External iliac artery extension causes greater aneurysm sac regression than the bell-bottom technique or iliac branch endoprosthesis for repair of concomitant infrarenal aortic and iliac artery aneurysm.

OBJECTIVE: Aneurysmal extension of abdominal aortic aneurysms (AAAs) to the common iliac artery (CIA) presents a technical challenge to successful endovascular abdominal aortic aneurysm repair (EVAR). In the present study, we compared sac shrinkage and perioperative outcomes after the bell-bottom technique (BBT), internal iliac artery embolization and external iliac artery extension (EIE), and iliac branch endoprosthesis (IBE). METHODS: Using the Vascular Quality Initiative database, a retrospective analysis was conducted for patients who had undergone EVAR from 2013 to 2019. The demographic, anatomic, and perioperative data were analyzed. All patients with a proximal aortic neck length <10 mm and aortic graft diameter >32 mm were excluded from the analysis. The patients were subdivided into four groups according to the distal limb strategy: group 1, control group with a bilateral common iliac artery limb <20 mm; group 2, BBT with either a unilateral or bilateral limb >20 mm; group 3, EIE technique; and group 4, IBE. The primary endpoint was the maximal change in the aortic diameter during follow-up. The secondary endpoints included postoperative complications and the rate of endoleak. RESULTS: The records for 14,455 patients who had undergone EVAR were queried and 5788 met the anatomic criteria. The average age was 73 years, and 86.3% were men. The maximal change in the aortic diameter in the control, BBT, IBE, and EIE groups was -7.2 mm, -6.1 mm, -4.6 mm, and -6.8 mm, respectively (P = .06). The differences were not statistically significant on univariate analysis at an average follow-up of 405 days. However, on multivariable analysis (P = .01), compared with the control group, the BBT and IBE groups were 18.4% (odds ratio [OR], 0.816; 95% confidence interval [CI], 0.68-0.98) and 48.0% (OR, 0.52; 95% CI, 0.33-0.82) less likely to experience aneurysmal shrinkage, respectively. In contrast, the EIE group showed no significant difference in shrinkage compared with that in the control group. Multivariable analysis of the groups also revealed that compared directly with the BBT group, the EIE group was 69.5% more likely to have experienced shrinkage in the aortic aneurysmal diameter (OR, 1.70; 95% CI, 1.05-2.75). The BBT and IBE groups had a significantly higher rate of type II endoleaks (17.63% and 16.95%, respectively; P = .03). The EIE group had a higher rate of type Ib endoleaks (1.9%) compared with the BBT (1.1%), IBE (1.7%), and control (0.3%) groups (P = .01). No differences were found between the groups in terms of postoperative myocardial infarction (P = .47) or respiratory (P = .61) or intestinal (P = .71) complications. However, the rates of limb complications and reoperation were higher in the EIE group. CONCLUSIONS: The present study revealed that the EIE technique was more likely to demonstrate shrinkage in the aortic aneurysmal diameter than were the BBT and IBE groups compared with the control group on multivariable analysis. The EIE technique was also more likely to result in aneurysmal sac shrinkage than was the BBT group, albeit with greater rates of limb-related complications.

Spinal Cord Ischemia following Simultaneous EVAR and TEVAR for Concomitant Thoracic and Abdominal Aortic Aneurysms.

