Locoregional Versus General Anesthesia for Carotid Artery Stenting in the American College of Surgeons National Surgical Quality Improvement Project.

OBJECTIVES: Carotid artery stenting (CAS) may be performed by transfemoral or transcervical (TCAR) approaches and with a variety of anesthetic techniques. No current literature clearly supports one anesthetic method over another. We therefore sought to evaluate the outcomes of CAS procedures based on anesthetic approach. DESIGN: Retrospective cohort study. SETTING: American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2018. PARTICIPANTS: All individuals undergoing CAS during the study period. INTERVENTIONS: Anesthetic type (locoregional versus general [GA]). MEASUREMENTS AND MAIN RESULTS: Locoregional anesthesia for CAS was used for 754 (65.5%) patients, with the remainder under GA. Demographic variables were comparable, as were the incidence of symptomatic presentation, high-risk anatomy or physiology, severity of the stenosis, and presence/severity of contralateral carotid disease. There was no difference in composite outcome (stroke, myocardial infarction [MI], and death) (7.0% v 6.1%, p = 0.53). The GA group had lower odds ratio of MI (0.12, p = 0.0362) but higher odds ratio of death (3.33, p = 0.008) and postoperative pneumonia (3.87, p = 0.0083), although on multivariable analysis the risk of death appeared confounded by respiratory variables. Multivariable and propensity score-weighted analyses did not identify a significant association of GA with the composite outcome. CONCLUSIONS: In patients undergoing CAS in the National Surgical Quality Improvement Program, GA was not associated with the composite outcome but was associated with increased rates of postoperative pneumonia and decreased rates of MI. Further investigation should attempt to better clarify these relationships.

The effect of incremental increases in the number of packed red blood cell units transfused on perioperative outcomes in open abdominal aortic aneurysm repair.

INTRODUCTION: Despite abundant evidence in the surgical and critical care literature demonstrating inferior outcomes in transfused patients, liberal use of blood transfusion, particularly after the initial unit, remains common in vascular surgery. We therefore sought to investigate the incremental risk of each additional unit of blood transfused intraoperatively for patients undergoing elective open repair of abdominal aortic aneurysm (AAA) with regards to postoperative mortality and complications. METHODS: Patients in the Vascular Quality Initiative registry undergoing elective open infrarenal AAA repair from 2003 to 2020 were included. Exclusion criteria were age greater than 90, prior aortic surgery, concomitant iliac aneurysm, and concomitant additional major procedure. Multivariable logistic regression was used to calculate adjusted odds ratios for in-hospital mortality with incremental increases in packed red blood cells (pRBCs) given intraoperatively. Univariate analysis was performed for secondary outcomes including postoperative cardiac, respiratory, renal, and wound complications. RESULTS: Of 4608 patients who underwent elective open AAA repair, 796 patients (16.9%) underwent perioperative transfusion. The overall in-hospital mortality rate was 2.5%. Adjusting for relevant factors, there was an increase in the odds of in-hospital mortality of 24% for each additional unit transfused. Incremental increases in the number of units transfused were associated with significantly higher risk of postoperative myocardial infarction, congestive heart failure, pulmonary complications, renal failure, and wound complications. DISCUSSION: There appears to be an important increase in the odds of mortality for each additional unit transfused during infrarenal open AAA repair even when controlling for confounders.

Identification and characterization of new candidates for abdominal aortic aneurysm screening in patients outside of current accepted guidelines.

BACKGROUND: Previous studies have identified groups of patients with abdominal aortic aneurysm (AAA) that fall outside of currently accepted screening guidelines. Population-based studies have found AAA screening would be cost-effective at a prevalence of 0.5% to 1.0%. The goal of this study was to determine the prevalence of AAA in patients that fall outside of the current screening guidelines. In addition, we analyzed outcomes of the groups with a prevalence of greater than 1%. METHODS: Using the TriNetX Analytics Network, several patient cohorts were abstracted with a diagnosis of ruptured or unruptured AAA based on previously identified groups with a potentially high risk for AAA that fall outside of currently accepted screening guidelines. Groups were also stratified by sex. For groups found to have a prevalence of greater than 1%, the unruptured patients were further analyzed for long-term rates of rupture and included male ever-smokers aged 45 to 65, male never-smokers aged 65 to 75, male never-smokers aged greater than 75, and female ever-smokers aged 65 or greater. Long-term mortality, stroke, and myocardial infarction rates were compared in patients with treated and untreated AAA after propensity score matching. RESULTS: We identified 148,279 patients across the four groups with a prevalence of AAA of greater than 1% with female ever-smokers aged 65 or older being the most prevalent (2.73%). In each of the four groups, the rate of AAA rupture increased every 5 years and all had rupture rates of greater than 1% at 10 years. Meanwhile, controls for each of these four subgroups without a previous AAA diagnosis had rupture rates between 0.090% and 0.013% at 10 years. Those who underwent repair of their AAA had decreased incidence of mortality, stroke, and myocardial infarction. Specifically, male ever-smokers aged 45 to 64 had a significant difference in incidence of mortality and myocardial infarction at 5 years and stroke at 1 and 5 years. CONCLUSIONS: Our analysis suggests male ever-smokers aged 45 to 65, male never-smokers aged 65 to 75, male never-smokers aged greater than 75, and female ever-smokers aged 65 or greater have a more than 1% prevalence of AAA and, therefore, may benefit from screening. Outcomes were significantly worse compared with well-matched controls in these groups.

