Determining patient risk factors associated with accelerated growth of popliteal artery aneurysms.

OBJECTIVE: The objective of this study was to determine the natural progression of popliteal artery aneurysms (PAAs) and clinical variables associated with their accelerated growth. METHODS: Retrospective chart review of 224 patients with encounters between January 2008 and May 2016 and with at least one PAA was conducted. From this group, 65 asymptomatic patients had either unilateral (n = 43) or bilateral (n = 22) PAAs that were observed for at least 1 year of medical management before intervention. We divided these aneurysms into two groups based on whether their overall growth rate was above or below the eventual mean. Aneurysm diameter was taken from duplex ultrasound and computed tomography angiography. RESULTS: There were 87 aneurysms evaluated among 65 patients. Mean age at diagnosis was 70.9 years (standard deviation [SD], 9.39 years), and 64 patients were male (98%); 50 (77%) were white and 7 (11%) were African American. The average body mass index was 27.69 (SD, 4.90). At or before initial diagnosis, 61 (94%) patients had a concomitant lower extremity or abdominal aortic aneurysm; 51 (78%) patients were current or former smokers; and 16 (25%) had atrial fibrillation. The average growth rate of all aneurysms was 1.22 mm/y (SD, 1.93 mm). The mean surveillance time from initial diagnosis to last follow-up or intervention was 3.12 years (SD, 1.66 years). Of 87 aneurysms, 25 (29%) were repaired; 18 (21%) were repaired because of size criteria, 2 (2%) because of symptom criteria (claudication or acute limb ischemia), and 5 (6%) because of both criteria. During our study window, 62 aneurysms (71%) remained asymptomatic or did not undergo an intervention. The mean initial diameter at diagnosis was 16.9 mm (SD, 5.32 mm). Within the study, 50 (57%) aneurysms presented with or developed mural thrombus. Univariate analysis identified larger initial diameter (19.2 vs 14.7 mm; P = .020), atrial fibrillation (35% vs 16%; P = .042), and mural thrombus (38% vs 20%; P < .001) as predictors of diameter expansion greater than the mean. Multivariable analysis of the significant univariate factors determined that only initial diameter (odds ratio, 5.53; P = .007) and the presence or development of mural thrombus (odds ratio, 4.00; P = .008) maintained significance. CONCLUSIONS: Patients presenting with a PAA at 20 mm or >20 mm in diameter, presence of luminal thrombus, or atrial fibrillation may need to be observed at more frequent scanning intervals than those without these risk factors. Further studies are required to validate these predictive growth factors.

Abdominal aortic aneurysm anatomic severity grading score predicts implant-related complications, systemic complications, and mortality.

OBJECTIVE: The aim of our study was to examine the predictive value of the anatomic severity grading (ASG) score for abdominal aortic aneurysms (AAAs) on implant-related complications, systemic complications, and mortality at 30-day and midterm, defined as 2 years, follow-up assessments. METHODS: Patients who underwent endovascular aneurysm repair for infrarenal AAAs between 2009 and 2012 were retrospectively reviewed, and ASG scores were calculated from three-dimensonal computed tomography reconstructions. Two independent patient groups were created: those with a low ASG score (score <14) and those with a high ASG score (score ≥14). RESULTS: We identified 190 patients (77% male), with a mean age of 73 years, and 84% Caucasian, with 104 patients in the low-score group and 86 in the high-score group. Within 30 days of the index endovascular aneurysm repair, 10 implant-related complications occurred in six patients (3%) and 25 systemic complications in 18 (9%). The incidence of 30-day implant-related complications was not significantly different between the low-score group (2 [2%]) and the high-score group (4 [5%]; P = .41). The incidence of patients with 30-day systemic complications was significantly different between the low-score group (5 [5%]) and the high score group (13 [15%]; P = .023). A composite end point of combined implant-related and systemic complications at 30 days showed there was a statistically significant difference between the low-score (7 [7%]) and high-score group (17 [20%]; P = .007). At a midterm follow up of 26 months (range, 1-64 months), implant-related complications occurred in 21 patients (11%), and systemic complications occurred in 29 (15%). The incidence of implant-related complications was significantly different between the low-score group (7 [7%]) and the high-score group (14 [16%]; P = .037). The incidence of midterm systemic complications was significantly different between the low-score group (11 [11%]) and the high-score group (18 [21%]; P = .048). A composite end point of combined implant-related and systemic complications at midterm follow-up resulted in a statistically significant difference between the low-score group (16 [15%]) and the high-score group (26 [30%]; P = .014). Kaplan-Meier analysis revealed that the low-score group had fewer overall complications (combined implant-related and systemic) at 1 year (14% vs 34%) and 2 years (15% vs 45%) compared with the high-score group (P < .001). The low-scoring group also had significantly higher survival at 1 year (96% vs 86%) and 2 years (88% vs 84%) compared with the high-score group (P = .047). CONCLUSIONS: The AAA ASG score can be used to predict patients at risk for midterm implant-related complications, 30-day and midterm systemic complications, and all-cause mortality.

Anatomic severity grading score for primary descending thoracic aneurysms predicts procedural difficulty and aortic-related reinterventions after thoracic endovascular aortic repair.

