Onyx versus coil embolization for the treatment of type II endoleaks.

OBJECTIVE: Little evidence is available supporting the optimal treatment of type II endoleaks associated with aortic sac growth. Previous studies have lacked comparisons between treatment methods and long-term follow-up. The purpose of the present study was to review our center's experience with the treatment of type II endoleaks comparing Onyx (a liquid embolization agent consisting of ethylene vinyl alcohol; Medtronic, Minneapolis, Minn) embolization and coil embolization. METHODS: A retrospective review of prospectively collected data from a vascular surgery database was performed to identify all patients who had undergone embolization of a type II endoleak for aortic sac growth after endovascular aneurysm repair from 2005 to 2018. The Onyx and coil embolization groups were compared using univariate statistics. RESULTS: A total of 58 patients had undergone 77 embolization procedures for type II endoleaks with either Onyx (27 patients; 37 procedures) or coils (31 patients; 40 procedures). The average aneurysm size at embolization was larger in the Onyx group (77.9 ± 15.1 mm) compared with coil embolization (73.4 ± 11.9 mm). The mean follow-up was 57 months for the Onyx group and 74 months for the coil embolization group. Of the 27 patients who had undergone Onyx embolization, 2 (7.4%) had required graft explantation compared with 5 of the 31 patients (16.1%) who had undergone coil embolization (P = .33). The results of the per-patient analysis showed that the coil embolization group had a significantly greater rate of the need for further reintervention compared with the Onyx group (55% vs 19%; P < .01). Clinical success was observed in 13 patients (48%) in the Onyx embolization group compared with 10 patients (32%) in the coil embolization group (P = .04). Two patients in each group had presented with secondary rupture of the aneurysm sac after attempted embolization. CONCLUSIONS: Type II endoleaks associated with sac growth treated with Onyx were less likely to require further reinterventions than were those treated with coil embolization. A trend was found toward a greater need for endovascular aneurysm repair explant after coil embolization. With a high rate of further reintervention and potential for sac rupture, diligent follow-up is required after attempted type II embolization, regardless of the technique used.

Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians.

OBJECTIVE: Patients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up. METHODS: Retrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics. RESULTS: The study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P = .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P = .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P = .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P = .05) were higher in the endovascular treatment group. CONCLUSIONS: EVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients.

Incidence, natural course, and outcome of type II endoleaks in infrarenal endovascular aneurysm repair based on the ENGAGE registry data.

OBJECTIVE: The purpose of this study was to report the incidence, natural history, and outcome of type II endoleaks in the largest prospective real-world cohort to date. METHODS: Patients were extracted from the prospective Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE). Two groups were analyzed: first, patients with an isolated type II endoleak; and second, patients with a type II endoleak who later presented with a type I endoleak. A health status analysis between patients with an early type II endoleak and patients with no endoleak was performed. Second, an attempt was made to identify risk factors in patients with a type II endoleak who later presented with a type I endoleak. RESULTS: Through 5 years of follow-up, a total of 197 (15.6%) patients with isolated type II endoleaks were identified. Most were detected within the first 30 days (n = 73 [37.1%]) and through the first year (n = 73 [37.1%]), with the remainder being detected after 1 year of follow-up (n = 51 [25.8%]). Patients with a type II endoleak had a higher incidence of aneurysm growth and more secondary endovascular procedures (15.4% vs 7.5% at 5 years; P < .001). Overall survival was higher in the isolated type II endoleak group compared with patients with no endoleak (77.2% vs 67.0% at 5 years; P = .010). Twenty-two patients (10%) with a type II endoleak were diagnosed with a late type I endoleak (type IA, n = 10; type IB, n = 12), with a secondary intervention rate of 67.5% through 5 years. There was no difference in health status scores between patients with an early type II endoleak and patients without any type of endoleak at 1-year follow-up. CONCLUSIONS: In the ENGAGE registry, isolated type II endoleaks are present in 15.6% of patients during follow-up. The majority do not require secondary intervention, and an early isolated type II endoleak does not have an impact on health status through 1 year. However, a small group of patients with a type II endoleak will present with a type I endoleak, resulting in a high secondary intervention rate and significant risk of aneurysm-related complications.