A comparison of endovascular repair to medical management for acute vs subacute uncomplicated type B aortic dissections.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has emerged as a viable option of treatment for uncomplicated type B aortic dissection (UTBAD) due to the potential for inducing favorable aortic remodeling. The aim of this study is to compare outcomes of UTBAD treated medically or with TEVAR in either the acute (1 to 14 days) or subacute period (2 weeks to 3 months). METHODS: Patients with UTBAD between 2007 and 2019 were identified using the TriNetX Network. The cohort was stratified by treatment type (medical management; TEVAR during the acute period; TEVAR during the subacute period). Outcomes including mortality, endovascular reintervention, and rupture were analyzed after propensity matching. RESULTS: Among 20,376 patients with UTBAD, 18,840 were medically managed (92.5%), 1099 patients were in the acute TEVAR group (5.4%), and 437 patients were in the subacute TEVAR group (2.1%). The acute TEVAR group had higher rates of 30-day and 3-year rupture (4.1% vs 1.5%; P < .001; 9.9% vs 3.6%; P < .001) and 3-year endovascular reintervention (7.6% vs 1.6%; P < .001), similar 30-day mortality (4.4% vs 2.9%; P < .068), and lower 3-year survival compared with medical management (86.6% vs 83.3%; P = .041). The subacute TEVAR group had similar rates of 30-day mortality (2.3% vs 2.3%; P = 1), 3-year survival (87.0% vs 88.8%; P = .377) and 30-day and 3-year rupture (2.3% vs 2.3%; P = 1; 4.6% vs 3.4%; P = .388), with significantly higher rates of 3-year endovascular reintervention (12.6% vs 7.8%; P = .019) compared with medical management. The acute TEVAR group had similar rates of 30-day mortality (4.2% vs 2.5%; P = .171), rupture (3.0% vs 2.5%; P = .666), significantly higher rates of 3-year rupture (8.7% vs 3.5%; P = .002), and similar rates of 3-year endovascular reintervention (12.6% vs 10.6%; P = .380) compared with the subacute TEVAR group. There was significantly higher 3-year survival (88.5% vs 84.0%; P = .039) in the subacute TEVAR group compared with the acute TEVAR group. CONCLUSIONS: Our results found lower 3-year survival in the acute TEVAR group compared with the medical management group. There was no 3-year survival benefit found in patients with UTBAD who underwent subacute TEVAR compared with medical management. This suggests the need for further studies looking at the necessity for TEVAR when compared with medical management for UTBAD as it is non-inferior to medical management. Higher rates of 3-year survival and lower rates of 3-year rupture in the subacute TEVAR group compared with the acute TEVAR group suggest superiority of subacute TEVAR. Further investigations are needed to determine the long-term benefit and optimal timing of TEVAR for acute UTBAD.

Incidence of Procedure-Related Complications in Patients Treated With Atherectomy in the Femoropopliteal and Tibial Vessels in the Vascular Quality Initiative.

PURPOSE: To compare procedural complications in patients undergoing atherectomy plus angioplasty (A+A) and plain balloon angioplasty (POBA). MATERIALS AND METHODS: Patients in the Vascular Quality Initiative (VQI) registry undergoing first-time peripheral vascular intervention (PVI) were included. Those undergoing aortoiliac or pedal interventions, primary stenting, or hybrid procedures were excluded. Patients were stratified by lesion location (femoropopliteal [FP] or tibial [TIB]). The primary outcomes were target vessel dissection, distal embolization, and provisional stent placement. Secondary outcomes included postoperative complications and the need for subsequent interventions. RESULTS: 12 499 patients undergoing FP (49.6% A+A) and 6736 patients undergoing TIB (17.0% A+A) interventions were identified. In the FP group, A+A was associated with greater intraoperative target vessel dissection (4.5% vs 2.6%, p<0.001), distal embolization (1.5% vs 0.7%, p =0.001), and provisional stent placement (1.5% vs 0%, p<0.001); and greater postoperative target vessel dissection (4.2% vs 2.0%, p<0.001) and distal embolization (0.9% vs 0.4%, p=0.034). In the TIB group, A+A was associated with fewer intraoperative vessel dissection (0.8% vs 2.3%, p=0.011) but greater provisional stent placement (0.3% vs 0%, p<0.001). TIB A+A was also associated with higher rates of technical success (97.6% vs 95.1%, p<0.001). CONCLUSIONS: Atherectomy was associated with increased procedural-related complications in femoropopliteal, but not in tibial vessels. Future studies addressing lesion morphology, device design, and technique may help define its role in peripheral vascular interventions.

Does the Hospital Day of Surgery for Endovascular Repair of Symptomatic Abdominal Aortic Aneurysms Affect Outcomes?