BACKGROUND: In patients with abdominal aortic aneurysms, 10-20% has concomitant thoracic aortic pathologies. These are typically managed with staged endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) due to a perceived higher risk of spinal cord ischemia from a simultaneous intervention. We aimed to determine the outcomes of patients undergoing simultaneous EVAR and TEVAR for concomitant aneurysms. METHODS: A retrospective cohort study was performed using the Vascular Quality Initiative registry from December 2003 to January 2021. Patients undergoing same day EVAR and TEVAR were included and analyzed in accordance with the Society for Vascular Surgery reporting standards. Primary outcomes were technical success and spinal cord ischemia. RESULTS: Simultaneous EVAR and TEVAR were performed in 25 patients. Median age was 75.0 (interquartile range [IQR], 63.0-79.0) years and 20 (80.0%) patients were male. Two (4.0%) patients were symptomatic and 4 (16.0%) presented with rupture. Median maximum infrarenal and thoracic aortic diameter was 57.0 (IQR, 52.0-65.0). Infrarenal aortic neck length was 15.0 mm (IQR, 10.0-25.0), and diameter was 27.0 mm (IQR, 24.5-30.0). Median procedure time was 185.0 min (IQR, 117.8-251.3), fluoroscopy time 32.7 min (IQR, 21.8-63.1), and contrast volume 165 mL (IQR, 115.0-207.0). There were 3 (12.0%) Type Ia endoleaks and 3 (12.0%) Type II endoleaks in EVAR's, with 1 (4.0%) Type Ia and 1 (4.0%) Type II endoleak in TEVARs. In-hospital mortality occurred in 3 (12.0%) patients (1 elective, 2 ruptures). Spinal cord ischemia occurred in 1 (4.0%) patient. This patient had a symptomatic aneurysm. Thoracic coverage extended from Zone 4 to Zone 5 and an emergent spinal drain was placed postoperatively. Symptoms were present on discharge. There was 1 (4.0%) conversion to open repair which occurred in a ruptured aneurysm. Technical success was achieved in 19 (76.0%) patients, however when excluding ruptured aneurysms, was achieved in 17 (81.0%) patients. Follow-up data was available for 19 (76.0%) patients at a median of 426.0 (IQR, 329.0-592.5) days postoperatively. A total of 3 (12.0%) patients died during the late mortality period, at a mean of 509.0 (±503.7) days. Median change in abdominal and thoracic aortic sac diameter was -1.35 mm (IQR, -11.5 to 2.5) and 8.0 (IQR, -10.5 to 12.0), respectively. CONCLUSIONS: Simultaneous EVAR and TEVAR for concomitant abdominal and thoracic aortic aneurysms can be performed with low rates of spinal cord ischemia. Short- and mid-term outcomes are acceptable.

Periprocedural Outcomes of Popliteal vs Upper Extremity Access in the Treatment of Superficial Femoral Artery Occlusive Disease.

PURPOSE: Percutaneous lower extremity revascularization is being performed via upper extremity, pedal, or popliteal access with increasing frequency. This study aimed to compare periprocedural outcomes of popliteal (POA) and upper extremity (UEA) access for the treatment of isolated superficial femoral artery (SFA) occlusive disease. MATERIALS AND METHODS: A retrospective cohort study compared the outcomes of patients undergoing primary percutaneous intervention of SFA occlusive disease with POA or UEA using the Vascular Quality Initiative database from December 2010 to June 2019. Our primary endpoint was technical success. Secondary endpoints included factors associated with perioperative complications. RESULTS: A total of 349 patients underwent isolated SFA intervention through the popliteal, radial, or brachial artery. UEA was performed in 188 (53.9%) patients and POA in 161 (46.1%). Technical success with TASC A lesions was 95.8% and with TASC D lesions, 65.0%. POA had a higher proportion of TASC D lesions (24.8% vs 10.6%, p<0.001), and larger (≥7 Fr) sheath size (14.3% vs 2.7%, p<0.001). UEA had a higher proportion of no calcification (27.1% vs 11.2%, p<0.001), and smaller (4-5 Fr) sheath size (46.8% vs 34.8%, p=0.023). There was no difference in technical success between UEA and POA (88.8% vs 84.5%, p=0.230), which was also seen on multivariable analysis (p=0.985). Univariate analysis revealed technical failure was associated with TASC D lesions (45.7% vs 12.9%, p<0.001) and the presence of severe calcifications (39.1% vs 17.5%, p=0.002). Multivariable analysis confirmed technical failure was associated with degree of calcification (OR, 2.4; 95% CI, 1.18 to 4.89; p=0.016) and TASC D lesions (OR, 5.01; 95% CI, 2.45 to 10.24; p<0.001). Postoperative complications were associated with UEA on univariate (p=0.041) and multivariate analysis (OR, 2.08; 95% CI, 0.80 to 5.37; p=0.016). Access site complications were also associated with UEA compared to POA (4.3% vs 0.0%, p=0.027). CONCLUSIONS: There is no difference in technical success between UEA and POA when treating isolated SFA occlusive disease, and UEA is associated with a higher complication rate. Technical success is dependent on calcification and TASC II classification. Based on similar technical success rates and low complication rates, POA should be considered as a viable alternative to UEA when planning endovascular interventions.

A Systematic Review and Pooled Meta-Analysis on the Incidence and Temporal Occurrence of Type II Endoleak Following an Abdominal Aortic Aneurysm Repair.