BACKGROUND: An anatomic severity grading (ASG) score for primary descending thoracic aortic aneurysms (DTAs) was developed. The objective of this study was to determine if an ASG score cutoff value for DTAs is predictive of procedural complexity, aortic-related reinterventions, and mortality in patients who undergo thoracic endovascular aortic repair (TEVAR). METHODS: A retrospective review from 2008 to 2013 of patient records was conducted of all consecutive patients who underwent TEVAR for a primary DTA. A comprehensive scoring system of preoperative DTA morphology on the basis of computed tomography angiography images was established to identify and classify anatomic features that might influence outcome after TEVAR. ASG score calculations were achieved using preoperative computed tomography angiography images. Primary outcomes included primary technical success, aortic-related reinterventions, aneurysm-related mortality, and all-cause mortality. Secondary outcomes included procedural complexity (unplanned adjunctive procedures, number of endografts implanted, contrast volume, and procedure time), endoleak formation, endoleak requiring reintervention, stroke and paraplegia, and conversion to open repair. RESULTS: Of 469 patients with a diagnosis of a thoracic aortic aneurysm, 62 patients (13%) underwent TEVAR and had adequate preoperative imaging (mean age, 71 years). Applying the ASG score, we identified 39 patients (63%) with a score ≥24 (high-score group) and 23 patients (37%) with a score <24 (low-score group). Mean follow-up was 15.3 months (range, 4 days to 3.7 years; standard deviation, 1 year) for both groups. Freedom from all-cause mortality was significantly different in the high-score (87% at 1 year, 79% at 2 years, and 57% at 3 years) vs the low-score group (100% at 1, 2, and 3-years; log-rank test, P < .021). There was no significant difference between mortality in the high-score (97% at 1 year, 87% at 2 years, and 69% at 3 years) compared with the low-score group (100% at 1, 2, and 3 years; log-rank test, P = .162). Freedom from aortic-related reinterventions was significantly lower in the high-score (82% at 1 year, 68% at 2 years, and 35% at 3 years) compared with the low-score group (100% at 1, 2, and 3 years; log-rank test, P = .002). Operative difficulty in the form of intraoperative adjunct procedures, number of endografts implanted, and procedural time had significant differences between groups (18% vs 0%, P = .038; 79% vs 39%, P = .004; 120 vs 79 minutes, P = .005, respectively). No significant difference in 30-day combined stroke and paraplegia (16%) was present between groups, and no patient had a conversion to open repair during the follow-up period. CONCLUSIONS: Preoperative ASG score for primary DTAs predicted procedure complexity and aortic-related reinterventions after TEVAR.

Patient compliance limits the efforts of quality improvement initiatives on arteriovenous fistula maturation.

OBJECTIVE: Our institutional quality-improvement (QI) initiative instituted a well-defined office follow-up schedule after arteriovenous fistula (AVF) creation, including an office visit within 30 days, fistulogram within 40 days, if indicated, and a second office visit within 55 days. In addition, a patient liaison contacted patients and dialysis units to improve follow-up. The purpose of this study was to determine the effect of the QI initiative on patient compliance and overall time to AVF permission to cannulate. METHODS: We performed a retrospective review of patients undergoing first-time radiocephalic, brachiocephalic, and basilic vein transposition creation before the QI initiative (pre-QI group: January to April 2012) and during the QI period (QI group: January to April 2013). Categoric data were compared using χ(2) analysis, and nominal data were compared using the Student t-test. RESULTS: We reviewed 198 first-time AVF creations in patients (57% male) with a mean age of 61 years. Demographics and comorbidities between the pre-QI and QI groups were similar. Compliance with the first 30-day postoperative appointment increased significantly after the QI initiative, from 48% in the pre-QI group to 65% in the QI group (P = .015). Yet, the QI initiative did not maintain an effect on the subsequent follow-up checkpoints. No statistical difference was identified for compliance with fistulogram within 40 days of access creation (pre-QI, 12% vs QI, 25%; P = .093) or for compliance with the 55-day postoperative appointment (pre-QI, 33% vs QI, 23%; P = .457). Both checkpoints demonstrated a very high noncompliance rate. Accordingly, the mean time to permission to cannulate was 88 days for both the pre-QI and QI groups, with a failure to mature rate of 22% for the pre-QI group and 21% for the QI group (P = .816). CONCLUSIONS: The QI initiative significantly increased the number of patients complying with the first 30-day follow-up appointment after AVF access creation. However, patient compliance with a timely fistulogram and the second follow-up appointment was poor and not influenced by the QI initiative, limiting the functional effect of the QI initiative on the time to AVF permission to cannulate.

Volumetric analysis of the initial index computed tomography scan can predict the natural history of acute uncomplicated type B dissections.