OBJECTIVE: Symptomatic abdominal aortic aneurysms (sAAA) are considered surgically urgent. Recent data suggest delaying surgery allows for medical optimization without affecting outcomes. We investigated the association of the hospital day of surgery with 30 day outcomes. METHODS: Patients with infrarenal sAAA undergoing endovascular aortic repair (EVAR) between 2011 and 2018 in the American College of Surgeons National Surgery Quality Improvement Project database were included. The primary outcome was 30 day mortality. Additional outcomes included myocardial infarction, pulmonary complications, length of stay, and discharge disposition. Days-to-surgery were classified as the day of presentation (D0), day 1, day 2, days 3 and 4, days 5 to 7 (D5), and day 8 or more (D8). RESULTS: A total of 804 patients were identified. D8 patients had higher proportions of dyspnea on exertion, chronic obstructive pulmonary disease, congestive heart failure, and history of dialysis. D0 surgery appeared protective of mortality (odds ratio [OR] 0.34, p=0.0132). Each additional day increased the mortality risk (OR 1.23, p<0.001) although not within the first 4 days. There was increased mortality for patients having surgery at D5 (7.7%) and D8 (23.8%) compared with repair earlier (1%-4%, p=0.03). Bivariable analysis revealed no significant differences in secondary outcomes. Multivariable modeling revealed increased mortality for D8 versus D0 (adjusted OR of 6.8, 95% confidence interval 1.7-26.5). CONCLUSIONS: While D0 appears to have the lowest risk of mortality, EVAR for sAAA up to 4 days may not be associated with increased mortality. Further research should determine delay etiologies and whether they improve operative planning and optimization without impacting morbidity and mortality.

Panel composition and disparities in the topics of presentation in vascular surgery conferences.

BACKGROUND: Previous studies identified gender disparities in surgical conference presenters and moderators. We sought to assess disparities in the representation of women in terms of speakers and moderators, but with particular emphasis on panels and topics of discussion at vascular surgery conferences. METHODS: Data regarding presenters and moderators from the Southern Association of Vascular Surgery, Western Vascular Society, Vascular and Endovascular Surgical Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery conferences was obtained from online meeting archives and via email correspondence. Scientific session speakers, moderators, and panelists were identified by sex. Specific vascular topics for each discussion were also identified. Keynote speakers or special guests were excluded. RESULTS: Compared to men, women were less often presenters (18% versus 82%, p < .002) and moderators (16% versus 84%, p < .001) of conference sessions. Women were most likely to present on dialysis access and least likely to present on venous disease overall. Women were more likely to present on aortic (24% vs 19%; p < .013) and cerebrovascular disease (33% vs 27%; p < .021) at regional compared to national conferences. Of panels assessed, 68% were all-male. Subgroup analysis suggests that some improvements have been made over time. CONCLUSIONS: Significant disparities persist in the topics presented and in panel composition suggesting potential areas for improvement in equity. Further study should focus on evaluating trends in the training level of the presenter and the topics presented, and assessing parity in structural factors that impact research presentation opportunities.

Initiation of hemodialysis at one month following fistulogram in patients with advanced kidney disease.

OBJECTIVE: Previous studies have demonstrated that low contrast volume used in access-related interventions had limited effects on the progression of chronic kidney disease (CKD) after fistulography, but studies are limited and heterogeneous. We sought to evaluate the rate of and factors associated with progression to dialysis (HD) within 1 month after fistulography for patients with advanced CKD. METHODS: A single-institution retrospective cohort analysis of patients with CKD stage IV and V, not yet on HD, undergoing fistulography from 1 January 2014 to 31 December 2018 was performed. The primary outcome was progression to HD within 1 month. Additional variables and the association with the primary outcome such as medical comorbidities, contrast type or volume were assessed. RESULTS: A total of 34 patients underwent 41 fistulograms prior to HD initiation. Progression to HD within 1 month of fistulogram occurred in seven patients (all CKD V). The mean time between fistulogram and HD was 271 days for 31 of 34 patients who ultimately progressed to HD. Those with CKD IV began HD in 549 days on average, while those with CKD V began HD in 190 days on average. Three patients had not initiated HD at a mean of 539 days of follow-up. The only factors associated with progression to HD within 1 month included use of isovue (p = .005) and elevated contrast volume, with a mean of 40 mL (p = .027). CONCLUSION: Although none of the patients with CKD IV required HD within 1 month after fistulogram, the use of larger iodinated contrast volume was associated with progression to HD within 1 month of fistulography for patients with CKD V. Further studies should investigate the safety of iodinated and alternative (e.g., carbon dioxide) contrast media in fistulography or duplex-based HD access procedures for CKD patients, especially CKD V, not yet on HD.

Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions.

