Preoperative proteinuria is independently associated with mortality after fenestrated endovascular aneurysm repair.

OBJECTIVE: Fenestrated endovascular aneurysm repair (FEVAR) has become a mainstay in treating complex aortic aneurysms, though baseline patient factors predicting long-term outcomes remain poorly understood. Proteinuria is an early marker for chronic kidney disease and associated with adverse cardiovascular outcomes, but its utility in patients with aortic aneurysms is unknown. We aimed to determine whether preoperative proteinuria impacts long-term survival after FEVAR. METHODS: A single-institution, retrospective review of all elective FEVAR was performed. Preoperative proteinuria was assessed by urinalysis: negative (0-29 mg/dL), 1+ (30-100 mg/dL), 2+ (101-299 mg/dL), and 3+ (≥300 mg/dL). The cohort was stratified by patients with proteinuria (≥30 mg/dL) vs those without (<30 mg/dL). Baseline, perioperative, and long-term outcomes were compared. The primary outcome, all-cause mortality, was evaluated by Kaplan-Meier analysis and independent predictors with Cox proportional hazards modeling. RESULTS: Among 181 patients who underwent standard FEVAR from 2012 to 2022 (mean follow-up 33 months), any proteinuria was noted in 30 patients (16.6%). Patients with proteinuria were more likely to be Black (10.0% vs 1.3%) with a lower estimated glomerular filtration rate (eGFR) (52.7 ± 24.7 vs 67.7 ± 20.5 mL/min/1.73 m2), higher Society for Vascular Surgery comorbidity score (10.9 ± 4.3 vs 8.2 ± 4.7) and calcium channel blocker therapy (50.0% vs 29.1%), and larger maximal aneurysm diameter (67.2 ± 16.9 vs 59.8 ± 9.8 mm) (all P < .05). Thirty-day mortality was higher in the proteinuria group (10.0% vs 1.3%; P = .03). Overall survival at 1 and 5 years was significantly lower for those with proteinuria (71.5% vs 92.3% and 29.5% vs 68.1%; log-rank P < .001). On multivariable analysis, preoperative proteinuria was independently associated with over threefold higher hazard of mortality (hazard ratio [HR]: 3.21, 95% confidence interval [CI]: 1.66-6.20; P < .001), whereas preoperative eGFR was not predictive (HR: 0.99, 95% CI: 0.98-1.01; P = .28). Additional significant predictors included chronic obstructive pulmonary disease (HR: 2.04), older age (HR: 1.05), and larger maximal aneurysm diameter (HR: 1.03; all P < .05). CONCLUSIONS: In our 10-year experience with FEVAR, preoperative proteinuria was observed in 17% of patients and was significantly associated with worse survival. In this cohort, proteinuria was independently associated with all-cause mortality, whereas eGFR was not, suggesting that urinalysis may provide an additional simple metric for risk-stratifying patients before FEVAR.

Sex Related Differences in Perioperative Outcomes after Complex Endovascular Aortic Aneurysm Repair.

BACKGROUND: Prior studies suggest female sex is associated with worse outcomes after complex endovascular aortic aneurysm repair (EVAR) due to anatomic differences. Therefore, we aimed to compare 30-day perioperative and long-term outcomes after complex EVAR by sex. METHODS: A single-center retrospective review of consecutive elective and emergent complex EVAR with company-manufactured devices, laser fenestration, snorkel/periscope, or octopus technique was performed from 2012-2023. The primary outcome was a composite endpoint of any major adverse event (MAE), new-onset dialysis, or death within 30 days. Secondary 30-day technical and long-term outcomes were also assessed. RESULTS: 293 patients (57 females, 19%), mean age 74 years, underwent complex EVAR with commercially available Zenith fenestrated endovascular graft (71%), p-Branch (2%), laser fenestration (8%), snorkel/periscope (16%), or octopus (2%) techniques. Females had significantly different aneurysm-related anatomic characteristics compared to males, including smaller aneurysm diameters (58 ± 7.2 vs. 64 ± 13.2 mm, P < 0.001), more involved aneurysm extent (21.7% vs. 9.8% thoracoabdominal, P = 0.04), increased renal artery calcification (43.9% vs. 27.1%, P = 0.01), and smaller iliac (7.6 ± 1.3 vs. 8.9 ± 1.8 mm, P < 0.01). Operative outcomes were similar; however, females had a greater need for adjunctive access conduits (21.1% vs. 10.6%, P = 0.04), lower technical success (91.2% vs. 98.3%, P = 0.02), and longer median [interquartile range] length of stay (3.0 [4.0] vs. 2.0 [2.5] days, P < 0.001). The composite 30-day outcome of any MAE, new dialysis, or death was not significantly different (15.8% females vs. 11.4% males, P = 0.37). Technical endpoints including 30-day rates of target artery occlusion and type 1 or 3 endoleak were also similar between groups. At mean follow-up of nearly 3 years, females had significantly lower rate of renal function decline (16.0% vs. 41.9%, P < 0.001), but no differences were found in long-term all-cause mortality, aneurysm sac regression, reintervention, or total follow-up imaging studies between groups. CONCLUSIONS: Females undergoing complex EVAR had challenging anatomy with higher intraoperative target artery occlusion, conduit use, and longer length of stay. However, 30-day and long-term outcomes were similar, suggesting females can undergo complex EVAR with high technical success and comparable perioperative outcomes to males. Females appeared to have protection from long-term renal function decline, which will be important for future study.