OBJECTIVE: Our objective was to characterize the predictive impact of computed tomography (CT) scan volumetric analysis on the natural history of acute uncomplicated type B aortic dissections (ADs). METHODS: We conducted a retrospective review of patients with acute type B ADs from 2009 to 2014. On an iNtuition workstation (TeraRecon, Foster City, Calif), volume measurements were obtained using the true lumen volume (TLV), false lumen volume (FLV), and total aortic volume from the left subclavian artery to the celiac artery. Growth rate was calculated as the change in maximal diameter between first and last available CT scans during the time interval. The primary outcome of the study was delayed aortic intervention. P < .05 was considered statistically significant. RESULTS: During a 5-year period, 164 patients had CT scan evidence of acute type B ADs; 11 patients were excluded for lack of subsequent follow-up imaging; 36 patients who underwent urgent repair (<14 days from presentation) were also excluded. We evaluated a total of 117 patients: 85 patients who did not require intervention and 32 who underwent delayed (>14 days) thoracic endovascular aneurysm repair (29) or open repair (3). Mean age was 66 ± 12 years. Mean TLV/FLV ratio on initial CT scan was significantly higher in patients who did not eventually require an operation (1.55 vs 0.82; P = .02). The mean growth rate was higher in those eventually requiring operation (2.47 vs 0.42 mm/mo; P = .003). Patients were divided into three subgroups on the basis of their initial imaging TLV/FLV ratios (<0.8, 0.8-1.6, and >1.6). There was a significant difference in the growth rates between these three groups (4.6 vs 2.4 vs 0.8 mm/mo; P < .025). Area under the receiver operating characteristic curve analysis revealed that a TLV/FLV ratio <0.8 was highly predictive for requiring an intervention (area = 0.8; sensitivity, 69%; specificity, 84%: positive predictive value, 71%; negative predictive value, 81%), with an odds ratio of 12.2 (confidence interval, 5-26; P < .001). Conversely, a TLV/FLV ratio of >1.6 was highly predictive for freedom from delayed operation (sensitivity, 91%; specificity, 42%; positive predictive value, 61%; negative predictive value, 86%). After Kaplan-Meier analysis, 1-year and 2-year survival free of aortic interventions was 60% and 42% with a TLV/FLV ratio <0.8 and 92% and 82% with a ratio >1.6 (P = .001). CONCLUSIONS: Initial CT scan volumetric analysis in patients presenting with uncomplicated acute type B ADs is a useful tool to predict growth and need for future intervention.

The effect of demographic factors and lesion severity on iliac stent patency.

OBJECTIVE: The aim of our study was to perform a large multivariate analysis to identify demographic, anatomic, or procedural factors that affect iliac artery stent primary patency (PP). METHODS: Patients receiving iliac stents from 2007 to 2013 were retrospectively reviewed. Univariate analysis assessed cohort characteristics and their effect on PP. Variables considered significant (P < .05) were brought forward in the multivariate analysis. RESULTS: A total of 213 patients underwent primary iliac artery stenting, and 307 limbs were analyzed. The average age was 66 years (range, 38-93 years), 54% were male, and 55% were Caucasian. Indications for procedure were claudication in 68%, rest pain in 20%, and tissue loss in 12%. All TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classifications were included: 51% TASC II A, 25% TASC II B, 13% TASC II C, and 11% TASC II D. The treated anatomic locations were 27% isolated external iliac artery (EIA), 56% isolated common iliac artery, and 17% combined common iliac artery and EIA. Multivariate analysis found three factors were correlated with decreased PP: non-Caucasian race (hazard ratio [HR], 1.84; 95% confidence interval [CI], 1.08-3.13; P = .025), younger age (HR, 1.04; 95% CI, 1.01-1.08; P = .006), and presence of EIA occlusion (HR, 2.02; 95% CI, 1.05-3.89; P = .036). Overall, Kaplan-Meier analysis at 1 and 3 years revealed a PP of 86% and 53%, assisted PP of 98% and 89%, and secondary patency of 99% of 98%. Kaplan-Meier analysis showed PP at 1 year for was 91% Caucasian patients vs 77% for non-Caucasian (P = .001). PP was 75% in patients aged <60 years, 86% in patients aged 60-70 years, and 96% in patients aged >70 years, with a significant difference between all groups (P < .001). PP was significantly different for those with and without EIA occlusion (P = .002), with 1-year PP of 71% and 88%, respectively. CONCLUSIONS: In our experience with a large number of iliac interventions, younger age, non-Caucasian race, and EIA occlusion were strong predictors for loss of PP.

Aortic remodeling after thoracic endovascular aortic repair for intramural hematoma.

BACKGROUND: Intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and aortic dissection comprise a spectrum of acute aortic pathologies. Although thoracic endovascular aortic repair (TEVAR) has increasingly been applied to aortic dissection, there is a paucity of data on the anatomic effect of TEVAR for IMH. Our goal was to investigate the extent of aortic remodeling after TEVAR. METHODS: A retrospective chart review from 2006 to 2012 was conducted on patients who underwent TEVAR for IMH. Data were collected from the electronic medical record. Radiology images were reviewed and primary data points included diameter (TLD) and volume measurements for aortic true lumen and total aortic diameter (TAD) and volume at the site of maximal pathology. Aortic remodeling was evidenced by a TAD/TLD ratio closest to 1.0. Patients with no imaging beyond 30 days postoperatively were excluded. RESULTS: During the 6-year period, 44 patients underwent TEVAR for IMH. Twenty-five patients had an IMH with concomitant PAU. There were 25 (57%) female patients. Mean age was 71 ± 11 years, and 40 (91%) patients had hypertension. Operative indications included intractable pain in 31 (70%), rapidly progressing IMH or conversion to dissection in 13 (30%), rupture in 10 (23%), and uncontrolled hypertension in 6 (14%). Technically successful TEVAR was performed in all patients with 42 (95%) reporting complete relief of symptoms. The 30-day mortality rate was 5% with a 5% rate of permanent paraplegia or paraparesis. At a mean follow-up of 26 months, there were no additional aortic-related deaths and overall survival was 80% with a reintervention rate of 11%. For our imaging analysis, 10 patients were excluded because of lack of follow-up imaging beyond 30 days. At a mean follow-up of 13 months, all measured data points were statistically improved from before to after TEVAR: thickness of IMH (12 mm vs. 4 mm; P = .01), mean TLD (35 mm vs. 37 mm; P = .04), mean TAD (47 mm vs 42 mm; P = .02), TAD/TLD ratio (1.35 vs. 1.14; P < .01), and IMH volume (103 cm3 vs. 14 cm3; P < .01). The mean Δ in TAD/TLD ratio from before to after TEVAR for the reintervention group was Δ0.14, and the mean Δ in TAD/TLD ratio for the nonreintervention group was Δ0.29 (P = .05). Analysis of patients with isolated IMH and those with concomitant PAU revealed no statistical differences. CONCLUSIONS: TEVAR is safe and effective in treating IMH and based on longitudinal computed tomography scan analysis, aortic remodeling is evidenced by normalization of all measured indices.