Editor's Choice - Infrainguinal Bypass Following Failed Endovascular Intervention Compared With Primary Bypass: A Systematic Review and Meta-Analysis.

OBJECTIVES: Patients with infrainguinal peripheral arterial disease often undergo multiple revascularisation procedures. Although many centres have adopted an endovascular first approach, some are reluctant to do so for fear of compromising the outcomes of any subsequent bypasses. All studies that compared the outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention were analysed. METHODS: A systematic review was conducted of MEDLINE, EMBASE, and CENTRAL databases for studies comparing outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention for peripheral arterial disease. Abstracts and full text studies were screened independently by two reviewers with data abstraction done in duplicate. Dichotomous outcome measures were reported using the OR and 95% CI, and pooled using random effects models. RESULTS: Abstracts were screened (2,528), with 50 selected for full text review. Of these, 15 studies involving 11,886 patients met the inclusion criteria. Pooling the results of studies comparing primary bypass with bypass after failed endovascular intervention showed no significant difference in 30 day mortality (OR 1.00; 95% CI 0.65-1.54), or 30 day amputation rates (OR 1.26; 95% CI 0.95-1.65). Interestingly, one year amputation free survival was higher in the patients who had primary bypass (OR 1.30; 95% CI 1.10-1.52) compared with patients who had bypass after failed endovascular therapy. There was also worse one year primary patency (OR 1.65; 95% CI 1.04-2.62) for patients with prior failed endovascular intervention. The review demonstrated a trend towards higher rates of early graft occlusion (OR 4.54; 95% CI 0.97-21.28). CONCLUSIONS: Meta-analysis of the existing literature comparing primary bypass with bypass following failed endovascular intervention shows worse one year amputation free survival and worse primary patency in those patients who undergo bypass after failed endovascular intervention. There is also a trend towards higher rates of early graft occlusion, although these results were not statistically significant. These conclusions are limited by observational study design, inconsistent patient selection, and significant heterogeneity between studies.

Editor's Choice - Five Year Outcomes of the Endurant Stent Graft for Endovascular Abdominal Aortic Aneurysm Repair in the ENGAGE Registry.

OBJECTIVE/BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR) is commonly used to treat abdominal aortic aneurysm (AAA). However, the incidence of long-term complications and the need for re-interventions after EVAR remain a concern. Newer generation stent grafts have encouraging short and mid-term outcomes, but thorough analysis of their long-term performance is necessary. METHODS: The ENGAGE registry includes a total of 1263 patients with AAA enrolled from March 2009 to April 2011 at 79 centres across 30 countries. The aim of this study is to present standard EVAR outcomes in the registry after five years. RESULTS: A significant proportion of the ENGAGE patients presented with challenging features, such as 15.2% with an AAA diameter >7 cm, 12.0% with proximal neck lengths <15 mm, and 10.2% with infrarenal neck angles >60°. Of the 1263 enrolled subjects, 17.8% were implanted outside of the instructions for use for the device. At the five year follow up, the Kaplan-Meier overall survival rate was 67.4% and the freedom from aneurysm related mortality was 97.8%. Freedom from aneurysm rupture, secondary procedures, and conversion to open repair at five years were 98.6%, 84.3%, and 97.9% respectively. The five year freedom from type IA endoleaks was 95.2% and for type III endoleaks 97.4%. Aneurysm sac diameter at five years was observed to have either decreased ≥5 mm in diameter or remained stable in 89.4% of the patients. CONCLUSION: Five year follow up of patients in the ENGAGE registry demonstrates sustained safety, effectiveness, and durability in an international cohort that is reflective of real world experience. Additional follow up is expected through to 10 years.

Patient satisfaction with the consent discussion is not improved by showing patients their computed tomography or angiography images before they undergo vascular surgery.