OBJECTIVE: Limited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes. METHODS: Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) carotid artery stenting surveillance project registry and the SVS VQI CEA modules who had undergone carotid artery intervention (TCAR, TFCAS, or CEA) for RICS were included. Those aged >90 years and those with concomitant interventions (eg, coronary bypass) were excluded. A composite of death, myocardial infarction (MI), and stroke was the primary outcome. The secondary outcomes included death, MI, stroke, cranial nerve injury (CNI), and other local and systemic complications. Multivariable logistic regression controlling for presenting symptomatic status and comorbid medical conditions was conducted for the outcome variables, except for death, which was analyzed using Cox regression modeling. RESULTS: A total of 1927 patients with RICS had undergone CEA (n = 1172), TCAR (n = 253), or TFCAS (n = 502). The CEA group had a higher rate of diabetes (31% vs 25% for TCAR and 25% for TFCAS; P = .01), hypertension (85% vs 82% for TCAR and 79% for TFCAS; P < .01), and peripheral vascular disease (8% vs 4% for TCAR and 4% for TFCAS; P < .01). The TCAR and TFCAS groups had higher rates of coronary artery disease (21% for CEA vs 30% for TCAR and 29% for TFCAS; P < .01). The patients who had undergone TFCAS were more likely to have had symptomatic lesions (57% for TFCAS vs 47% for CEA and 41% for TCAR; P < .01) and prior stroke (55% for TFCAS vs 47% for CEA and 40% for TCAR; P < .001). The composite outcome occurred in 3.2% of TCAR patients, 11.2% of TFCAS patients, and 11.1% of CEA patients (P < .01) with an odds ratio of 0.27 for TCAR, 0.91 for TFCAS, and 1.00 for CEA. However, no differences in the individual outcomes were noted for any procedure. TCAR exhibited the lowest odds ratio for CNI (0.15) compared with TFCAS at 0.9, both relative to CEA (P = .03). CONCLUSIONS: RICS patients treated by TCAR in the SVS VQI had the lowest risk of the composite of stroke, death, and MI and CNI. Therefore, TCAR might be the preferred treatment modality. Further comparative studies are needed to evaluate the long-term outcomes in this population and to elucidate the relationship of these procedures to the individual outcomes of stroke, MI, and death.

Outcomes of acute limb ischemia in COVID-19.

OBJECTIVE: The inflammatory cascade caused by severe acute respiratory syndrome coronavirus 2 infection may result in arterial thrombosis and acute limb ischemia (ALI) with devastating consequences. The aims of this study were to compare outcomes of ALI in the lower extremities in patients with and without coronavirus disease 2019 (COVID-19), and to determine if ALI development in the context of COVID-19 portends a worse prognosis compared with COVID-19 without ALI. METHODS: Queries were built on TriNetX, a federated network of health care organizations across the United States that provides de-identified patient data. International Classification of Diseases, 10th revision diagnostic codes were used to identify patients with acute limb ischemia of the lower extremities and COVID-19. The study timeframe was defined as January 20, 2020 to May 20, 2021. Statistical analyses, including propensity-score matching, were done through TriNetX's internal software. Outcomes looked at are rates of mortality, stroke, myocardial infarction, major adverse limb events, re-intervention, respiratory failure, sepsis, mental health complications, and acute renal failure. Baseline cohort characteristics were also collected. RESULTS: Patients with ALI with COVID-19 (ALI C19+; n = 526) were significantly less likely than patients with ALI without COVID-19 (ALI; n = 14,131) to have baseline comorbidities, including nicotine dependence (18% vs 33%; P < .0001). In contrast, ALI C19+ patients had significantly more comorbidities than hospitalized patients with COVID-19 without ALI (n = 275,903), including nicotine dependence (18% vs 10%; P < .0001). After propensity matching was performed, ALI C19+ patients had significantly higher rates of mortality (24.9% vs 9.2%; P < .0001), major adverse limb events (5.8% vs 2.9%; P = .0223), and acute renal failure (22.2% vs 14.9%; P = .0025) than patients with ALI. Compared with hospitalized patients with COVID-19 without ALI, ALI C19+ patients had higher propensity-matched rates of respiratory failure and being placed on assisted ventilation (32.9% vs 27%; P = .0369), sepsis (16.9% vs 12.2%; P = .0288), acute renal failure (22.1% vs 14.6%; P = .0019), and mortality (24.7% vs 14.4%; P < .0001). CONCLUSIONS: Patients who developed ALI following COVID-19 present with significantly different demographics and comorbidities from those who develop ALI without COVID-19. After controlling for these variables, higher rates of major adverse limb events, acute renal failure, and mortality in patients with ALI with COVID-19 suggest that not only may COVID-19 precipitate ALI, but it may also exacerbate ALI sequelae. Furthermore, development of ALI in COVID-19 portends worse prognosis compared with patients with COVID-19 without ALI.

Impact of tibial bypass conduit on long-term amputation-free survival and primary patency in the Vascular Quality Initiative.