In situ laser fenestration during emergent thoracic endovascular aortic repair is an effective method for left subclavian artery revascularization.

BACKGROUND: Retrograde laser fenestration of the left subclavian artery (LSA) during emergent thoracic endovascular aortic repair (TEVAR) uses a relatively simple intraoperative method of endograft modification to revascularize aortic branches for a variety of acute thoracic aortic pathologies. This study presents our expanded experience and midterm outcomes of TEVAR with laser fenestration to revascularize the LSA as an alternative to debranching. METHODS: Patients who underwent TEVAR with LSA revascularization by laser graft fenestration from September 2009 through August 2012 were retrospectively reviewed. TEVAR was performed with deployment of a Dacron (DuPont, Wilmington, Del) endograft over the LSA orifice. Laser catheter fenestration of the graft was performed through retrograde brachial access, followed by balloon-expandable covered stent deployment through the fenestration to traverse the endograft and LSA. Routine postoperative follow-up imaging with computed tomography angiography was performed to assess TEVAR and LSA fenestration patency, endoleak, and aneurysm/dissection exclusion. RESULTS: TEVAR with laser fenestration was successfully performed in 22 patients (12 men; mean age, 57 years) in an urgent or emergent setting secondary to unremitting symptoms or rupture. Twelve patients had large symptomatic thoracic aortic aneurysms (eight secondary to chronic dissection); four patients had acute symptomatic type B aortic dissection, and six patients had an intramural hematoma or penetrating aortic ulcer, or both. An average of two endografts (range, 1-4) were deployed. LSA-covered stents were 8 to 10 mm in diameter. Mean operative time was 154 ± 65 minutes. Average hospital length of stay was 12 ± 7 days. No major fenestration-related complications occurred. One patient developed postoperative paraplegia. One patient died in the postoperative period, for an in-hospital mortality rate of 4.5%. Two patients died of non-TEVAR-related causes at a mean follow-up of 10 months (range, 1-40 months). Follow-up computed tomography angiography imaging demonstrated a 100% primary patency for the LSA stents. One patient had an asymptomatic LSA stent stenosis. Type II endoleaks from the LSA in two patients required endovascular coil embolization. No fenestration-related type I or III endoleaks were noted. CONCLUSIONS: In situ retrograde laser fenestration is a feasible and effective option for LSA revascularization during TEVAR involving a spectrum of acute thoracic aortic pathology. Laser fenestration provides a rapid, reproducible method of fenestrating the endograft material. The high technical success, low fenestration-related morbidity, and excellent midterm patency support this technique of intraoperative endograft modification.

Endovascular foreign body retrieval.

OBJECTIVE: The number of endovascular procedures performed is increasing exponentially as technology improves. A serious complication of endovascular therapy is loss of a foreign body in the vasculature. We reviewed our experience and evaluated the cause, management, and outcomes of intravascular foreign body (IVFB) misplacement. METHODS: We completed a retrospective review of patients who underwent endovascular retrieval of IVFBs between 2005 and 2010. Patients were identified by current procedural terminology code or by our hospital's risk management team. Patients undergoing routine endovascular retrieval of temporary vena cava filters were excluded. RESULTS: Twenty-seven IVFBs were identified in 26 patients. Twenty patients were asymptomatic (76.9%). Six patients were symptomatic (22.2%) with either pain (n = 4) or abnormal physical findings (n = 2). There were 13 (48.1%) catheter fragments, six (22.2%) guidewires, five (18.5%) inferior vena cava (IVC) filter (embolisms), two (7.4%) stents, and one (3.7%) sheath fragment. There were five (15.6%) embolizations of an IVFB into the right heart, three (9.4%) into a pulmonary artery, eight (25%) into the vena cava, eight (25%) into peripheral veins, five (15.6%) into peripheral arteries, one (3.1%) into a coronary artery, one (3.1%) into a hepatic vein, and one (3.1%) into adjacent soft tissue. The mechanism of endovascular loss was device fracture in 16 (59.3%) cases, loss of control in six cases (22.2%), migration in four (14.8%) cases, and incorrect device deployment in one case (3.7%). The probable cause of foreign body loss was technical error in eight (29.6%) cases. In three cases, IVFB retrieval was not attempted. The misplacement and retrieval were completed during the same procedure in 13 (48%) cases. Twenty-four endovascular retrievals were performed. Fifteen (62.5%) procedures used a snare to remove the IVFB and two (8.2%) used balloon catheters. Three IVFBs could not be removed and two cases were converted to open procedures. Technical success was achieved in 19/24 cases (79.2%). There were no immediate complications related to the retrieval of the IVFB; however, there was a single late complication of pulmonary embolism after failed endovascular retrieval (1/24, 4.2%). Thirty-day survival was 100%. CONCLUSIONS: Intravascular foreign bodies are a serious complication of endovascular therapy that can be minimized with proper device selection and deployment. When an intravascular foreign body is identified, endovascular retrieval should be attempted due to its high success rate and minimal morbidity.