OBJECTIVE: Patient-based decision aids and other multimedia tools have been developed to help enrich the preoperative discussion between surgeon and patient. Use of these tools, however, can be time-consuming and logistically challenging. We investigated whether simply showing patients their images from preoperative computed tomography (CT) or angiography would improve patients' satisfaction with the preoperative discussion. We also examined whether this improved the patient's understanding and trust and whether it contributed to increased preoperative anxiety. METHODS: Patients undergoing either elective abdominal aortic aneurysm repair or lower limb revascularization were randomly assigned to either standard perioperative discussion or perioperative discussion and review of images (CT image or angiogram). Randomization was concealed and stratified by surgeon. Primary outcome was patient satisfaction with the preoperative discussion as measured by a validated 7-item scale (score, 0-28), with higher scores indicating improved satisfaction. Secondary outcomes included patient understanding, patient anxiety, patient trust, and length of preoperative discussion. Scores were compared using t-test. RESULTS: Overall, 51 patients were randomized, 25 to the intervention arm (discussion and imaging) and 26 to the control arm. Most patients were male (69%), and the average age was 70 years. Forty percent of patients underwent abdominal aortic aneurysm repair, whereas 60% underwent lower limb revascularization. Patient satisfaction with the discussion was generally high, with no added improvement when preoperative images were reviewed (mean score, 24.9 ± 3.02 vs 24.8 ± 2.93; P = .88). Similarly, there was no difference in the patient's anxiety, level of trust, or understanding when the imaging review was compared with standard discussion. There was a trend toward longer preoperative discussions in the group that underwent imaging review (8.18 vs 6.35 minutes; P = .07). CONCLUSIONS: Showing patients their CT or angiography images during the preoperative discussion does not improve the patient's satisfaction with the consent discussion. Similarly, there was no effect on the patient's trust, understanding, or anxiety level. Our conclusions are limited by the lack of a standardized measure of patient understanding and not measuring outcomes postoperatively, both of which should be considered in future studies.

Preoperative point-of-care ultrasound and its impact on arteriovenous fistula maturation outcomes.

OBJECTIVE: Duplex ultrasound as a preoperative assessment tool in the clinic may help identify anatomic factors predictive of fistula maturation. Preoperative point-of-care ultrasound (POCUS) offers surgeons an alternative to routine formal vein mapping as it can be performed by the operator during the initial clinic visit. We sought to determine the impact of POCUS as an adjunct to physical examination on arteriovenous fistula maturation. METHODS: All consecutive patients undergoing first-time dialysis access creation from December 2007 to December 2014 were retrospectively reviewed. Surgeons who routinely use POCUS to assess preoperative maximal vein diameter and quality were compared with surgeons who relied only on physical examination. All access and patency definitions were in accordance with the Society for Vascular Surgery's reporting standards. The effects of POCUS on fistula maturation rate and fistula abandonment were analyzed using logistic regression, controlling for comorbidities of the patient, anticoagulant use, and location of fistula. RESULTS: A total of 316 patients were included in the study; 250 patients were assessed exclusively with physical examination, and 66 patients underwent preoperative ultrasound examination by the vascular surgeon in the clinic. The primary failure rate in the ultrasound group was 18% compared with 47% (P < .001) in the group of patients who did not undergo ultrasound examination. In patients without preoperative ultrasound, there were higher rates of new access creation (31% vs 9%; P < .001) and fistula abandonment (66% vs 39%; P < .001). Multivariable analysis demonstrated that fistulas created without preoperative ultrasound were associated with a 3.56 greater risk of failure (95% confidence interval, 1.67-7.59; P = .001) compared with fistulas in the POCUS group. Similarly, the rate of fistula abandonment was 2.63 times higher (95% confidence interval, 1.38-5.05; P = .003) when ultrasound was not used preoperatively. Time to functional fistula maturation was better in the ultrasound group (P < .001). At 1 year, 12% of fistulas in the ultrasound group and 32% in the clinical examination group had yet to be cannulated. Secondary patency at 1 year was better in the POCUS group at 73% compared with 59% in the group with no preoperative ultrasound (P = .01). CONCLUSIONS: POCUS as an adjunct to physical examination for dialysis access patients leads to decreased rates of primary failure, new access creation, and fistula abandonment compared with patients who undergo only physical examination. Ultrasound examination improved times to functional fistula maturation and secondary patency. Further studies are required to compare POCUS with formal preoperative vein mapping for arteriovenous fistula planning.