OBJECTIVE: Much research remains focused on tibial bypass conduit selection. We sought to describe long-term amputation-free survival (AFS) and primary patency (PP) of patients undergoing tibial bypass by conduit type and configuration across several permutations in the Society for Vascular Surgery Vascular Quality Initiative. METHODS: Patients in the Vascular Quality Initiative registry undergoing elective first-time femoral- or popliteal-to-tibial bypass for occlusive disease involving rest pain or tissue loss were identified. Prior ipsilateral infrainguinal bypass or concomitant procedures were excluded. Outcomes of interest included patient AFS at 22 months and PP at 1 year (defined as freedom from revision, thrombectomy, or graft occlusion). RESULTS: A total of 4192 bypasses were identified. The majority utilized great saphenous vein (GSV) (76.2%), followed by polytetrafluoroethylene (10.6%), nonautologous biologic (6.5%), composite (3.3%), arm vein (2.8%), and small saphenous vein (0.6%). Compared with all prosthetic and composite bypasses, vein grafts had the best AFS (76.4%; P < .0001) and PP (68.1%; P = .041). Of the single segment vein conduits, GSV bypasses had the best PP (69.1%) and arm vein the worst (60.2%). AFS and PP were similar between single-segment GSV orientations. Single-segment GSV bypasses exhibited better PP than multiple segment bypasses (69.1% vs 54.6%; P = .0016). PP was significantly better for polytetrafluoroethylene compared with nonautologous biologic (68.4% vs 51.2%; P = .0039). PP did not significantly differ between vein cuff for prosthetic bypass compared with no vein cuff (69.1% vs 59.7%; P = .091). PP was not significantly different between single-segment GSV and prosthetic grafts with vein cuff (69.1% vs 69.1%; P = .51). There were no significant differences in AFS comparing arm vein, prosthetic bypass with vein cuff, or composite grafts (67.2% vs 63.8% vs 59.3%; P = .092), as well as in PP (60.2% vs 69.1% vs 54.8%; P = .14). CONCLUSIONS: Single-segment vein bypass was only marginally the most optimal conduit. Surprisingly, there may be more equipoise among conduit types, particularly in the absence of adequate GSV. Prosthetic grafts overall may not be as disadvantaged in the long term as initially thought, especially when compared with arm vein, as prosthetic bypass with vein cuff did not significantly differ in PP. Similarly, a composite conduit may not impact long-term outcomes. These data suggest that conduit choice may not impact outcomes to the degree previously thought and that other factors may have a greater impact than presumed, especially in conduit limited situations.

Physician-Modified Endografts Versus Chimney/Snorkel for Ruptured and Symptomatic Juxtarenal and Paravisceral Aneurysms in the Vascular Quality Initiative.

OBJECTIVES: Ruptured and symptomatic juxtarenal and paravisceral aneurysms present technical challenges during endovascular repair. We sought to compare physician modification and fenestrated (PMEG) versus chimney/periscope/snorkel (CHIMPS) repair techniques for the treatment of ruptured and symptomatic paravisceral and juxtarenal aortic aneurysms (r/sPJAA). METHODS: Patients in the thoracic and complex endovascular aneurysm module of the Vascular Quality Initiative (VQI) national registry undergoing CHIMPS and PMEG for r/sPJAA were included. Patients who underwent thoracic aneurysm repair with only celiac intervention or who had coverage or occlusion only of one renal or visceral branch vessel were excluded. One-year mortality was the primary outcome. Secondary outcomes included peri- and postoperative endoleak, hospital and ICU length of stay, reintervention, and other local and systemic complications. RESULTS: A total of 81 CHIMPS and 47 PMEG patients were identified. Patients undergoing PMEG were more frequently symptomatic, had a history of CHF and were taking aspirin, statin and P2Y12 antiplatelet medications. Patients undergoing CHIMPS presented more frequently with rupture. There was no significant survival advantage for CHIMPS over PMEG patients (P = 0.5). There were no apparent long-term differences in the numbers of endoleaks or in the rates of subsequent reinterventions between the two groups. CONCLUSIONS: It does not appear that the procedure type (CHIMPS versus PMEG) is associated with postoperative survival in patients with r/sPJAA. Not surprisingly, survival is associated with postoperative complications, particularly myocardial infarction and intestinal ischemia. Further research should evaluate reasons for failure to rescue from and the impact of postoperative complications on the postoperative survival after endovascular repair of r/sPJAA.

The current state of vascular surgery presence and educational content in Google and YouTube internet search results.

BACKGROUND: Information on the internet regarding vascular disease has not been extensively assessed. Our goal was to compile and appraise the information available via Google and YouTube searches regarding various topics of interest for vascular surgeons (VS) and related procedures with a focus on the role of the VS. METHODS: The Google and YouTube platforms were independently queried for 25 keywords/phrases relating to common vascular diagnoses and procedures by two separate researchers from March to July 2019. Paid advertisements or a Society for Vascular Surgery (SVS) webpage or affiliated video in the first 25 results was documented. Results were reviewed for information regarding the responsible medical specialty and the target audience, and disease-related information (screening, risk factors, risk reduction, diagnostic testing, operative treatment, alternative treatment, follow-up, complications, and recovery). RESULTS: From the Google search, 357 unique domains of 1241 total webpages were identified with 75% directed toward the public. An SVS page was present in 56% of the first-page results and least likely to be present in searches for claudication, gangrene, carotid stent, rib resection, and thrombolysis. VS were mentioned as referral physicians in 56% of the 68% of websites that mentioned a specialty, endovascular specialists/interventional radiology in 20%, and cardiothoracic surgeons in 19%. Only 4% of the websites contained information from all categories, with the greatest number for aortic dissection. Advertisements were present in 18% of all searches (most commonly for "varicose vein," "varicose vein surgery," and "inferior vena cava filter"). From YouTube, 1247 search results (613 unique videos) were evaluated with 64% directed toward the public. An SVS affiliated video was present in 36% of searches. In the 47% of videos where a specialty was mentioned, 56% mentioned VS, interventional radiology in 10%, and cardiothoracic surgeons in 7%. Only 0.24% of the videos contained information from all categories. The greatest number of content categories was in videos related to peripheral arterial disease. Across both platforms, dialysis access searches yielded results with the least number of content categories. CONCLUSIONS: Patient-related information regarding vascular surgical topics is readily available on the internet, but the content is highly variable and not comprehensive. Only half of the searches mention VS as the referral physician of choice or authority for these medical conditions. Further efforts should focus on developing the online presence of vascular surgery, improving the quality of education of vascular disease on the internet, and directing patients to the vascular specialists to treat these conditions.