Distal revascularization and interval ligation procedure for radial-basilic forearm transposition arteriovenous fistula.

The distal revascularization and interval ligation procedure is commonly performed for steal syndrome in upper arm arteriovenous accesses and is rarely performed in the forearm. We present a case of distal revascularization and interval ligation procedure performed for a 60-year-old male who presented with a 3-month history of a nonhealing ulcer of his left middle finger as a result of ischemic steal syndrome 4 years after having a left radial-basilic forearm transposition arteriovenous fistula.

Comparative analysis of celiac versus mesenteric artery outcomes after angioplasty and stenting.

BACKGROUND: Open bypass is the gold standard for treatment of mesenteric ischemia. With the refinement of endovascular therapy, visceral stenting is an attractive minimally invasive alternative, but the data are limited and which vessel responds best to stenting has not been addressed. This study compares the outcomes of superior mesenteric artery (SMA) and celiac artery (CA) stenting. METHODS: All consecutive patients who underwent visceral stenting between January 2002 and May 2009 were reviewed. Standard statistical analyses, including Kaplan-Meier tests, were performed. Primary patency was defined as peak systolic velocities <350 cm/s for CAs and <450 cm/s for SMAs. Clinical patency was maintenance of either primary patency or the absence of recurrent symptoms. At arteriography, stenosis ≥70% was considered a loss of primary patency. RESULTS: One hundred twenty-one patients received 140 visceral stents in the SMA (n = 92; 65.7%), the CA (n = 40; 28.6%), and the inferior mesenteric artery (n = 8; 5.7%). Twenty-nine stents were placed in men (20.7%) and 111 stents were placed in women (79.3%) with a mean age of 72.9 years (range, 20.5-93.9). The combined SMA/CA stent mean follow-up was 12.8 months. Technical success was 100% for all. Overall 30-day morbidity and mortality rates were 14% and 0.8%, respectively. One-year primary patency was significantly higher for SMA than for CA stents: 55% versus 18%, respectively (P < .0001). Six-month clinical patency was 86% for the SMA and 67% for the CA (P < .005). Loss of CA primary patency was associated with stent diameter <6 mm (P = .042) and age <50 years (two patients; P = .038). These factors did not correlate with loss of primary patency for SMA. Overall freedom from bypass was 93% at 4 years. CONCLUSIONS: Visceral stenting has an exceptionally high technical success rate with low procedural morbidity and mortality. Clinical primary patency and primary patency were significantly higher for the SMA group than for the CA group. Our data suggest that CA atherosclerotic lesions do not respond well to endovascular stenting, bringing into question its clinical utility.

Atherectomy offers no benefits over balloon angioplasty in tibial interventions for critical limb ischemia.

BACKGROUND: Endovascular adjuncts, like atherectomy, were developed to improve outcomes of endovascular arterial interventions. The true impact of atherectomy on endovascular outcomes remains to be determined, and little data exist on the influence of atherectomy on tibial interventions. Our study compares early and late outcomes of tibial intervention with angioplasty vs atherectomy-assisted interventions. METHODS: We completed a retrospective review of all tibial interventions between 2008 and 2010. Outcomes were analyzed using single and multivariate analysis, Cox regression, and Kaplan-Meier curves. Primary outcomes were primary, primary assisted, and secondary patency rates, as well as limb salvage and survival rates. RESULTS: Over a 2-year period, 480 tibial interventions were completed for 421 patients. Eighty-seven percent (n = 418) of interventions were performed for critical limb ischemia (CLI) and 13% (n = 62) for claudication. The CLI cohort of 418 interventions was analyzed. These patients had a mean age of 71 years with a mean follow-up time of 16 ± 15 months (range, 0-59 months). Of the 418 interventions, 339 underwent percutaneous transluminal angioplasty (PTA): 333 PTA alone, six PTA + stent. The remaining 79 interventions received atherectomy: 33 laser, 13 directional, and 33 orbital either alone or in conjunction with PTA (11 atherectomy only, 68 atherectomy + PTA). The groups did not differ significantly in terms of demographics, risk factors, or technical success. The atherectomy group had more TASC B lesions (54% vs 38%; P = .013), while the PTA-alone group had more TASC D lesions (25% vs 13%; P = .004). TASC A and C lesions did not differ significantly between the groups. No significant differences existed with respect to the early (30-day) outcomes of loss of patency (11% vs 13%; P = .699), complications (8% vs 13%; P = .292), or major amputation (17% vs 13%; P = .344) in the PTA-alone group vs the atherectomy-assisted group. Kaplan-Meier analysis revealed no difference for all primary outcomes of PTA alone vs the atherectomy-assisted group at 12 and 36 months: primary patency (69%, 55% vs 61%, 46%; P = .158), primary assisted patency (83%, 71% vs 85%, 67%; P = .801), secondary patency (94%, 89% vs 95%, 89%; P = .892), limb salvage (79%, 70% vs 81%, 77%; P = .485), or survival (77%, 56% vs 80%, 50%; P = .944). CONCLUSIONS: The adjunctive use of atherectomy offered no improvement in primary outcomes over PTA alone in either early or late outcomes in CLI patients who underwent endovascular tibial interventions. Considering the additional cost and increased procedural time, these findings put into question the routine use of adjunctive atherectomy.