BACKGROUND: The aim in this study was to systematically review the literature to identify the time of occurrence of a newly diagnosed Type II endoleak (T2E) following an endovascular aneurysm repair (EVAR) for an infrarenal abdominal aortic aneurysm (AAA) and its potential impact on aneurysmal sac diameter changes. METHODS: A comprehensive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane until January 2020. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity. RESULTS: Thirty-three observational studies were deemed eligible and provided data for 2643 T2E detected following EVAR. A total of 1432 (54.2%) T2E were diagnosed before 30 days follow-up, while 1035 (39.1%) T2E were diagnosed beyond 30 days following EVAR. A total of 222 (8.4%) T2E were diagnosed after 12 months of follow-up. A pooled meta-analysis of 6 studies, showed that early diagnosed T2E had a statistically significant higher odds of resolving as compared to those detected late (OR: 2.41; 95% CI: 1.14-5.09; P = 0.021; I2 = 68.9%). Sac expansion was documented in 313 (29%) T2E. The ruptured endoleaks were 14 (1.1%). CONCLUSIONS: The occurrence of a T2E is a dynamic process detected throughout the lifetime of a patient with 8% detected beyond 12 months following EVAR. Long-term follow up is required with future prospective studies with consist reporting on changes in sac diameter, the thrombus characteristics. Long-term outcomes are needed to optimize management of patients with a newly diagnosed T2E.

Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

Cross-clamp location affects short-term survival in patients undergoing open abdominal aortic aneurysm repair.

INTRODUCTION: Open abdominal aortic aneurysm (oAAA) repair in the era of advanced endovascular aortic techniques is used in challenging anatomy. The impact of the location of the proximal aortic cross-clamp (suprarenal [SR] vs infrarenal [IR]) on outcomes remains to be determined. The aim of this study was to analyze the effect of proximal aortic cross-clamp location on short-term and overall survival after oAAA repair in a contemporary series. METHODS: A retrospective cohort study was performed comparing the outcomes of patients undergoing oAAA repair with SR and IR aortic cross-clamping using the Vascular Quality Initiative registry from January 2003 to September 2018. Our primary end point was short-term mortality. RESULTS: There were 7601 patients who underwent oAAA repair. Their mean age was 69.3 ± 8.5 years and 5555 patients (73.1%) were male. The aortic cross-clamp location was IR in 4044 patients (53.2%). The SR group had increased maximum AAA diameter (58 mm vs 56 mm; P < .0001), hypertension (85.5% vs 82.0%; P < .0001), preoperative creatinine (1.11 vs 1.08; P = .001), and were more likely to be in American Society of Anesthesiologists class IV (37.4% vs 30.6%; P < .0001). Postoperative renal failure occurred significantly more often in the SR group (24.4 vs 11.4%; P < .0001). Short-term mortality was 2.7% in the IR group and 4.7% in the SR group (P < .0001). Kaplan-Meier survival estimates were 93.7% and 83.8% in the IR group and 90.9% and 81.2% in the SR group at 1 and 5 years, respectively (P = .007). Multivariable analysis demonstrated that SR cross-clamping was significantly associated with short-term mortality (hazard ratio, 1.38; 95% confidence interval, 1.07-1.78; P = .01); however, it did not affect overall survival (hazard ratio, 1.13; 95% confidence interval, 1.00-1.28; P = .06). CONCLUSIONS: A SR cross-clamp location is associated with an increased short-term mortality in patients undergoing oAAA repair. Overall survival is not affected by a SR cross-clamp location.

Embolization Techniques for Arteriovenous Malformations in Parkes-Weber Syndrome.

