appropriate. RESULTS: Troponin was measured in 83.7% (267/319) of patients who underwent elective oAAA repair. Routine troponin checks were obtained in 79.9% (255/319) of patients. ET was identified in 16.5% of those with RC (42/255) and 4.7% of those with NRC (3/64). Of patients with ET, 37.8% (17/45) had a cardiology consultation, 4.4% (2/45) had a percutaneous coronary intervention (PCI), and 4.4% (2/45) had another cardiac intervention. All 4 patients undergoing PCI or other cardiac intervention had received routine troponin checks. Patients with ET were older (71.2 vs. 68.6; P = 0.04), more likely to receive intraoperative blood products (P = 0.003), had longer operative times (P = 0.011), higher length of stay (9 vs. 7 days; P < 0.01), and higher 30-day MI rate (3 vs. 0; P = 0.04). They had neither longer aortic clamp times nor worse preoperative cardiac function, and the proximal clamp position during oAAA repair did not impact troponin detection. Additionally, 3-year overall mortality was increased in patients who had ET but there was not a significant difference in 3-year mortality between groups receiving routine troponin checks versus not. CONCLUSIONS: ET, identified after elective oAAA repair, was associated with a higher risk of 30-day MI and lower overall survival. However, it was not demonstrated that routine assessment of troponin levels postoperatively leads to decreased 3-year mortality in this setting.

Hypogastric artery luminal diameter predicts common-external iliac stent patency and major adverse limb events in patients with aortoiliac occlusive disease.

OBJECTIVE: Hypogastric coverage may be required for occlusive disease at the iliac arterial bifurcation. In this study, we sought to determine patency rates of common-external iliac artery (C-EIA) bare metal stents (BMS) spanning the hypogastric origin in patients with aortoiliac occlusive disease (AIOD). In addition, we sought to identify predictors of C-EIA BMS patency loss and major adverse limb events (MALE) in patients requiring hypogastric coverage. We hypothesized that worsening stenosis of the hypogastric origin would negatively influence C-EIA stent patency and freedom from MALE. METHODS: This is a single center, retrospective review of consecutive patients undergoing elective, endovascular treatment of aortoiliac disease (AIOD) between 2010 and 2018. Only patients with C-EIA BMS coverage of a patent IIA origin were included in the study. Hypogastric luminal diameter was determined from preoperative CT angiography. Analysis was performed using Kaplan-Meier survival analysis, univariable and multivariable logistic regression, and receiver operator characteristics (ROC). RESULTS: There were 236 patients (318 limbs) who were included in the study. AIOD was TASC C/D in 236/318 (74.2%) of cases. C-EIA stent primary patency was 86.5% (95% confidence interval: 81.1, 91.9) at 2 years and 79.7% (72.8, 86.7) at 4 years. Freedom from ipsilateral MALE was 77.0% (71.1, 82.9) at 2 years and 68.7% (61.3, 76.2) at 4 years. Luminal diameter of the hypogastric origin was most strongly associated with loss of C-EIA BMS primary patency in multivariable analysis (hazard ratio: 0.81, p = .02). Insulin-dependent diabetes, Rutherford's class IV or above, and stenosis of the hypogastric origin were significantly predictive of MALE in both univariable and multivariable analyses. In ROC analysis, luminal diameter of the hypogastric origin was superior to chance in prediction of C-EIA primary patency loss and MALE. Hypogastric diameter >4.5 mm had a negative predictive value of 0.94 for C-EIA primary patency loss and 0.83 for MALE. CONCLUSIONS: Patency rates of C-EIA BMS are high. Hypogastric luminal diameter is an important and potentially modifiable predictor of C-EIA BMS patency and MALE in patients with AIOD.

Outcomes of Gore iliac branch endoprosthesis with internal iliac component versus Gore Viabahn VBX.