Early experience with arterial thromboembolic complications in patients with COVID-19.

BACKGROUND: Little is known about the arterial complications and hypercoagulability associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We sought to characterize our experience with arterial thromboembolic complications in patients with hospitalized for coronavirus disease 2019 (COVID-19). METHODS: All patients admitted from March 1 to April 20, 2020, and who underwent carotid, upper, lower and aortoiliac arterial duplex, computed tomography angiogram or magnetic resonance angiography for suspected arterial thrombosis were included. A retrospective case control study design was used to identify, characterize and evaluate potential risk factors for arterial thromboembolic disease in SARS-CoV-2 positive patients. Demographics, characteristics, and laboratory values were abstracted and analyzed. RESULTS: During the study period, 424 patients underwent 499 arterial duplex, computed tomography angiogram, or magnetic resonance angiography imaging studies with an overall 9.4% positive rate for arterial thromboembolism. Of the 40 patients with arterial thromboembolism, 25 (62.5%) were SARS-CoV-2 negative or admitted for unrelated reasons and 15 (37.5%) were SARS-CoV-2 positive. The odds ratio for arterial thrombosis in COVID-19 was 3.37 (95% confidence interval, 1.68-6.78; P = .001). Although not statistically significant, in patients with arterial thromboembolism, patients who were SARS-CoV-2 positive compared with those testing negative or not tested tended to be male (66.7% vs 40.0%; P = .191), have a less frequent history of former or active smoking (42.9% vs 68.0%; P = .233) and have a higher white blood cell count (14.5 vs 9.9; P = .208). Although the SARS-CoV-2 positive patients trended toward a higher the neutrophil-to-lymphocyte ratio (8.9 vs 4.1; P = .134), creatinine phosphokinase level (359.0 vs 144.5; P = .667), C-reactive protein level (24.2 vs 13.8; P = .627), lactate dehydrogenase level (576.5 vs 338.0; P = .313), and ferritin level (974.0 vs 412.0; P = .47), these differences did not reach statistical significance. Patients with arterial thromboembolic complications and SARS-CoV-2 positive when compared with SARS-CoV-2 negative or admitted for unrelated reasons were younger (64 vs 70 years; P = .027), had a significantly higher body mass index (32.6 vs 25.5; P = .012), a higher d-dimer at the time of imaging (17.3 vs 1.8; P = .038), a higher average in hospital d-dimer (8.5 vs 2.0; P = .038), a greater distribution of patients with clot in the aortoiliac location (5 vs 1; P = .040), less prior use of any antiplatelet medication (21.4% vs 62.5%; P = .035), and a higher mortality rate (40.0% vs 8.0%; P = .041). Treatment of arterial thromboembolic disease in COVID-19 positive patients included open thromboembolectomy in six patients (40%), anticoagulation alone in four (26.7%), and five (33.3%) did not require or their overall illness severity precluded additional treatment. CONCLUSIONS: Patients with SARS-CoV-2 are at risk for acute arterial thromboembolic complications despite a lack of conventional risk factors. A hyperinflammatory state may be responsible for this phenomenon with a preponderance for aortoiliac involvement. These findings provide an early characterization of arterial thromboembolic disease in SARS-CoV-2 patients.

Aortic Neck Dilatation Following Thoracic Endovascular Aortic Repair.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has become a mainstay of treatment for a variety of thoracic aortic pathologies. Expansion of the proximal aortic neck after endovascular repair of abdominal aortic aneurysms has been demonstrated; however, dilatation of the proximal aortic neck after TEVAR has not been well described. We sought to describe remodeling of the proximal neck following TEVAR. METHODS: This is a retrospective, single institution review of patients who underwent TEVAR for thoracic aortic aneurysm (TAA) and dissection with aneurysmal degeneration from 2010 to 2019. Postoperative computed tomography scans were reviewed and aortic diameter was measured in orthogonal planes using 3-dimensional centerline reconstruction software. The primary outcome was change in aortic diameter at the proximal aortic neck as compared to the initial postoperative computed tomography scan. Clinical and operative data were analyzed to identify factors associated with significant neck dilatation. RESULTS: Of 87 patients who underwent TEVAR during the study period, 30 met inclusion criteria. Median follow up was 20.5 months. Median age was 67 years, and 15 patients (50%) were female. The proximal aortic neck experienced an overall increase over time in aortic diameter. Five mm distal to the graft showed the greatest rate of expansion, with a median increase of 1.3, 2.9, and 6.2 mm at one year, two years, and three years, respectively. When comparing patients who had mean expansion at this location of >2.0 mm/year to patients who did not, a higher percentage had dissection pathology (81.8% vs. 31.6%, P = 0.008), had graft placement at aortic landing zone 2 (36.4% vs. 5.3%, P = 0.028), and were smokers (100% vs. 52.6%, P = 0.006). Higher percent oversizing was shown to be associated with significant aortic neck dilatation for true aneurysms only. CONCLUSIONS: Aortic neck dilatation occurs over time for the majority of patients following TEVAR with the distal neck experiencing the highest rate of expansion. Dissection pathology, aortic landing zone 2, and smoking were found to be associated with a higher rate of neck dilatation.