Association of Baseline Chronic Kidney Disease Stage With Short- and Long-Term Outcomes After Fenestrated Endovascular Aneurysm Repair.

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) is a well-established treatment approach for juxtarenal and short-neck infrarenal aortic aneurysms. Recommendations and clinical outcomes are lacking for offering FEVAR in patients with chronic kidney disease (CKD). We aimed to compare short- and long-term outcomes for patients with none-to-mild versus moderate-to-severe CKD undergoing FEVAR. METHODS: We retrospectively reviewed consecutive patients undergoing standard FEVAR with Cook devices at a single institution. The cohort was stratified by preoperative CKD stage none-to-mild or moderate-to-severe (CKD 1-2 and CKD 3-5, respectively). The primary outcome was postoperative acute kidney injury (AKI). Secondary outcomes included 30-day perioperative complications, 1- and 5-year rates of overall survival, dialysis, renal target artery patency, endoleak, and reintervention assessed by the Kaplan-Meier method. Aneurysm sac regression, number of surveillance computed tomography (CT) scans, and CKD stage progression were assessed at latest follow-up. Multivariate Cox proportional hazards modeling was used to evaluate the association of CKD stage 3 and stage 4-5 with all-cause mortality, controlling for differences in baseline characteristics. RESULTS: From 2012- to 2022, 184 patients (of which 82% were male) underwent FEVAR with the Cook ZFEN device (mean follow-up 34.3 months). Group CKD 3-5 comprised 77 patients (42%), was older (75.2 vs. 73.0 years, P = 0.04), had increased preoperative creatinine (1.6 vs. 0.9 mg/dL, P < 0.01), and demonstrated increased renal artery ostial calcification (37.7% vs. 21.5%, P = 0.02) compared with Group CKD 1-2. Perioperatively, CKD 3-5 sustained higher estimated blood loss (342 vs. 228 ml, P = 0.01), longer operative times (186 vs. 162 min, P = 0.04), and longer length of stay (3 vs. 2 days, P < 0.01). Kaplan-Meier 1- and 5-year survival estimates were lower for CKD 3-5 (82.3% vs. 95.1%, P < 0.01 and 55.4% vs. 70.8%, P = 0.02). Fewer CKD 3-5 patients remained free from chronic dialysis at 1 year (94.4% vs. 100%, P = 0.015) and 5 years (84.7% vs. 100%, P < 0.01). There were no significant differences in postoperative AKI rate (CKD 1-2 6.5% vs. CKD 3-5 14.3%, P = 0.13), long-term renal artery patency, reinterventions, type I or III endoleak, mean sac regression, or total follow-up CT scans between groups. CKD stage progression occurred in 47 patients (31%) at latest follow-up but did not differ between stratified groups (P = 0.17). On multivariable modeling, age (hazard ratio 1.05, 95% confidence interval 1.01-1.09, P = 0.02) and CKD stage 4-5 (hazard ratio 6.39, 95% confidence interval 2.26-18.05, P < 0.01) were independently associated with mortality. CONCLUSIONS: Preoperative CKD status did not negatively impact the durability or technical success related to aneurysm outcomes after FEVAR. Worsening CKD stage was associated with lower 1- and 5-year overall survival and freedom from dialysis after FEVAR with no statistically significant differences in 30-day or long-term technical aneurysm outcomes.

Validity of the Global Vascular Guidelines in Predicting Outcomes Based on First-Time Revascularization Strategy.