A case-matched validation study of anatomic severity grade score in predicting reinterventions after endovascular aortic aneurysm repair.

BACKGROUND: In 2002, the Society for Vascular Surgery created the anatomic severity grading (ASG) score to classify abdominal aortic aneurysms (AAAs). Our objective was to identify the predictive capability and cutoff value of preoperative ASG score for reintervention after endovascular aneurysm repair (EVAR). METHODS: We completed a retrospective review of AAA patients treated with elective EVAR from 2007 through 2011. Patients who had reinterventions as well as preoperative M2S (M2S Inc, West Lebanon, NH) three-dimensional reconstructions were identified and compared with a case-matched control group of patients without reintervention. ASG component scores (neck, aortic, and iliac) and total ASG scores were calculated using M2S software. RESULTS: Of the 623 patients treated with EVAR, 79 (13%) had reinterventions of which 45 had preoperative M2S three-dimensional reconstructions available for ASG score calculation. The reintervention group (mean age, 74 ± 8; 80% male) had a mean ASG score of 18 ± 5 (range, 8-30) compared with a cohort of 45 EVAR patients (mean age, 74 ± 7; 80% male) who had a mean ASG score of 13 ± 4 (range, 6-21; P < .0001). The mean AAA diameter for all patients was 52 mm ± 14 and was not significantly different between the groups. After area under the receiver-operating curve analysis, an ASG score of 17 was highly predictive for reintervention (area = 0.8; sensitivity = 60%; specificity = 78%; positive predictive value = 73%; negative predictive value = 66%). An ASG score of 13 was highly predictive for freedom from reintervention (sensitivity = 93%; specificity = 47%; positive predictive value = 64%; negative predictive value = 88%). The lowest ASG score that yielded a 100% reintervention rate was 22. The majority of reinterventions fell into three categories: proximal extension cuff (n = 18; 40%), distal extension limb (n = 7; 16%), and type II endoleak embolization (n = 13; 29%). Those that received proximal extensions had significantly higher mean total ASG score (19 vs 15; P = .0005), mean neck score (3.28 vs 2.36; P = .047), and mean aorta score (7.39 vs 2.36; P = .004). Those that received distal extensions had a significantly higher mean iliac score (9.00 vs 6.86; P = .013), and those that required an embolization had a significantly higher mean aorta branch score (1.92 vs 1.19; P = .017). CONCLUSIONS: Preoperative total ASG score strongly predicts reintervention after EVAR. Use of a cutoff ASG value predictive of prohibitive reintervention rates could help guide the decision between endovascular vs open AAA repair.

Nitric oxide differentially affects ERK and Akt in type 1 and type 2 diabetic rats.

BACKGROUND: We have shown that nitric oxide (NO) is more effective at inhibiting neointimal hyperplasia in type 2 diabetic rats than in nondiabetic rats, but is not effective in type 1 diabetic rats. Insulin signaling is mediated by the ERK and Akt pathways, and thus we hypothesized that NO differentially affects ERK and Akt activity in type 1 versus type 2 diabetic rats. MATERIALS AND METHODS: To investigate this hypothesis, we induced type 2 diabetes in Zucker diabetic fatty (ZDF) rats by feeding them Purina 5008 chow. To induce type 1 diabetes, lean Zucker (LZ) rats were injected with streptozotocin (STZ; 60 mg/kg). The carotid artery injury model was performed. Groups included injury and injury + PROLI/NO (20 mg/kg) (n = 6/group). RESULTS: Three days following injury, all animal models exhibited an increase in pERK levels. Whereas NO reduced pERK levels in LZ and STZ rats, NO had no effect on pERK levels in ZDF rats. Following a similar pattern, NO reduced pAkt levels in LZ and STZ rats but increased pAkt levels in ZDF rats. Fourteen days following injury, NO increased total pERK levels throughout the arterial wall in both the STZ and ZDF rats. These changes were greatest in the adventitia. Interestingly, whereas NO decreased total pAkt levels in LZ and STZ rats, NO increased pAkt levels in ZDF rats. Evaluation of the pERK:pAkt ratio revealed that NO increased this ratio in LZ and STZ rats but decreased the ratio in ZDF rats. CONCLUSIONS: We report that NO differentially affects the expression of pERK and pAkt in type 1 versus type 2 diabetic rats. Given that NO is more effective at inhibiting neointimal hyperplasia in type 2 diabetic animals, the pERK:pAkt ratio may be the best surrogate to predict efficacy.

In situ laser fenestration for revascularization of the left subclavian artery during emergent thoracic endovascular aortic repair.