OBJECTIVE: The Gore Excluder iliac branch endoprosthesis (IBE; W.L. Gore & Associates, Flagstaff, AZ) is the only iliac branch device approved in the United States to preserve blood flow to the external and internal iliac arteries (IIAs). Some surgeons have used the Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associates) in the IIA rather than the self-expanding endograft designed for the IBE, the internal iliac component (IIC). The objective of the present study was to examine the outcomes for patients treated for aortoiliac artery aneurysms using the IBE with either the IIC or VBX stent. METHODS: We performed a retrospective, single-center review of patients treated for aortoiliac artery aneurysms using the Gore IBE device, with either the IIC or VBX stent into the IIA, from February 2016 to March 2021. The patient demographics, procedure details, 30-day morbidity and mortality, and 6-month and 1-year outcomes and mortality were analyzed. The categorical factors are summarized using frequencies and proportions. Continuous measures are summarized as the mean ± standard deviation. A significance level of P = .05 was assumed for all test results. The analyses were performed using SAS software, version 9.4 (SAS Institute, Cary, NC). RESULTS: A total of 62 patients (64 arteries) had undergone elective aortoiliac artery aneurysm repair with the IBE. The IIC was used exclusively in 35 cases (55%) and the VBX in 29 (45%). The patients who had received the VBX had had a higher American Society of Anesthesiologists class (P = .006). Upper extremity access was used for VBX delivery in 24.1% of the procedures. No return to the operating room was required in either group. No differences were found in technical success (IIC, 97.1%; VBX, 93.1%; P = .59), the presence of endoleak on completion (20.0% vs 6.9%; P = .17), readmission (97.1% vs 93.1%; P = .59), or mortality (1.6% vs 0%; P = .45) at 30 days. No differences were found in the requirement for any IBE reintervention after 30 days. No type Ia, Ib, or III endoleaks had occurred in either group at any follow-up point. No significant difference was found in internal iliac limb primary patency (IIC, 100%; VBX, 96.3%) between groups. A nonstatistically significant trend was found toward fewer trunk-ipsilateral leg type II endoleaks in the VBX group during follow-up. CONCLUSIONS: These data suggest that the VBX is a reasonable substitute for the IIC, with a comparable safety and efficacy profile. Given its inherent conformability, greater range of diameters, and longer working length, the VBX stent offers expanded IIA branch options with the IBE.

Natural history and growth rates of isolated common iliac artery aneurysms.

OBJECTIVE: The natural history of isolated common iliac artery aneurysms (CIAAs) has not been well-studied. The optimal size threshold for elective repair of isolated CIAAs is also not well-defined. We sought to determine the natural history and growth rates of isolated CIAAs to justify a surveillance protocol and size for elective repair. METHODS: Isolated CIAAs (>2 cm) identified from January 1, 2008, through February 29, 2020, at a single center were reviewed. Patient demographics, comorbidities, and details of CIAA operative repairs were retrospectively collected. All available duplex ultrasound and computed tomography scans were reviewed from time of CIAA identification through June 2020. RESULTS: There were 244 isolated CIAAs found in 167 patients. The cohort was 94% male with an average age of 68.1 ± 8.8 years at the time of CIAA detection. CIAAs were identified with ultrasound examination 69% of the time with a mean CIAA diameter of 2.3 cm. Operative repair of a CIAA was performed in 11.4% of the cohort at an average diameter of 3.30 ± 1.02 cm. The majority of these repairs were performed via an endovascular approach (73.7%; n = 14). There were no symptomatic or ruptured isolated CIAAs. Concurrent aortic growth that led to an abdominal aortic aneurysm with diameter of at least 3 cm occurred in 10.6% (n = 26) of isolated CIAAs. The average length of time from CIAA diagnosis to repair was 65.7 ± 47.1 months. The overall CIAA growth rate was 0.4 mm/y. A subgroup analysis based on CIAA size demonstrated a growth rate of 0.2 mm/y fore CIAAs 2.00 to 2.49 cm, 0.3 mm/y for CIAAs 2.50 to 2.99cm, and 1.3 mm/y for CIAAs 3.0 cm or larger. There were two CIAAs greater than 3.0 cm with extreme growth, which significantly impacted the CIAA growth rate on sensitivity analysis. After excluding those two CIAAs from the model, the overall CIAA growth rate was 0.3 mm/y. The subgroup analysis then demonstrated a growth rate of 0.2 mm/y for CIAAs 2.00 to 2.49cm, 0.3 mm/y for CIAAs 2.50 to 2.99cm, and 0.5 mm/y for CIAAs 3 cm or larger. CONCLUSIONS: Isolated CIAAs are typically slow growing aneurysms that expectedly grow faster as they enlarge. Given the rare occurrence of rapid isolated CIAA growth, we recommend surveillance at 3 years for 2.00 to 2.49 cm isolated CIAAs, 2 years for 2.50 to 2.99 cm isolated CIAAs, and yearly for isolated CIAAs greater than 3.0 cm. The lack of symptomatic or ruptured isolated CIAAs in this study supports delaying elective repair until an isolated CIAA diameter reaches at least 3.5 cm. These recommendations should be considered for isolated CIAA practice guidelines.

Natural History of Nonoperative Management of Grade II Blunt Thoracic Aortic Injury.

BACKGROUND: The morbidity and mortality of thoracic blunt aortic injury (BAI) has been both diminished and revolutionized by the advent of endovascular repair. Nevertheless, the question remains as to what severity of injury requires endovascular repair. We therefore conducted a retrospective analysis of our experience with nonoperative grade II BAI of the thoracic aorta. METHODS: The records of patients with BAI from 2007 to 2017 at a Level I trauma center were retrospectively reviewed. Images were reviewed and graded by a radiologist according to the Society of Vascular Surgery Guidelines (grade I-IV). Demographics, injury severity, and outcomes were recorded. RESULTS: We identified 111 patients with BAI. Of these, 15 were deemed grade II injuries and were managed nonoperatively. Mean patient age was 45 ± 21 years; 60% of patients were male. The mean injury severity scale was 36 ± 13. No patients had progression of BAI to a more severe grade requiring intervention. Until now, the survival rate is 86.7% with a mean follow-up of 69 months (range 7-138). CONCLUSIONS: Within the grade II BAI cohort, injury progression did not occur, nor were any operative interventions performed. We conclude that grade II BAI can be managed nonoperatively. However, given that progression of the BAI is possible, follow-up aortic imaging is encouraged as well as appropriate blood pressure control and exercise restriction.