BACKGROUND: The Global Vascular Guidelines (GVG) recommend selecting an endovascular versus open-surgical approach to revascularization for chronic limb-threatening ischemia (CLTI), based on the Global Limb Anatomic Staging System (GLASS) and wound, ischemia, and foot infection (WIfI) classification systems. We assessed the utility of GVG-recommended strategies in predicting clinical outcomes. METHODS: We conducted a single-center, retrospective review of first-time lower-extremity revascularizations within a comprehensive limb-preservation program from 2010 to 2018. Procedures were stratified by (1) treatment concordance with GVG-recommended strategy (concordant versus nonconcordant groups), (2) GLASS stages I-III, and (3) endovascular versus open strategies. The primary outcome was 5-year freedom from major adverse limb events (FF-MALE), defined as freedom from reintervention or major amputation, and secondary outcomes included 5-year overall survival, freedom from major amputation, freedom from reintervention, and immediate technical failure (ITF) during initial revascularization. Kaplan-Meier (KM) survival analysis and multivariate analysis with Cox proportional hazard models were performed on the primary and secondary outcomes. RESULTS: Of 281 first-time revascularizations for CLTI, 251 (89.3%) were endovascular and 186 (66.2%) were in the concordant group, with a mean clinical follow-up of 3.02 ± 2.40 years. Within the concordant group alone, 167 (89.8%) of revascularizations were endovascular. The concordant group had a higher rate of chronic kidney disease (60.8% vs. 45.3%, P = 0.02), WIfI foot infection grade (0.81 ± 1.1 vs. 0.56 ± 0.80, P = 0.03), and WIfI stage (3.1 ± 0.79 vs. 2.8 ± 1.2, P < 0.01) compared to the non-concordant group. After both KM and multivariate analyses, there were no significant differences in 5-year FF-MALE or overall survival between concordant and non-concordant groups. There was higher freedom from major amputation in the non-concordant group on KM analysis (83.9% vs. 74.2%, P = 0.025), though this difference was non-significant on multivariate analysis (hazard ratio [HR]: 0.49, 95% confidence interval [CI]: 0.21-1.15, P = 0.10). The open group had lower MALE compared to the endovascular group (HR: 0.39, 95% CI: 0.17-0.91, P = 0.029) attributed to a lower reintervention rate in the open group (HR: 0.31, 95% CI: 0.11-0.87, P = 0.026). GLASS stage was not associated with significant differences in outcomes, but the severity of GLASS stage was associated with ITF (2.1% in stage 1, 6.4% in stage 2, and 11.7% in stage 3, P = 0.01). CONCLUSIONS: In this study, CLTI treatment outcomes did not differ significantly based on whether treatment was received in concordance with GVG-recommended strategy. There was no difference in overall survival between the endovascular and open groups, though there was a higher reintervention rate in the endovascular group. The GVG guidelines are an important resource to help guide the management of CLTI patients. However, in this study, both concordance with GVG guidelines and GLASS staging were found to be indeterminate in differentiating outcomes between complex CLTI patients treated primarily with an endovascular-first approach. The revascularization approach for a CLTI patient is a nuanced decision that must take into account patient anatomy and clinical status, as well as physician skill and experience and institutional resources.

Reintervention does not affect long-term survival after fenestrated endovascular aneurysm repair.

OBJECTIVE: Fenestrated endovascular aneurysm repair (FEVAR) is increasingly used in the treatment of juxtarenal aortic aneurysms and short-neck infrarenal aneurysms. Reinterventions (REIs) occur frequently, contributing to patient morbidity and resource utilization. We sought to determine whether REI affects long-term survival after FEVAR. METHODS: A single-institution retrospective review of all Cook Zenith fenestrated (ZFEN; Cook Medical, Inc, Bloomington, IN) repairs was performed. Patients with ≥6 months of follow-up and without adjunctive branch modifications were included. REI was defined as any aneurysm, device, target branch, or access-related intervention after the index procedure. REIs were categorized as early (<30 days) or late (≥30 days), by indication (ie, branch, endoleak, limb related, access related, other), and by target branch or device components. Patients were stratified into REI vs no REI groups and branch REI vs non-branch REI groups. RESULTS: Of 219 consecutive ZFEN repairs from 2012 to 2021, 158 patients met the inclusion criteria. Of these 158 patients, 41 (26%) required a total of 51 REIs (10 early and 41 late) during a mean follow-up of 33.9 months. The most common indication for REI was branch-related (31 of 51; 61%), with the renal arteries the most frequently affected (26 of 51; 51%). The only differences found in baseline, aneurysm, and device characteristics were a higher mean Society for Vascular Surgery comorbidity score (9.6 vs 7.9; P = .04) and larger suprarenal neck angle (23.3° vs 17.1°; P = .04) in the no REI group. In contrast, the REI group had a larger mean proximal seal zone diameter (26.3 mm vs 25.1 mm; P = .03) and device diameter (31.9 mm vs 30.0 mm; P = .002) compared with the no REI group. Technical success and operative characteristics were similar between the groups, except for a longer mean fluoroscopy time (74.9 minutes vs 60.8 minutes; P = .01) and longer median length of stay (2 vs 2 days; P = .006) for the REI group. Although the rate of early (<30 days) major adverse events was greater for the REI group (24.4% vs 6.0%; P = .001), the difference in 30-day mortality was not statistically significant (4.9% vs 0.9%; P = .10). On Kaplan-Meier analysis, freedom from REI at 1 and 5 years was 85.7% and 62.6%, respectively, for the overall cohort. No difference was found in the estimated 5-year survival between the REI and no REI groups (62.8% vs 63.5%; log-rank, P = .87) and branch REI and non-branch REI groups (71.8% vs 49.9%; log-rank, P = .16). On multivariate analysis, REI was not an independent predictor for mortality. However, age, Society for Vascular Surgery comorbidity score, and preoperative maximum aneurysm diameter each increased the hazard of death (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.02-1.12 [P = .007]; HR, 1.10; 95% CI, 1.01-1.18 [P = .02]; HR, 1.05; 95% CI, 1.02-1.08 [P = .003], respectively). CONCLUSIONS: After ZFEN, 41 patients (26%) had required a total of 51 REIs, with most occurring ≥30 days after the index procedure, and 61% were branch related, with no influence on 5-year survival. Age, comorbidity, and baseline aneurysm diameter independently predicted mortality. The use of FEVAR mandates lifelong surveillance and protocols to maintain branch patency. Despite their relative frequency, REIs did not influence 5-year postprocedural survival.