Higher surgeon annual volume, but not years of experience, is associated with reduced rates of postoperative complications and reoperations after open abdominal aortic aneurysm repair.

OBJECTIVE: Volume-outcome relationships for open abdominal aortic aneurysm (AAA) repair have received less attention in publicly funded health systems. Furthermore, the roles of surgeon seniority (years of experience) and composite volume (encompassing all major arterial cases) on outcomes after open AAA repair are less well known. We sought to determine the effects of surgeon volume, surgeon years of experience, and composite volume on outcomes after elective open AAA repairs performed in Ontario, Canada. METHODS: Using a population-based, prospectively collected health administrative database, all elective open AAA repairs occurring in the province of Ontario from 2005 to 2014 were identified. Surgeon annual volume was classified by quintiles, with the highest volume quintile acting as the reference category. Multivariable logistic regression modeling was used, adjusting for patient factors (age, sex, comorbidities, year of procedure, income) to investigate the relationship between surgeon annual volume and 30-day mortality, 30-day major complications, 30-day reoperations, 1-year mortality, and 1-year reoperations (related to index procedure). The potential effects of annual surgeon composite volume and surgeon years of experience on postoperative outcomes were also explored. RESULTS: A total of 7211 elective open AAA repairs performed by 101 surgeons were identified between 2005 and 2014. Most of the operations were performed by vascular surgeons (81.5%), followed by cardiac (12.1%) and general surgeons (6.1%). Median number of procedures in the lowest quintile group was 3 repairs/y, whereas the highest quintile group performed 54 repairs/y. Overall 30-day mortality was 3%. No difference in mortality was detected in comparing the lowest with the highest volume groups (1.89% vs 3.01%; adjusted odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33). The lowest volume group exhibited a higher 30-day complication rate (28.0% vs 20.4%; OR, 1.54; 95% CI, 1.15-2.06) and 30-day reoperation rate (10.53% vs 6.73%; OR, 1.64; 95% CI, 1.13-2.38) compared with the highest volume group. No effect of surgeon volume on 1-year mortality or 1-year reoperation was observed. Similarly, composite volume and surgeon years of experience were not associated with postoperative outcomes. CONCLUSIONS: In a single-payer system with a relatively high number of open AAA repairs/surgeon per year, surgeon annual volume had no effect on postoperative mortality but was associated with lower postoperative complication and reoperation rates.

Explaining endograft shortening during endovascular repair of abdominal aortic aneurysms in severe aortoiliac tortuosity.

OBJECTIVE: During endovascular aneurysm repair (EVAR), severely tortuous aortoiliac anatomy can alter the deployment and conformability of the endograft. The accuracy of treatment length measurements is commonly recognized to be affected by severe tortuosity. However, the exact mechanism of the postintervention length discrepancy is poorly understood. The objective of this study was to determine the mechanism of how severe aortoiliac tortuosity influences the endograft and native aorta during EVAR and its impact on the distal sealing zone. METHODS: A prospectively collected vascular surgery database was retrospectively reviewed at a university-affiliated medical center to identify the study patients. Patients who underwent EVAR with the main body device deployed on the side of the severely tortuous iliac artery were selected. Severe aortoiliac tortuosity was defined as having either aortoiliac or common iliac angulation <90 degrees. RESULTS: A total of 469 patients between 2008 and 2014 underwent EVAR using the Endurant endograft (Medtronic Cardiovascular, Santa Rosa, Calif). Severe aortoiliac tortuosity was observed in 36% of patients; 17 patients were found to have the main body placed on the side of severe tortuosity without an extension limb. There was a significant shortening of the main body endograft length from 169 mm before EVAR to 147 mm after EVAR (P < .001). The treatment length of the main body, measured from the lowest renal artery to hypogastric artery, also significantly shortened from 179 mm to 170 mm (P < .001). There was a decrease in tortuosity at the most angulated portion of the aneurysm after EVAR, in which angulation changed from 86 degrees to 114 degrees (P < .001). There was no significant change in treatment length (P = .859) and angulation (P = .195) on the nontortuous side of the aneurysm. CONCLUSIONS: The study observed significant shortening of endografts and native aorta and iliac arteries in patients with severe aortoiliac tortuosity during EVAR. This shortening effect can have a negative impact on the distal sealing zone during EVAR. A longer main body or an extension limb should be considered when one is faced with severely tortuous aneurysms.