Temporary mesenteric venous shunting for portal vein reconstruction: A novel technical adjunct.

Pancreatic resection not infrequently requires portal vein (PV) repair or replacement. PV reconstruction often requires bypass grafting or patch venoplasty, and these grafts and patches require time to thaw or harvest. Mesenteric ischemia and congestion with associated bowel edema may result from prolonged venous occlusion during thawing, harvesting, and reconstructing. Temporary shunting of the mesenteric venous circulation may mitigate these adverse effects. Twenty-one patients were shunted using Argyle shunts during PV reconstruction from 2010 to 2020. Reconstructions in this series consisted of aortic homograft interposition grafts (52%), bovine pericardial patches (38%), internal jugular vein interposition grafts (5%), and internal jugular patches (5%). No intraoperative complications resulted from shunt placement; technical success of PV reconstruction was 100%. Temporary venous shunting during PV reconstruction is safe, technically straightforward, and may serve to decrease the duration of venous mesenteric occlusion.

The timing of TGF-ß inhibition affects the generation of antigen-specific CD8+ T cells.

BACKGROUND: Transforming growth factor (TGF)-ß is a potent immunosuppressive cytokine necessary for cancer growth. Animal and human studies have shown that pharmacologic inhibition of TGF-ß slows the growth rate of established tumors and occasionally eradicates them altogether. We observed, paradoxically, that inhibiting TGF-ß before exposing animals to tumor cells increases tumor growth kinetics. We hypothesized that TGF-ß is necessary for the anti-tumor effects of cytotoxic CD8+ T lymphocytes (CTLs) during the early stages of tumor initiation. METHODS: BALB/c mice were pretreated with a blocking soluble TGF-ß receptor (sTGF-ßR, TGF-ß-blockade group, n=20) or IgG2a (Control group, n=20) before tumor inoculation. Tumor size was followed for 6 weeks. In vivo lymphocyte assays and depletion experiments were then performed to investigate the immunological basis of our results. Lastly, animals were pretreated with either sTGF-ßR (n=6) or IgG2a (n=6) prior to immunization with an adenoviral vector encoding the human papillomavirus E7 gene (Ad.E7). One week later, flow cytometry was utilized to measure the number of splenic E7-specific CD8+ T cells. RESULTS: Inhibition of TGF-ß before the injection of tumor cells resulted in significantly larger average tumor volumes on days 11, 17, 22, 26 and 32 post tumor-inoculation (p < 0.05). This effect was due to the inhibition of CTLs, as it was not present in mice with severe combined immunodeficiency (SCID) or those depleted of CD8+ T cells. Furthermore, pretreatment with sTGF-ßR inhibited tumor-specific CTL activity in a Winn Assay. Tumors grew to a much larger size when mixed with CD8+ T cells from mice pretreated with sTGF-ßR than when mixed with CD8+ T cells from mice in the control group: 96 mm3 vs. 22.5 mm3, respectively (p < 0.05). In addition, fewer CD8+ T cells were generated in Ad.E7-immunized mice pretreated with sTGF-ßR than in mice from the control group: 0.6% total CD8+ T cells vs. 1.9%, respectively (p < 0.05). CONCLUSIONS: These studies provide the first in vivo evidence that TGF-ß may be necessary for anti-tumor immune responses in certain cancers. This finding has important implications for our understanding of anti-tumor immune responses, the role of TGF-ß in the immune system, and the future development of TGF-ß inhibiting drugs.

T cell receptor (TCR)-transgenic CD8 lymphocytes rendered insensitive to transforming growth factor beta (TGFß) signaling mediate superior tumor regression in an animal model of adoptive cell therapy.

Tumor antigen-reactive T cells must enter into an immunosuppressive tumor microenvironment, continue to produce cytokine and deliver apoptotic death signals to affect tumor regression. Many tumors produce transforming growth factor beta (TGFß), which inhibits T cell activation, proliferation and cytotoxicity. In a murine model of adoptive cell therapy, we demonstrate that transgenic Pmel-1 CD8 T cells, rendered insensitive to TGFß by transduction with a TGFß dominant negative receptor II (DN), were more effective in mediating regression of established B16 melanoma. Smaller numbers of DN Pmel-1 T cells effectively mediated tumor regression and retained the ability to produce interferon-γ in the tumor microenvironment. These results support efforts to incorporate this DN receptor in clinical trials of adoptive cell therapy for cancer.