Large Fenestrations Versus Scallops for the Superior Mesenteric Artery during Fenestrated Endovascular Aneurysm Repair: Does it Matter?

BACKGROUND: Fenestrated endovascular aneurysm repair is an established customized treatment for aortic aneurysms with 3 current commercially available configurations for the superior mesenteric artery (SMA)-a single-wide scallop, large fenestration, or small fenestration, with the scallop or large fenestration most utilized. Outcomes comparing SMA single-wide scallops to large fenestrations with the Zenith fenestrated (ZFEN) device are scarce. As large fenestrations have the benefit of extending the proximal seal zone compared to scalloped configurations, we sought to determine the differences in seal zone and sac regression outcomes between the 2 SMA configurations. METHODS: We retrospectively reviewed our prospectively maintained complex endovascular aneurysm repair database and included all patients treated with the Cook ZFEN device with an SMA scallop or large fenestration configuration at its most proximal build. All first postoperative computed tomography scans (1-30 days) were analyzed on TeraRecon to determine precise proximal seal zone lengths, and standard follow-up anatomic and clinical metrics were tabulated. RESULTS: A total of 234 consecutive ZFEN patients from 2012 to 2021 were reviewed, and 137 had either a scallop or a large fenestration for the SMA as the proximal-most configuration (72 scallops and 65 large fenestrations) with imaging available for analysis. The mean follow-up was 35 months. The mean proximal seal zone length was 19.5 ± 7.9 mm for scallop versus 41.7 ± 14.4 mm for large fenestration groups (P < 0.001). There was no difference in sac regression between the scallop and large fenestration at 1 year (10.1 ± 10.9 mm vs. 11.0 ± 12.1, P = 0.63). Overall, 30-day mortality (1.3% vs. 2.5%, P = 0.51) and all-cause 3-year mortality (72.5% vs. 81.7%, P = 0.77) were not significantly different. Reinterventions within 30 days were primarily secondary to renal artery branch occlusions, with only 1 patient in the scallop group requiring reintervention for an SMA branch occlusion. CONCLUSIONS: Despite attaining longer proximal seal lengths, large SMA fenestrations were not associated with a difference in sac regression compared to scalloped SMA configurations at a one-year follow-up. There were no significant differences in reinterventions or overall long-term survival between the 2 SMA strategies.

Anatomic Factors Contributing to External Iliac Artery Endofibrosis in High-Performance Athletes.

BACKGROUND: External iliac artery endofibrosis (EIAE) classically presents in cyclists with intimal thickening of the affected arteries. We investigated possible anatomical predisposing factors including psoas muscle hypertrophy, arterial tortuosity, inguinal ligament compression, and arterial kinking via a case-control comparison of symptomatic and contralateral limbs. METHODS: All patients with unilateral EIAE treated surgically at our institution were reviewed. Each patient's symptomatic side was compared with their contralateral side using paired t-tests. Psoas hypertrophy was quantified by the transverse cross-sectional area (CSA) at L4, L5, and S1 vertebral levels, and inguinal ligament compression was measured as the anterior-posterior distance between the inguinal ligament and underlying bone. Tortuosity index for diseased segments and arterial kinking were measured on TeraRecon. RESULTS: Of 33 patients operated on for EIAE from 2004 to 2021, 27 with available imaging presented with unilateral disease, more commonly left-sided (63%). Most (96%) had external iliac involvement and 26% had ≥2 segments affected: 19% common iliac artery, 15% common femoral artery. The symptomatic limb had greater mean L5 psoas CSA (1,450 mm2 vs. 1,396 mm2, mean difference 54 mm2, P = 0.039). There were no significant differences in L4 or S1 psoas hypertrophy, tortuosity, inguinal ligament compression, or arterial kinking. 63% underwent patch angioplasty, and 85% underwent additional inguinal ligament release. 84% reported postoperative satisfaction, which was associated with a greater difference in psoas hypertrophy at L4 (P = 0.022). CONCLUSIONS: Psoas muscle hypertrophy is most pronounced at L5 and is associated with symptomatic EIAE. Preferential hypertrophy of the affected side correlates with improved outcomes, suggesting psoas muscle hypertrophy as a marker of disease severity.