BACKGROUND: Multiple high-flow arteriovenous malformations (AVMs) are the hallmark of Parkes-Weber syndrome (PWS). Surgical resection has historically shown poor outcomes with PWS. The aim of this study was to assess the management of PWS in the current era. METHODS: A retrospective review was performed from 2004 to 2017 on all patients presenting to a single institution for the management of PWS. Presentation, techniques, complications, and outcomes were reviewed. RESULTS: Fourteen patients (50% male) with PWS were seen at our institution, and mean age was 19.9 years (range, 4.7-68.8). The lower extremity was affected in 12 (86%) and the upper extremity in 2 (14%) patients. All patients presented with pain and swelling in the affected limb. Seven (50%) patients presented with ulcers, of which 3 (43%) had extensive wounds. Five (36%) patients had echocardiographic evidence of high-output cardiac failure. All patients underwent angiography with the intention to treat. Three (21%) patients were found to have diffuse arteriovenous communication with no discrete AVM nidus and thus did not undergo intervention. The remaining 11 (79%) patients underwent transcatheter embolization of the AVM's arterial inflow. Six (55%) patients required multiple or staged inflow embolization procedures, with a mean of 3.3 (range, 1-10) interventions. Thirty-two arterial embolization procedures were performed in total. n-Butyl-2-cyanoacrylate (nBCA) adhesive was used in 22 (69%), microspheres in 8 (25%), and a combination of coils and nBCA adhesive in 2 (6%) cases. Technical angiographic success was seen in all patients. Six (55%) patients also had interventions to treat the venous component of the malformation, either concomitantly or during a separate procedure. This included radiofrequency ablation in 1 (17%), coil embolization in 1 (17%), sodium tetradecyl sulfate (STS) sclerotherapy in 2 (33%), and a combination of STS, coil embolization, and vein stripping in 2 (33%) patients. Ten (91%) patients experienced a partial response and 1 (9%) patient experienced no response to treatment. No patients had a complete response, as expected with the diffuse nature of this disease. There were no periprocedural complications. Two of 3 patients with complex wounds required major amputations for gangrene, including one above-knee and one below-knee amputation at 128 months and 66 months after the index procedure, respectively. CONCLUSIONS: AVMs in PWS can be successfully treated by a transcatheter approach. Multiple interventions are usually required. Patients with extensive wounds remain at risk for loss of limb.

Risk Factors for Postoperative Hypotension and Hypertension following Carotid Endarterectomy.

BACKGROUND: Patients undergoing carotid endarterectomy (CEA) often experience postoperative hemodynamic changes that require intravenous medications for hypo- and hypertension. Prior studies have found these changes to be associated with increased risks of 30-day mortality, stroke, myocardial infarction (MI), and length of stay (LOS). Our aim is to investigate preoperative risk factors associated with the need for postoperative intravenous medications for blood pressure control. METHODS: A retrospective review of an internally maintained prospective database of patients undergoing carotid interventions between January 2014 and March 2019 was performed. Demographic data, clinical history, and perioperative data were recorded. Carotid artery stents and reinterventions were excluded. Our primary end points were the need to intervene with intravenous medication for either postoperative hypotension [systolic blood pressure (SBP) <100 mm Hg] or postoperative hypertension (SBP >160 mm Hg). RESULTS: A total of 221 patients were included in the study after excluding those with a prior ipsilateral CEA or carotid artery stent. The mean age was 72.3 (±8.9) years, 157 (71%) patients were male, and 78 (35.3%) were Caucasian. Following CEA, 151 (68.3%) patients were normotensive, while 33 (14.9%) and 37 (16.7%) required medication for hypotension and hypertension, respectively. A univariate logistic regression identified 5 variables as being associated with postoperative blood pressure including race, history of MI, prior percutaneous transluminal coronary angioplasty (PTCA), statin use, and angiotensin-converting enzyme-inhibitor/angiotensin-receptor blocker (ARB) use. A stepwise regression selection found race, prior MI, and statin use to be associated with our primary end points. The hypertensive group was more likely to have a history of MI compared to the hypotensive and normotensive groups (40.5% vs. 27.3% vs. 18.5%, P = 0.02), PTCA (43.2% vs. 39.4% vs. 23.8%, P = 0.03), and statin use (94.6% vs. 93.9% vs. 78.8%, P = 0.01). Mean LOS was also the highest for the hypertensive group, followed by hypotensive and normotensive patients [2.0 (±1.6) vs. 1.8 (±2.4) vs. 1.3 (±0.8), P = 0.002]. Multivariable logistic regression demonstrated that non-Caucasian patients [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.26-5.86, P = 0.01] and those with a history of MI (OR 2.98, 95% CI 1.33-6.67) were more likely to have postoperative hypertension compared to patients who were Caucasian or had no history of MI. CONCLUSIONS: Postoperative hypertension is associated with non-Caucasian race and a history of MI. Given the potential implications for adverse perioperative outcomes including MI, mortality, and LOS, it is important to continue to elucidate potential risk factors in order to further tailor the perioperative management of patients undergoing CEA.

Complexity of Aortic Arch Anatomy Affects the Outcomes of Transcarotid Artery Revascularization Versus Transfemoral Carotid Artery Stenting.