PURPOSE: To present midterm outcomes of thoracic endovascular aortic repair (TEVAR) with laser fenestration to revascularize the left subclavian artery (LSA) as an alternative to debranching. METHODS: Six symptomatic patients (3 men; mean age of 50 years) underwent emergent TEVAR with LSA revascularization via laser graft fenestration. Three patients had large thoracic aortic aneurysms (2 secondary to chronic dissection); 1 patient had an acute symptomatic type B aortic dissection, and 2 patients had intramural hematomas. Emergent TEVAR was carried out with deployment of a Dacron endograft over the orifice of the left LSA. Through retrograde brachial access, a 0.018-inch wire was placed at the ostium of the LSA followed by laser catheter fenestration of the graft. A 10-mm covered stent was deployed through the fenestration to traverse the endograft and LSA; the endograft portion of the covered stent was flared. RESULTS: Laser fenestration was successful in 5 of 6 attempts; 1 fenestration was abandoned secondary to an acute LSA takeoff in a type III aortic arch. In this case, the stent was placed as a snorkel to successfully revascularize the LSA with no adverse consequences. There were no fenestration-related complications and no neurological morbidity. At a mean 8-month follow-up (range 1-17), no patients had died, and all LSA stents were patent, with no fenestration-related endoleaks on imaging. CONCLUSION: In situ retrograde laser fenestration is a feasible and effective option for revascularizing the LSA during emergent TEVAR. Longer follow-up is necessary to determine the durability of this technique.

Anatomic severity grading score predicts technical difficulty, early outcomes, and hospital resource utilization of endovascular aortic aneurysm repair.

BACKGROUND: In 2002, a system for the grading of abdominal aortic aneurysms (AAAs) was developed by the Society for Vascular Surgery (SVS). Because the correlation of the anatomic severity grading (ASG) score to patient outcomes has yet to be validated, we provide our experience with calculating the ASG score using three-dimensional (3-D) image-rendering software and provide the practical translation of this score into early outcomes and hospital charges. METHODS: All patients who underwent an endovascular aneurysm repair (EVAR) for infrarenal AAAs between 2009 and 2010 were retrospectively reviewed for demographics, intraoperative data, and 30-day outcomes. ASG scores were calculated from morphologic measurements, and two independent patient groups were created: those with a low ASG score (score <14) and a high ASG score (score ≥14). RESULTS: We identified 108 patients (mean age, 75 years), of whom 56 were in the low-score ASG group and 52 were in the high-score ASG group. Operative outcomes significantly different in the low-score group vs high-score group were number of endograft implants (three vs four, P = .001), operative time (113 vs 210 minutes, P < .0001), blood loss (227 vs 866 mL, P = .0002), and contrast volume (100 vs 131 mL, P = .032). In the low-score group compared with the high-score group, access site adjuncts were 14% vs 50% (P < .0001), and intraoperative adjuncts were 54% vs 80% (P = .004). Most adjuncts (75%) were endovascular. No EVARs were converted to open. Mean hospital stay was 2 days for the low-score group and 5 days for the high-score group (P = .012). The 30-day operative mortality was zero. No aneurysm-related deaths occurred during follow-up. In the low-score vs high-score groups, mean operating room supply charge was $16,646 vs $25,765 (P = .006), and the mean total hospital charge was $70,956 vs $105,153 (P = .016). CONCLUSION: The anatomic severity grading score can be easily and rapidly calculated from computed tomography images with the aid of 3-D image-rendering software. The anatomic severity grading score correlates with the technical difficulty of EVAR and the extent of hospital resource utilization.

Isopropylamine NONOate (IPA/NO) moderates neointimal hyperplasia following vascular injury.

OBJECTIVE: Isopropylamine NONOate (IPA/NO) is a nitroxyl (HNO) donor at physiologic pH. HNO is a positive inotrope and vasodilator, but little is known about its effect on neointimal hyperplasia. The aims of this study are to determine the effect of IPA/NO on endothelial and vascular smooth muscle cells (VSMC) in vitro and to determine if IPA/NO inhibits neointimal hyperplasia in vivo. METHODS: VSMC were harvested from the abdominal aortas of male Sprague Dawley rats, and human umbilical vein endothelial cells were purchased from ATCC. In vitro, cellular proliferation was assessed by (3)H-thymidine incorporation, cell migration was assessed using the scrape assay, and cell death was assessed using Guava personal cell analysis (PCA). Cell cycle analysis was performed using propidium iodide staining and flow cytometry analysis. Protein expression was assessed using Western blot analysis. Phosphorylated proteins were assessed using immunoprecipitation and Western blot analysis. In vivo, the carotid artery injury model was performed on male Sprague Dawley rats treated with (n = 12) or without (n = 6) periadventitial IPA/NO (10 mg). Arteries harvested at 2 weeks were assessed for morphometrics using ImageJ. Inflammation was assessed using immunohistochemistry. Endothelialization was assessed by Evans blue staining of carotid arteries harvested 7 days after balloon injury from rats treated with (n = 6) or without (n = 3) periadventitial IPA/NO (10 mg). RESULTS: In vitro, 1000 micromol/L IPA/NO inhibited both VSMC (38.7 +/- 4.5% inhibition vs control, P = .003) and endothelial cell proliferation (54.0 +/- 2.9% inhibition vs control, P < or = 0.001) without inducing cell death or inhibiting migration. In VSMC, this inhibition was associated with an S-phase cell cycle arrest and increased expression of cyclin A, cyclin D1, and the cyclin-dependent kinase inhibitor p21. No change was noted in the phosphorylation status of cdk2, cdk4, or cdk6 by IPA/NO. In rodents subjected to the carotid artery balloon injury model, IPA/NO caused significant reductions in neointimal area (298 +/- 20 vs 422 +/- 30, P < or = .001) and medial area (311 +/- 14 vs 449 +/- 16, P < or = .001) compared with injury alone, and reduced macrophage infiltration to 1.7 +/- 0.8 from 16.1 +/- 3.5 cells per high power field (P < or = .001). IPA/NO also prevented re-endothelialization compared with injury alone (55.9 +/- 0.5% nonendothelialized vs 21 +/- 4.4%, respectively, P = .001). Lastly, a 50% mortality rate was observed in the IPA/NO-treated groups. CONCLUSIONS: In summary, while IPA/NO modestly inhibited neointimal hyperplasia by inhibiting VSMC proliferation and macrophage infiltration, it also inhibited endothelial cell proliferation and induced significant mortality in our animal model. Since HNO is being investigated as a treatment for congestive heart failure, our results raise some concerns about the use of IPA/NO in the vasculature and suggest that further studies be conducted on the safety of HNO donors in the cardiovascular system.