A national post-Match webinar panel improves knowledge and preparedness of medical students interested in vascular surgery training.

BACKGROUND: The current shortage of vascular surgeons is projected to worsen. Compared with other surgical residency programs, integrated vascular surgery residency (IVSR) offers fewer training positions and attracts fewer applicants. As a result, only a few medical students from each school match into the specialty, and conventional resources like Match panels are not available to students interested in vascular surgery. We hypothesize that a national post-Match panel webinar will improve medical students' knowledge of the IVSR application process. METHODS: A panel of four recently matched medical students shared their experiences on their successful Match into an IVSR through a 65-minute-long national webinar. Data were collected from students who attended the webinar through anonymous online surveys before and after the panel discussion. The participants' self-reported understanding of the IVSR was assessed using a 5-point Likert scale for 11 questions. Objective knowledge of the IVSR Match process was assessed using five data-based questions. All prewebinar and postwebinar responses were paired and compared using bivariate analysis. RESULTS: A total of 76 participants completed both the prewebinar and postwebinar surveys. The majority of respondents were first-year medical students (51.3%) and attended medical school in the Northeast (38.2%). Among these respondents, 57.6% indicated that their home institution had an IVSR program, 44.7% had an active vascular surgery interest group (VSIG), 14.5% had previously attended a vascular surgery conference, and 28.9% were very likely to apply into an IVSR. After the webinar, more students correctly identified the number of currently existing IVSR training positions (76.3% vs 89.5%; P = .002), duration of IVSR (56.6% vs 85.5%; P < .001), and median Step 1 score (50% vs 84.2%; P < .001) and minimum number of applications (38.2% vs 65.8%; P < .001) recommended for a successful Match into IVSR. Students who had a VSIG at their home institution were found to have a better baseline knowledge of the IVSR based on their higher aggregate scores on the data-based questions (3.4 ± 1 vs 1.9 ± 1.2; P < .001) compared with those without one. CONCLUSIONS: A national webinar run by recently matched students can effectively improve medical students' understanding of the IVSR application process. Students with a VSIG at their institutions have a better baseline knowledge of IVSR. In addition to expanding the VSIG, instituting an annual national postmatch webinar may help students become better prepared applicants and improve the overall application pool.

Impact of acute kidney injury on long-term outcomes after fenestrated and branched endovascular aortic aneurysm repair.

OBJECTIVE: Acute kidney injury (AKI) has been identified as a common complication after fenestrated and branched endovascular aneurysm repair (F/BEVAR), occurring in 5% to 29% of patients. Predictors of AKI and its impact on long-term outcomes remain unknown. We sought to identify independent predictors of AKI and its effect on long-term survival after F/BEVAR. METHODS: A single-institution retrospective review of all consecutive F/BEVAR procedures was performed (November 2010-September 2018). Data were collected prospectively through an Institutional Review Board-approved registry and a physician-sponsored investigational device exemption clinical trial (G130210). AKI was defined as a decrease in estimated glomerular filtration rate by >30% from baseline, within 30 days postoperatively. The cohort was stratified according to whether a patient experienced AKI. Demographics, operative details, perioperative complications, and length of stay between groups were compared. The primary outcome, long-term survival, was assessed with Kaplan-Meier analysis and Cox proportional hazards modeling. Independent predictors of AKI were identified using logistic regression. RESULTS: Among 219 consecutive F/BEVAR patients, AKI occurred in 41 patients (19%) and was the most common 30-day complication observed. Whereas preoperative creatinine concentration, estimated glomerular filtration rate, and target renal artery stenosis >50% did not predict AKI, the occurrence of intraoperative complications did correlate with AKI (37% vs 7.3%; P < .01). By 30 days, AKI resolved in 7 (17%) patients, persisted without need for dialysis in 26 (64%), and progressed to dialysis in 5 (12%); the remaining 3 (7%) patients died. Survival at 30 days was significantly lower in the AKI group (92.7% vs 98.9%; P = .047), and this difference persisted at 1 year (68% vs 87%; log-rank, P <.01) and 3 years (44% vs 60%; log-rank, P = .04). On multivariable modeling, AKI increased the hazard of death nearly twofold (hazard ratio, 1.92; 95% confidence interval [CI], 1.11-3.23; P = .019). Independent predictors of AKI on multivariable logistic regression were intraoperative complications (odds ratio, 4.10; 95% CI, 1.61-10.42; P < .01) and increased operating room time (odds ratio, 1.56; 95% CI, 1.22-2.00; P < .01). CONCLUSIONS: In our 8-year experience of F/BEVAR, AKI was the most common postoperative complication observed in nearly 20% of patients. AKI after F/BEVAR is associated with decreased short- and long-term survival. Whether AKI is causative or just associated with decreased survival remains to be elucidated. Further study is needed to determine whether the independent predictors of AKI, including intraoperative complications and operating room time, are generalizable across all centers performing F/BEVAR and to investigate how we might further mitigate this common and serious complication.