Anatomic and procedural determinants of fluoroscopy time during elective endovascular aortic aneurysm repair.

OBJECTIVE: To identify both the procedural and anatomic factors which determine duration of fluoroscopy during elective endovascular aortic aneurysm repair (EVAR). METHODS: We retrospectively analyzed our prospectively maintained EVAR database for the relationship between fluoroscopy time and both procedural (type of graft, configuration, number of components, surgeon) and anatomic factors reflective of aneurysm complexity (15 variables). RESULTS: A total of 128 patients underwent elective EVAR with a mean fluoroscopy time of 5.7 ± 3.4 min. The type of grafts used consisted of 41 (32%) Zenith, 85 (66.4%) Endurant and 2 (1.6%) Anaconda, with 105 (82%) being bifurcated and 23 (18%) being aorto-uni-iliac (AUI) in configuration. Both the surgeon performing the procedure (p = 0.001) and graft configuration (bifurcated vs. AUI, p = 0.03) were found to be predictive of fluoroscopy time; while procedural and anatomic variables were not. CONCLUSIONS: The surgeon's efficiency in the use of fluoroscopy during EVAR is the most important determinant of total fluoroscopy time. Anatomic complexity, make of device, and number of components inserted have minimal impact on duration of fluoroscopy. An endovascular surgeon's ability to curtail fluoroscopy duration is the key component in minimizing radiation exposure to both the surgical team and the patient.

Similar failure and patency rates when comparing one- and two-stage basilic vein transposition.

OBJECTIVE: Basilic vein transposition is recommended in patients who are not candidates for a radial or brachial artery to cephalic vein fistula for dialysis access. Both one-stage and two-stage procedures have their advantages and disadvantages. Which procedure results in improved outcomes remains unclear. METHODS: A systematic review was conducted of the MEDLINE and EMBASE databases for studies that compared one-stage and two-stage brachial-basilic vein transpositions. Abstracts and full-text studies were screened independently by two reviewers with data abstraction done in duplicate. Random-effects meta-analysis was used to identify differences in primary failure rates and 1-year primary and secondary patency rates. Study quality was assessed by a previously described tool designed for observational studies reporting on dialysis access outcomes. RESULTS: Of 1662 abstracts screened, 97 were selected for full-text review. Of these, eight studies (one randomized trial, seven observational studies) involving 882 patients met the inclusion criteria. The pooled odds ratio estimate for primary failure was 1.21 (95% confidence interval [CI], 0.73-1.98; P = .46), suggesting no difference in failure rate between one-stage and two-stage transpositions. Similarly, the estimated odds ratio for 1-year primary patency rate of 1.39 (95% CI, 0.71-2.72; P = .33) and 1-year secondary patency rate of 1.02 (95% CI, 0.36-2.87; P = .98) indicated no difference between the two groups. Study quality was limited by unclear outcome definitions, minimal control for confounding, and variable selection criteria. The decision to pursue a one-stage vs a two-stage procedure was often based on size of the basilic vein, with a two-stage procedure reserved for patients with smaller veins. CONCLUSIONS: Meta-analysis of the existing literature comparing one-stage and two-stage basilic vein transposition suggests no difference in failure and patency rates, despite the two-stage procedure's being used in patients with smaller basilic veins. These findings are limited by the small size, observational design, and inconsistent quality of included studies. Reserving a two-stage procedure for patients with smaller basilic veins appears justified, although the strength of the evidence is limited.