Ambulatory Status following Major Lower Extremity Amputation.

BACKGROUND: The ability to ambulate following major lower extremity amputation, either below (BKA) or above knee (AKA), is a major concern for all prospective patients. This study analyzed ambulatory rates and risk factors for nonambulation in patients undergoing a major lower extremity amputation. METHODS: A retrospective review of 811 patients who underwent BKA or AKA at our institution between January 2009 and December 2014 was conducted. Demographic information and co-morbid conditions, including the patients' functional status prior to surgery, at 6 months, and at latest follow up were recorded. Following exclusion criteria, 538 patients were included. Patients who were either independent or used an assistive device were considered ambulatory, while those who were completely wheelchair-dependent or bed-bound were considered nonambulatory. RESULTS: Pre-operatively, 83.1% of BKA patients were ambulatory, significantly more so than those undergoing AKA (44.9%, P < 0.0001). At 6-month follow-up these percentages dropped to 58.0% and 25.2%, respectively, for all patients. For patients who were ambulatory pre-operatively, 182/246 (73.9%) of BKA and 32/51 (62.7%) of AKA remained so post-amputation. Of those patients with both 6-month and greater than 1-year follow-up, there was no change in ambulatory status between the 2 time periods. On multivariable logistic regression, age greater than 70 years and female sex were associated with nonambulation post-operatively (P = 0.001, P = 0.015, respectively). None of the co-morbid conditions recorded (diabetes, renal insufficiency, end-stage renal disease, peripheral vascular disease, or body mass index > 35) was found to have a statistically significant correlation with post-operative ambulation using multivariable analysis. CONCLUSIONS: The majority of ambulatory patients undergoing a major amputation were able to remain ambulatory. Patients who failed to ambulate 6 months after their amputation, failed to resume ambulating. Age greater than 70 and female sex were found to have a statistically significant association with becoming nonambulatory following surgery.

Perioperative Opioid and Nonopioid Prescribing Patterns in AVF/AVG Creation.

BACKGROUND: To evaluate postoperative opioid prescribing patterns in patients undergoing hemodialysis access creation. METHODS: Operative logs were reviewed to identify patients undergoing creation of arteriovenous fistula (AVF) or graft (AVG) from September 2016 to January 2018. Immediate postoperative opioid prescriptions were compared for ambulatory patients versus inpatients. Opioid prescriptions at the time of discharge for inpatients were recorded. Rates of opioid prescribing were standardized by conversion to morphine milligram equivalents (MMEs). Opioid use postoperatively and at the time of discharge based on anesthetic technique, general anesthesia versus regional or local anesthesia with sedation were compared. Alternative pain medications administered and pain scores were recorded. Comparisons were made between the percentage of opioid use and doses administered between AVF and AVG patient groups, ambulatory and inpatients, and type of anesthetic technique used. Statistical analysis was performed with chi-square and t-tests. RESULTS: We identified 164 patients undergoing AV access creation but not receiving chronic opioid therapy. A significantly higher percentage of inpatients received opioids in the immediate postoperative period than ambulatory patients (AVF: 72% vs. 19%, P < 0.001; AVG: 62% vs. 25%, P = 0.001). Overall, all AVG patients were more likely to be discharged with an opioid prescription than all AVF patients (37% vs. 8%, P < 0.001). Of AVG patients managed in the ambulatory setting, 48% were discharged with an opioid prescription. The mean total opioid postoperative dose prescribed to inpatients was significantly higher than that prescribed to ambulatory patients for both fistulas (28.73 MMEs vs. 1.27 MMEs, P < 0.001) and grafts (22.11 MMEs vs. 2.16 MMEs, P = 0.005). General anesthesia patient groups were more likely to receive opioids postoperatively than local anesthesia with sedation patients for both AVF (54% vs. 24%, P = 0.027) and AVG creation (61% vs. 17% P < 0.001). Postoperative alternative medication use in the hospital was low with 18% acetaminophen and 1% nonsteroidal anti-inflammatory drug use for AVF patient groups and 24% acetaminophen and 0% nonsteroidal anti-inflammatory drug use for AVG patient groups. The percentage of patients reporting postoperative pain in the recovery room and on the inpatient units was comparable between ambulatory and inpatient settings (AVF: 21% vs. 28%, P = 0.534; AVG: 23% vs. 44%, P = 0.061). CONCLUSIONS: A higher percentage of inpatients undergoing hemodialysis access received opioids when compared with ambulatory patients in the immediate postoperative period. Inpatients were prescribed higher mean doses than ambulatory patients. AVG patient groups were prescribed more opioids than AVF patient groups. Alternative analgesic agent use was low, suggesting an opportunity for improved pain control and opioid reduction. Dialysis access creation represents an opportunity to improve on opioid prescribing patterns.

A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in Patients with Chronic Limb-Threatening Ischemia.

OBJECTIVES: Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention. METHODS: We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models. RESULTS: A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P < 0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization. CONCLUSIONS: An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.

Extended screening guidelines for the diagnosis of abdominal aortic aneurysm.

BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) guidelines are the most widely used criteria for screening for abdominal aortic aneurysms (AAA). However, when the USPSTF criteria are applied retrospectively to a group of patients who have undergone treatment for AAA, there are many patients who satisfy none of the AAA screening criteria. The more sensitive Society for Vascular Surgery (SVS) guidelines have expanded the criteria for screening for AAA with the hope of capturing a greater fraction of those individuals who can undergo treatment for their AAA before presenting with AAA rupture. We sought to identify the number of patients who would have been identified as having criteria for screening for AAA by both the USPSTF and SVS criteria, in a cohort of patients who have undergone treatment for AAA. METHODS: We assessed demographic, comorbidity, and perioperative complication data for all patients undergoing endovascular and open AAA repair in the Vascular Quality Initiative. Patients meeting each of the screening criteria were identified. Clinical factors and demographic variables were collected. RESULTS: We identified 55,197 patients undergoing AAA repair in the Vascular Quality Initiative, including 44,602 patients who underwent endovascular aneurysm repair (EVAR) and 10,595 patients undergoing open repair. Of these, the USPTF guidelines would have identified fewer than one-third of patients (32% EVAR and 33% open repair). Applying the SVS guidelines increased the number meeting criteria for screening by 6% and 12% for the EVAR and open repair cohorts, respectively. Finally, adoption of the expanded SVS guidelines (including the "weak recommendations") would have identified an additional 34% of EVAR patients and 21% of open AAA repair patients. Use of the expanded criteria would have resulted in 27% of patients undergoing EVAR and 33% of patients undergoing open AAA repair who would not have met any screening criteria. In EVAR patients not meeting the criteria, 52% were younger than 65 years had a history of heavy smoking. Of all those who did not meet screening criteria, ruptured AAA was twice as prevalent as those who met screening criteria (8.5% vs 4.4%; P ≤ .0001). CONCLUSIONS: Expanding established USPSTF screening guidelines to include the expanded SVS criteria may potentially double the number of patients identified with AAA. Smokers under the age of 65, and elderly patients 70 and older with no smoking history, represent two groups with AAA and potentially twice the risk of presenting with rupture.

Underutilization of Nonopioid Pain Medication in Patients Undergoing Abdominal Aortic Aneurysm Repair.

BACKGROUND: With increased focus on the opioid crisis, it was our goal to describe rates and risk factors for postoperative use of opioids in patients undergoing abdominal aortic aneurysm (AAA) repair as well as identify pain modalities that are underutilized. METHODS: We retrospectively analyzed perioperative analgesic prescriptions for endovascular (EVAR) and open AAA repair between January 1, 2010 and January 1, 2018. Patients' baseline opioid use, demographics, and medical comorbidities were obtained. The EVAR group was further subdivided into percutaneous (pEVAR) and cutdown (cEVAR) groups. Primary outcomes were postoperative and discharge pain medication prescriptions. Relative rates of opioid prescribing were obtained through the electronic medical record and normalized into morphine milligram equivalents (MMEs). RESULTS: Of the 128 patients analyzed in the entire cohort, 21.8% (n = 28) underwent open repair and 78.12% (n = 100) underwent EVAR (46 pEVAR, 54 cEVAR). As expected, open repair had increased postoperative pain reported compared to EVAR (2.67 ± 0.75 vs. 0.96 ± 0.19, P < 0.01). Adjunctive epidural reduced postoperative pain for open repair (0.77 ± 0.48 vs. 3.50 ± 0.96, P < 0.01). EVAR had less postoperative opioid prescriptions compared to open repair (35.0% vs. 77.3%, P < 0.01). In the endovascular group, there was no difference between postoperative opioid prescription based on access, pEVAR versus cEVAR (65.8% vs. 80.1%, P = 0.11). When stratifying patients by number of cutdowns, patients with bilateral cutdown as opposed to a single cutdown received more opioid prescriptions than pEVAR patients (84.44% vs. 65.8%, P = 0.036). Of those receiving opioids, the average MME for open repair was 320.94 mg compared to 28.82 mg for EVAR (P < 0.01). Those undergoing percutaneous repair had significantly less MME use during hospitalization compared to femoral cutdown (17 ± 3.52 vs. 31.90 ± 5.43 mg, P < 0.01). Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ketorolac, were rarely used in the postoperative period for open or EVAR (8.3% vs 1.1%). Percutaneous EVAR patients reported less pain at discharge compared to cEVAR patients (0.18 ± 0.12 vs. 0.88 ± 0.29, P = 0.036). Open and EVAR had comparable low rates of NSAID and acetaminophen prescriptions at discharge. Open patients had longer postoperative length of stay compared to EVAR patients (9.82 ± 1.27 vs. 3.86 ± 0.47, P < 0.01). pEVAR had a shorter length of postoperative course compared to cEVAR (3.2 ± 0.26 vs. 4.12 ± 0.30, P < 0.01). Patients undergoing EVAR with use of pain medications amounting to <20 MME had a significantly shorter length of stay. CONCLUSIONS: This single institutional retrospective study evaluated pain prescription patterns for patients undergoing AAA repair. AAA patients are predominantly treated with opioid pain medications with few adjunctive therapies. Intraoperative epidural and pEVAR may aid in decreasing the total MME used; however, the total number of opioids prescribed is similar for pEVAR and cEVAR despite the difference in approach. Clinicians must consider alternative nonopioid based pain management strategies.