Fenestrated/Branched Endovascular Aortic Aneurysm Repair Using a Supraceliac Aortic Proximal Seal Zone Versus an Infraceliac Aortic Proximal Seal Zone.

BACKGROUND: Fenestrated/branched endovascular aneurysm repair (F/B-EVAR) achieves more extensive proximal seal than conventional infrarenal devices, thereby increasing aneurysm exclusion durability. Optimal seal zone length remains undefined. We assessed relative risks and benefits of extending the proximal seal above the celiac artery. METHODS: The prospective database of all complex endovascular aortic aneurysm repairs at a single institution (institutional review board-approved, physician-sponsored investigational device exemption trial, 10/2010-6/2017) was used to classify repairs according to the number of target visceral-renal arteries incorporated: 4-vessel versus <4-vessel. Comparisons of aneurysm characteristics, perioperative details, and postoperative complications were performed, stratified by repair type. One-year survival, target artery patency, freedom from type 1 or 3 endoleak, and freedom from reintervention were estimated with Kaplan-Meier analysis. RESULTS: Among 175 F/B-EVARs, 38% (n = 67) were 4-vessel and 62% (n = 108) were <4-vessel. Intraoperatively, there was no difference in mean contrast use (76 mL vs. 74 mL, P = non significant [NS]) or dose area product (63,428 mGy cm2 vs. 96,015 mGy cm2), but there was increased median procedure time (4.8 hr, interquartile range [IQR] = 4.1-5.8 versus 3.6 hr, IQR = 2.9-4.1, P < 0.0001) and mean operating room direct costs ($52,532, standard deviation [SD] = 18,640 versus $40,128, SD = 15,135, P < 0.0001) in 4-vessel repairs. There were no differences in mortality (1.9% vs. 4.5%), paraparesis (0% vs. 3.0%), or paralysis (0.9% vs. 0%), all P = NS. There were no differences in one-year survival, target artery patency, or freedom from reintervention. There was a lower 1-year freedom from type 1 or 3 endoleak with 4-vessel repairs (82% vs. 94%, log-rank P = 0.02), driven by an increased rate of type 3 endoleaks. Endoleak resolution after treatment was equivalent in both groups (4-vessel, 10 of 12, 83% resolved; <4-vessel, 7 of 7, 100% resolved, P = NS). CONCLUSIONS: With F/B-EVAR, utilization of a supraceliac seal zone, compared with an infraceliac seal zone, is associated with statistical differences in operative characteristics/resource utilization, but with negligible clinical significance. Further innovation to eliminate type 3 endoleaks at fenestrations/branches remains an unmet need. To achieve adequate F/B-EVAR proximal seal zone length, one should have a low threshold to incorporate the celiac artery.

Fenestrated endovascular aortic aneurysm repair using physician-modified endovascular grafts versus company-manufactured devices.

OBJECTIVE: Fenestrated endografts are customized, patient-specific endovascular devices with potential to reduce morbidity and mortality of complex aortic aneurysm repair. With approval from the U.S. Food and Drug Administration, our center began performing fenestrated endovascular aneurysm repair through a physician-sponsored investigational device exemption (IDE #G130210), using both physician-modified endografts (PMEGs) and company-manufactured devices (CMDs). Because these techniques are associated with specific advantages and disadvantages, we sought to investigate differences in outcomes between PMEG and CMD cases. METHODS: A single-institution retrospective review of all fenestrated endovascular aneurysm repairs was performed. The cohort was analyzed by device type (PMEG or CMD) after matching of cases on the basis of (1) number of target vessels intended for treatment, (2) extent of aneurysm, (3) aneurysm diameter, (4) device configuration, and (5) date of operation. Outcomes of ruptures, common iliac artery aneurysms, and aortic arch aneurysms were excluded. Demographics, operative details, perioperative complications, length of stay, and reinterventions were compared. For patients with >1 year of follow-up time, survival, type I or type III endoleak rate, target artery patency, and reintervention rate were estimated using the Kaplan-Meier method. RESULTS: Between November 30, 2010, and July 30, 2016, 82 patients were identified and matched. The cohort included 41 PMEG and 41 CMD patients who underwent repair of 38 juxtarenal (PMEG, 17; CMD, 21; P = .38), 14 pararenal (PMEG, 6; CMD, 8; P = .56), and 30 thoracoabdominal type I to type IV (PMEG, 18; CMD, 12; P = .17) aneurysms. There were significant differences in presentation requiring urgent aneurysm repair (PMEG, 9; CMD, 0; P = .002), total fluoroscopy time (PMEG, 76 minutes; CMD, 61 minutes; P = .02), volume of contrast material used (PMEG, 88 mL; CMD, 70 mL; P = .02), in-operating room to out-of-operating room time (PMEG, 391 minutes; CMD, 319 minutes; P = .001), incision to surgery end time (PMEG, 276 minutes; CMD, 224 minutes; P = .002), and 1-year reintervention rate (PMEG, 37%; CMD, 13%; log-rank P = .04). No differences in perioperative complications, overall length of stay, type I or type III endoleak, or survival were observed between PMEG and CMD. For the entire cohort including both PMEG and CMD, the overall rate of any 30-day postoperative complication was 39%, and the Kaplan-Meier estimate of survival at 1 year was 86%. CONCLUSIONS: In this single-institution experience of fenestrated endovascular aneurysm repair, the primary differences between PMEG and CMD related only to operative metrics and the need for postoperative reinterventions. No statistically significant advantage was found for one approach over the other; we therefore cannot conclude that one approach is better than the other. Both remain viable options that may compare favorably with open repair of complex aortic aneurysms. Further studies are necessary to determine whether this relative equivalence represents a type II error or lack of long-term durability data or whether true equivalence between PMEG and CMD approaches exists.