Durability and survival are similar after elective endovascular and open repair of abdominal aortic aneurysms in younger patients.

OBJECTIVE: The role of endovascular repair (EVAR) of aortic aneurysms in young patients is controversial. The purpose of this study was to determine the long-term outcomes and reintervention rates in patients 60 years of age or younger who underwent elective open or endovascular repair of an abdominal aortic aneurysm. METHODS: Retrospective review of a prospectively collected vascular surgery database at a university-affiliated medical center was performed to identify all patients who underwent elective repair of an abdominal aortic aneurysm between 2000 and 2013 and were 60 years of age or younger at the time of the repair. Preoperative anatomic measurements were performed and compared with instructions for use (IFU) criteria for the endografts. RESULTS: The study cohort comprised 169 patients 60 years of age or younger (mean age, 56.7 ± 2.8 years) who underwent elective repair (119 open repair, 50 EVAR). Patients treated with open repair and EVAR had similar comorbidities, except that EVAR patients were more likely to have hypertension (P = .03) and poor left ventricular function (P = .04). The open repair group had significantly larger suprarenal (P = .004) and infrarenal (P = .005) neck angles, shorter neck lengths (P < .001), and larger maximum aneurysm diameter (P = .02) compared with the EVAR group. Only five patients (13%) in the EVAR group did not meet all IFU criteria. The overall in-hospital mortality rate was 1.8% (0% EVAR, 2.5% open repair; P = .56). Overall mean life expectancy was 11.5 years (9.8 years EVAR, 11.9 years open repair; P = .09). The 1-year (98% EVAR, 96% open repair), 5-year (86% EVAR, 88% open repair), and 10-year (54% EVAR, 75% open repair) survival did not differ between EVAR and open repair (P = .16). Long-term survival (78% EVAR, 85% open repair; P = .09) and reintervention rates (12% EVAR, 16% open repair; P = .80) did not differ. No late aneurysm rupture or aneurysm-related deaths were observed. The most common causes of long-term mortality were malignant disease and cardiovascular events. Reinterventions in the open repair group were exclusively laparotomy related (incisional hernia repairs), whereas all reinterventions in the EVAR group were aortic related, including one conversion to open repair. CONCLUSIONS: After elective aneurysm repair, younger patients have a moderate life expectancy related to malignant disease and cardiovascular health. EVAR offers durability and long-term survival similar to those with open repair in these younger patients as long as aneurysm anatomy and IFU are adhered to.

Canadian vascular surgery residents' perceptions regarding future job opportunities.

The objective was to determine the employment environment for graduates of Canadian vascular surgery training programs. A cross-sectional survey of residents and graduates (2011-2012) was used. Thirty-seven residents were invited with a response rate of 57%, and 14 graduates with a response rate of 71%; 70% of graduates felt the job market played an important role in their decision to pursue vascular surgery as a career compared to 43% of trainees. The top three concerns were the lack of surgeons retiring, the overproduction of trainees, and saturation of the job market. The majority (62%) of trainees see themselves extending their training due to lack of employment. All of the graduates obtained employment, with 50% during their second year (of two years) of training and 30% after training was completed. Graduates spent an average of 12 ± 10.6 months seeking a position and applied to 3.3 ± 1.5 positions, with a mean of 1.9 ± 1.3 interviews and 2 ± 1.2 offers. There was a discrepancy between the favorable employment climate experienced by graduates and the pessimistic outlook of trainees. We must be progressive in balancing the employment opportunities with the number of graduates. Number and timing of job offers is a possible future metric of the optimal number of residents.

Identification of patient-derived outcomes after aortic aneurysm repair.