A novel anatomic severity grading score for acute Type B aortic dissections and correlation to aortic reinterventions after thoracic endovascular aortic repair.

BACKGROUND: We introduce a novel preoperative anatomic severity grading system for acute type B aortic dissections and validate the system in a cohort of patients who underwent thoracic endovascular aortic repair. METHODS: We identified a cohort of patients who received thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection from 2008 to 2014. We developed an anatomic severity grading score (ASG) to measure attributes of aortic anatomy that we hypothesized may affect difficulty or durability of repair. Measurements were made using computed tomography angiography images and based on hypothesized severity, giving a potential score range of 0-38. RESULTS: We analyzed the computed tomography angiography images on a cohort of 30 patients with acute type B aortic dissection who underwent TEVAR. We created an area under the receiver operating characteristic curve (AUROC) using anatomic severity grading to predict aortic-related reinterventions. The AUROC was 0.72 (95% CI 0.39 to 1.1). Guided by the AUROC, we divided patients into two groups: a low-score group with anatomic severity grading scores <23 (n = 22), and a high-score group with scores ≥23 (n = 8). With this cutoff, anatomic severity grading exhibited 80% sensitivity and 84% specificity in predicting aortic-related reinterventions, with reinterventions in 50% of high-score patients and 4.5% of low-score patients (P = 0.011). The high score group also had significantly greater blood loss (200 vs 100 mL, P = 0.038), fluoroscopy time (36.0 vs 16.6 min; P = 0.022), and a trend for increased procedure time (164 vs 95 min; P = 0.083) than the low-risk group. Kaplan-Meier analysis revealed that the high-score group had a significantly decreased freedom from aortic-related reinterventions than the low-score group (38% vs 100% at 12-month followup; log rank P = 0.001). CONCLUSIONS: A preoperative anatomic severity grading score for acute type B aortic dissections consists of analysis of the proximal landing zone, curvature and tortuosity of the aorta, dissection anatomy, aortic branch vessel anatomy, and supraceliac aorta anatomy. Anatomic severity grading scores ≤23 are an excellent predictor of aortic-related reinterventions.

Analysis of vascular closure devices after transbrachial artery access.

INTRODUCTION: We seek to determine whether vascular closure devices (VCDs) are safe and effective for brachial artery access. METHODS: A retrospective review of brachial artery access using either manual compression (MC) or a VCD for hemostasis from November 2005 to February 2011 was performed. RESULTS: Brachial artery access was performed on 154 limbs: MC on 134 limbs and VCD on 20 limbs. The incidence of thrombotic (VCD n = 0 [0%] vs MC n = 7 [5.2%], P = .37), hemorrhagic complications (VCD n = 1 [5%] vs MC n = 7 [5.2%], P = .72), or major adverse events (VCD n = 1 [5%] vs MC n = 16 [12%], P = .32) was not significantly different between the techniques. After univariate and multivariate analysis, female sex (P = .07, relative risk [RR] = 5.7), sheath size > 6F (P = .008, RR = 14.6), and diagnostic versus interventional procedure (P = .04, RR = 0.4) all impacted the occurrence of thrombosis. CONCLUSIONS: Use of VCD in the brachial artery following an endovascular procedure showed equivalence to MC.

Identifying the target lesions for 245 laser angioplasty cases and a review of the literature.

OBJECTIVE: To provide a detailed report of our experience with laser atherectomy in a large patient population with an extensive follow-up period. METHOD: A retrospective chart review was conducted on 222 patients who underwent laser atherectomy. RESULTS: Overall primary patency rates at 1 and 3 years were 48% and 37%, primary-assisted rates were 53% and 40%, and secondary patency rates were 69% and 51%, respectively. Limb salvage rates were 91% and 83%. The 1- and 3-year primary patency rates were significantly different between the native (51% and 39%) and the in-stent group (20% and 20%; P = .027). There were no differences in primary-assisted patency (P = .11), secondary patency (P = .094), and limb salvage rates (P= .83) between the 2 groups. CONCLUSIONS: Although the primary patency of laser angioplasty was higher in native vessels versus the in-stent stenosis, there were no differences in the primary-assisted patency, secondary patency, or limb salvage rates between the 2 groups.