Reinterventions after fenestrated or branched endovascular aortic aneurysm repair.

OBJECTIVE: Reinterventions after fenestrated or branched endovascular aneurysm repair (F/B-EVAR) are sometimes necessary to maintain aneurysm exclusion or endograft and target artery patency. These reinterventions are nontrivial, potentially associated with morbidity, mortality, and resource utilization. Whereas rates, types, and outcomes of reintervention after infrarenal EVAR have been well described, they have not been well described for F/B-EVAR. We sought to characterize the morbidity, mortality, and resource utilization due to reinterventions after F/B-EVAR. METHODS: All F/B-EVAR variables collected prospectively through a single-institution, Institutional Review Board-approved registry, which included patients enrolled in a physician-sponsored investigational device exemption trial (G130210), were reviewed (November 2010-December 2016). Reinterventions were defined as any procedure that was aneurysm related, device related, or target artery related. For patients with more than one reintervention, each intervention occurrence was treated as a discrete event. Reintervention type, indication, timing (perioperative, days 0-30; short term, days 31-180; midterm, >180 days), inpatient/outpatient, length of stay, and morbidity/mortality were recorded. Reintervention success was defined as resolution of the indication. RESULTS: Among 123 consecutive F/B-EVARs (mean follow-up, 25 months), 32 patients (25%) underwent 54 reinterventions (one reintervention, 20 (63%) patients; two reinterventions, 6 (19%) patients; three reinterventions, 4 (13%) patients; four reinterventions, 1 (3.1%) patient; and six reinterventions, 1 (3.1%) patient). The most frequent indications were type III endoleaks (n = 15 [28%]), target artery occlusions (n = 7 [13%]), and stenoses (n = 6 [11%]). These were performed in the perioperative, short-term, and midterm time frames 17%, 41%, and 43% of the time, respectively. Reinterventions were percutaneous (67%), inpatient procedures (61%), with median length of stay of 5 days. Of the 32 reintervention patients, 4 experienced access site complications and 4 died <30 days after reintervention (3 were adjudicated as not aneurysm related/not reintervention related). In 31 of 32 (97%) patients, reintervention success was achieved. CONCLUSIONS: Reinterventions after F/B-EVAR were necessary in 26% of patients, most commonly for type III endoleaks and target artery complications. Whereas all but one reintervention was successful, many of these required complex procedures with significant morbidity and mortality. Development of strategies to eliminate type III endoleaks by improving component junction integrity and to ensure target artery primary patency are key next steps in the evolution of F/B-EVAR.

Racial, ethnic, and socioeconomic inequities in amputation risk for patients with peripheral artery disease and diabetes.

Peripheral artery disease and diabetes are highly prevalent diseases and the leading cause of limb loss. Despite advances in medical and surgical techniques, there are stark differences in delivery and outcomes of lower extremity amputation among populations when stratified by race, ethnicity, and socioeconomic status. We reviewed studies from the last 2 decades (1999-2022) to provide a comprehensive assessment of the current impact of disparities on the risk for, and management of, lower extremity amputation and offer action items that can optimize health outcomes.

Artificial intelligence in clinical workflow processes in vascular surgery and beyond.