OBJECTIVE: Relatively few outcomes have been examined in randomized comparisons of endovascular and open aortic aneurysm repair, and no patient input was obtained in the selection of these outcomes. The aim of this study was to identify patient-derived, potentially novel outcomes that may be used to guide future clinical trials in aneurysm surgery. METHODS: Focus group interviews were conducted with patients who had undergone endovascular or open aortic aneurysm repair. The discussions were transcribed and the transcript was analyzed by two indexers using constant-comparison analysis and grounded theory to identify potentially novel, patient-derived outcomes. Other potential themes relating to the patients' experience and their decision-making were also sought. RESULTS: Six focus groups were conducted (three with endovascular aneurysm repair patients and three with open aortic aneurysm repair patients), with a median of six participants, 2 to 12 months from surgery. Functional outcomes were most commonly mentioned and emphasized by patients. Recovery time and energy level were most frequently verbalized as important in the decision-making process between endovascular and open aneurysm repair. Other potential outcomes identified as important to patients included postoperative pain, time to walking normally, loss of appetite, extent and location of incisions, impact on cognition, being able to go home after surgery, and impact on caregivers. In addition to these outcomes, we identified three themes relating to the patient's experience: undervaluing or underappreciating the risk of death during surgery, differing informational needs and level of involvement in decision-making, and unrealistic patient expectations about the risks of and recovery after the procedure. CONCLUSIONS: Functional outcomes emerged as most important during qualitative analysis of patients' experiences with aneurysm repair. Perceived differences in recovery time were identified as an important consideration for aneurysm patients in deciding between open and endovascular repair. More work needs to be done clarifying the concept of recovery and other related functional outcomes for the development of methods to assess and to evaluate these in prospective clinical trials.

Debate: Whether level I evidence comparing thoracic endovascular repair and medical management is necessary for uncomplicated type B aortic dissections.

Type B aortic dissections continue to be one of the most challenging clinical scenarios confronting vascular surgeons. In the era of open surgery, the therapeutic options were limited to medical management of hypertension and large open thoracoabdominal operations. In the current endovascular era, the operative strategies have become less invasive but the questions regarding therapeutic approaches have become more numerous and complex. In patients with acute uncomplicated type B aortic dissections, we are still unsure as to which patients are best treated with medical therapy alone or with the addition of early endovascular repair. Data from single centers and registries have provided some guidance; however, questions remain. Perhaps level 1 evidence from well-designed randomized controlled trials will answer all of our questions. This is the topic of the current debate.

Impact of preoperative embolization on outcomes of carotid body tumor resections.

OBJECTIVE: This study assessed neurovascular complications in the surgical management of carotid body tumors (CBTs), with emphasis on those treated with and without preoperative embolization. METHODS: We reviewed the clinical data of all consecutive patients with CBTs treated by surgical resection at our institution from 1985 to 2010. Outcomes were compared between Shamblin class II and III CBTs treated with preoperative embolization (EMB group) and with no preoperative embolization (NEMB group). RESULTS: A total of 131 patients (80 women, 51 men), who were aged 48 years (range, 16-84 years), had resection of 144 CBTs and 12 concurrent cervical paragangliomas. This included 18 patients who had bilateral resections and 29 with familial CBTs. Succinate dehydrogenase (SDHx) mutations were confirmed in 17 patients. Mean tumor volume was 20.5 cm(3) (range, 0.8-101.3 cm(3)), and there were two biochemically active CBTs (1%). There were 71 Shamblin II and 33 Shamblin III. The EMB group underwent 33 CBT resections, and the NEMB group underwent 71. There were more patients in the EMB group with bilateral (48% vs 22%; P = .01) and familial (34% vs 14%; P = .01) CBT; otherwise, patient demographics, Shamblin class, and tumor diameter and volumes were similar. No strokes or other major complications occurred after preoperative embolization with polyvinyl alcohol particles 1 day before surgery. The EMB group required less extensive procedures (simple excision in 97% vs 82%, P = .03; internal carotid artery clamping in 15% vs 37%, P = .04) and had less blood loss (mean estimated blood loss, 263 vs 599 mL; P = .002) than the NEMB group. However, there were no significant differences in operative time (250 vs 265 minutes; P = .49), temporary cranial nerve injury (52% vs 38%; P = .21), clinically apparent cranial nerve deficits after 1 year (12% vs 7%; P = .46), deaths (0% vs 0%; P > .99), stroke (0% vs 1%; P > .99), or postoperative length of stay (4.1 vs 4.2 days; P = .91). CONCLUSIONS: Large CBTs can be resected safely with or without preoperative embolization. Preoperative embolization may simplify the conduct of the operation and reduce blood loss but does not decrease rates of cranial nerve injury, although most are temporary.