In the past decade, artificial intelligence (AI)-based applications have exploded in health care. In cardiovascular disease, and vascular surgery specifically, AI tools such as machine learning, natural language processing, and deep neural networks have been applied to automatically detect underdiagnosed diseases, such as peripheral artery disease, abdominal aortic aneurysms, and atherosclerotic cardiovascular disease. In addition to disease detection and risk stratification, AI has been used to identify guideline-concordant statin therapy use and reasons for nonuse, which has important implications for population-based cardiovascular disease health. Although many studies highlight the potential applications of AI, few address true clinical workflow implementation of available AI-based tools. Specific examples, such as determination of optimal statin treatment based on individual patient risk factors and enhancement of intraoperative fluoroscopy and ultrasound imaging, demonstrate the potential promise of AI integration into clinical workflow. Many challenges to AI implementation in health care remain, including data interoperability, model bias and generalizability, prospective evaluation, privacy and security, and regulation. Multidisciplinary and multi-institutional collaboration, as well as adopting a framework for integration, will be critical for the successful implementation of AI tools into clinical practice.

A fenestrated, double-barrel technique for proximal reintervention after open or endovascular abdominal aortic aneurysm repair.

Objective: Proximal endovascular reintervention after prior endovascular aortic repair (EVAR) or open abdominal aortic aneurysm repair (OR) can be challenging due to the short distance to the visceral branches. We present a novel solution to allow the use of the commercially available ZFEN device using a double-barrel, kissing-limb technique. Methods: Patients who underwent fenestrated repair for proximal failure after EVAR or OR were identified. The ZFEN device is deployed above the prior graft flow divider. Once the visceral branches are secured, kissing limbs are used to connect with the prior graft limbs. The distal diameter of the standard ZFEN is 24 mm, accommodating two 20 mm components according to the formula 2πDLIMB = πDZFEN + 2DZFEN. Results: Of 235 patients who underwent repair using ZFEN from 2012 to 2021 at a single institution, 28 were treated for proximal failure of prior repairs, with 13 treated using the double-barrel technique (8 EVAR, 5 OR). The distance from the flow divider to the lowest renal artery was 67 ± 24.4 mm (range, 39-128 mm), and the distance to the superior mesenteric artery (SMA) was 87 ± 30.5 mm (range, 60-164 mm). Technical success was 100%. Seven patients had standard ZFEN builds (2 renal small fenestrations, SMA large fen/scallop). The minimum distance to the lowest renal artery and SMA to accommodate a standard ZFEN build was 56 and 60 mm, respectively. Four patients required adjunctive snorkel grafts and two required laser fenestrations. Two patients had gutter leaks at 1 month that self-resolved; one patient developed a late type 1a endoleak. Freedom from reintervention was 90%, 72%, and 48% at 1, 2, and 3 years, respectively. Conclusions: This double-barrel technique allows for distal seal of commercial ZFEN devices into prior open or endovascular repairs with good technical success. Long-term outcomes remain to be quantified.

Bicycle exercise ankle brachial index recovery time as a novel metric for evaluating the hemodynamic significance of external iliac endofibrosis in competitive cyclists.

Subtle radiographic findings can increase the challenge of diagnosing external iliac artery endofibrosis. We evaluated a new metric, the bicycle exercise ankle brachial index recovery time (BART), in a cohort of cyclists with symptomatic external iliac artery endofibrosis. BART was defined as the time required in minutes for the ankle brachial index to return to 0.9 after a period of exercise. Surgical correction resulted in an improvement in BART postoperatively (4.5 ± 4.1 vs 9.1 ± 4.3 minutes; P < .001), with improved values correlating with better patient satisfaction. Documentation of the BARTs before and after surgical treatment provides an additional measure of postoperative hemodynamic improvement.

The Use and Relevance of the Hippocratic Oath in 2015-a Survey of US Medical Schools.

INTRODUCTION: We determined the extent and context in which the Hippocratic or other oaths are administered at accredited medical schools in the United States. METHODS: An online survey was used to gather data about oath ceremonies at every allopathic medical school in the US. RESULTS: Sixty-seven of 141 contacted medical schools (48%) had medical students recite an oath. Fifty-nine (88% of responding institutions) had students swear an oath more than once during medical training and 30 (45%) used more than one oath. Responses show that 29 (43%) schools used the classic Hippocratic Oath or a modified version of it, 29 (43%) used oaths authored by students and/or faculty, and 28 (42%) used some other oath. All reporting institutions (67, 100%) incorporated an oath into a White Coat Ceremony (62, 92%), a ceremonial event where medical students are given short white coats to be worn during clinical rotations, or Commencement (62, 93%). DISCUSSION: Oaths play a significant role in medical school ceremonies with an unknown impact on shaping the medical ethics of student physicians. Although sections of the Hippocratic Oath may seem outdated, its principles remain vastly applicable to the ethical practice of modern medicine. On the contrary, we argue that many features of the oath are more applicable than ever before to the modern clinician. We believe that the Hippocratic Oath ought to remain a vital part of today's medical education and clinical practice.