Improvements in patient outcomes with next generation endovascular aortic repair devices in the ENGAGE Global Registry and the EVAR-1 clinical trial.

BACKGROUND: The outcomes from the randomized controlled trials (RCTs) comparing endovascular aortic aneurysm repair (EVAR) to open surgical repair (OSR) may no longer be reflective of currently technology. Here the EVAR-1 trial and the ENGAGE registry are examined to assess potential improvements in outcomes with modern stent graft systems. METHODS: EVAR-1 was a multicenter, prospective, randomized controlled trial in the UK and patients were enrolled between 1999 and 2004 and treated with first- and second-generation devices. ENGAGE is an observational, nonrandomized, prospective registry that completed enrollment between 2009 and 2011. All ENGAGE patients were treated with the Endurant AAA Stent Graft System. A descriptive comparison of the published four-year outcomes of all-cause mortality (ACM), aneurysm-related mortality (ARM), rupture after elective EVAR, and reinterventions are reported. RESULTS: Through the four-year timepoint, freedom from ACM was 74.4% in the EVAR-1 Trial and 74.6% in the ENGAGE registry. ARM in the EVAR-1 trial was 4.2% and in the ENGAGE registry was 1.9%. Death due to rupture through four years was 1.6% (10/626) and 0.5% (6/1263) in the EVAR-1 and ENGAGE patients, respectively. In the EVAR-1 trial, the proportion of patients requiring at least one reintervention through the four-year timepoint was 19.3% (121/626) whereas in the ENGAGE registry, reinterventions occurred in 10.9% (138/1263) of patients. CONCLUSIONS: EVAR patient outcomes have improved since the time of the original EVAR vs. OSR trials and data from real-world registries should be considered a primary resource for developing new guidelines for patient selection and management.

Obstruction of Small Arterioles in Patients with Critical Limb Ischemia due to Partial Endothelial-to-Mesenchymal Transition.

Critical limb ischemia (CLI) is a hazardous manifestation of atherosclerosis and treatment failure is common. Abnormalities in the arterioles might underlie this failure but the cellular pathobiology of microvessels in CLI is poorly understood. We analyzed 349 intramuscular arterioles in lower limb specimens from individuals with and without CLI. Arteriolar densities were 1.8-fold higher in CLI muscles. However, 33% of small (<20 µm) arterioles were stenotic and 9% were completely occluded. The lumens were closed by bulky, re-oriented endothelial cells expressing abundant N-cadherin that uniquely localized between adjacent and opposing endothelial cells. S100A4 and SNAIL1 were also expressed, supporting an endothelial-to-mesenchymal transition. SMAD2/3 was activated in occlusive endothelial cells and TGFß1 was increased in the adjacent mural cells. These findings identify a microvascular closure process based on mesenchymal transitions in a hyper-TGFß environment that may, in part, explain the limited success of peripheral artery revascularization procedures.

Vascular surgery resident training in Canada.

The training of vascular surgeons in Canada has evolved over the past decade. Direct entry into a vascular surgery training program after medical school has been offered since 2012. At some institutions, it is the only option for surgery training. The smaller population of Canada and a single-payer health care system has resulted in unique opportunities and challenges for the training of vascular surgeons and providing opportunities for trainees to transition into clinical practice.