BACKGROUND: Transcarotid artery revascularization (TCAR) has been shown to have half the rates of transient ischemic attack (TIA), stroke, and death compared with transfemoral carotid artery stenting (TFCAS). Successful outcomes of TFCAS require careful patient selection. The aim of this study was to determine the outcomes of TFCAS versus TCAR in both simple (type I) and complex (type II and III) aortic arches. METHODS: A retrospective cohort study was performed comparing the outcomes of patients undergoing TFCAS versus TCAR with simple and complex aortic arches using the Vascular Quality Initiative registry from August 2011 to May 2019. The primary outcome was a composite of in-hospital TIA/stroke/death. RESULTS: About 6,108 carotid artery interventions were analyzed, including 3,536 (57.9%) patients with type I, 2,013 (33.0%) with type II, and 559 (9.2%) with type III aortic arch. In 3,535 patients with a simple arch, 1,917 underwent TFCAS and 1,619 had TCAR. Mean age was 70.6 (±9.5) years, and 2,382 (67.4%) patients were males. The primary outcome of postoperative TIA/stroke/death was seen significantly less frequently in those undergoing TCAR compared with TFCAS in simple arches (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.43-0.94; P = 0.0236). Although the individual outcome of death occurred less often in TCAR (P = 0.0025), there was no difference in the occurrence of in-hospital stroke (P = 0.8836) or TIA (P = 0.4608). On multivariable analysis, TCAR was associated with improved outcomes (P = 0.0062). A worse outcome was associated with increasing age (P < 0.001), a prior stroke (P < 0.0001), and increasing number of stents (P = 0.0483). In 2,572 patients with a complex arch, 1,416 underwent TFCAS and 1,156 had TCAR. Mean age was 73.0 (±9.1) years, and 1,655 (64.4%) were males. In complex arch anatomy, the primary outcome of in-hospital TIA/stroke/death was seen significantly less frequently in TCAR compared with TFCAS (OR, 0.49; 95% CI, 0.31-0.77; P = 0.0022). Again noted was a significant difference in death, with better outcomes in TCAR (P = 0.0133). Although the occurrence of in-hospital TIA was no different between the 2 approaches (P = 0.6158), there were significantly fewer strokes in those treated with TCAR (P = 0.0132). TCAR (P = 0.0146) was associated with improved outcomes. A worse outcome was seen with advancing age (P = 0.0003), prior strokes (P = 0.01), and a left-sided lesion (P = 0.0176). CONCLUSIONS: TCAR has improved outcomes of TIA/stroke/death compared with TFCAS in both simple and complex aortic arch anatomy. In simple aortic arches, there is no difference in neurologic outcomes between both approaches. In complex arch anatomy, TCAR has fewer strokes.

Major Limb Amputations in Patients with Congenital Vascular Malformations.

BACKGROUND: The need for major amputations in patients with vascular malformations is rare. This study reviews our contemporary experience with major amputations in patients with vascular malformations. METHODS: A retrospective review from April 2014 to November 2018 identified 993 patients undergoing management of a vascular malformation involving the upper or lower extremity at a tertiary center. This population was analyzed to identify those requiring either a transfemoral or transhumeral amputation. This cohort was investigated for clinical course, surgical procedures, and outcomes. RESULTS: Five patients (0.5%) underwent major amputation, including 3 transhumeral and 2 above-knee amputations. The median age was 37.8 years (interquartile range (IQR): 25.4-40.2), and 2 (40%) were male. Four (80%) patients had high-flow arteriovenous malformations, including 1 (20%) with Parkes-Weber syndrome. One (20%) patient had a low-flow venous malformation associated with Klippel-Trénaunay syndrome. All patients had malformation extending into the chest or pelvis, with the amputation being at the level of residual malformation. As such, amputation had been initially felt to be high risk because of the proximal extent of the lesions. Before amputation, a median of 11 procedures (IQR: 4-39) were performed per patient. This included 29 transarterial embolizations, 4 transvenous embolizations, 20 direct stick embolizations, 3 debulking procedures, 38 debridements, 6 skin grafts or muscle flaps, and 4 minor amputations. The median time course of treatment before amputation was 117 months (IQR: 44-171). Indications for major amputation included chronic pain and recurrent bleeding in all 5 (100%) patients, loss of function in 2 (40%), nonhealing wounds in 2 (40%), and sepsis in 1 (20%) patient. There were no perioperative deaths. The median blood loss was 1,000 mL (IQR: 650-2,750). All patients required transfusion of packed red blood cells with a mean of 1.6 units (standard deviation: 0.54). Transhumeral amputation was facilitated by transcatheter embolization in 1 (33%) and an occlusion balloon within the subclavian artery in 2 (66%) patients. The median length of stay was 6 days (IQR: 5-13). The median length of follow-up was 132 months (IQR: 68-186) from initial intervention and 12 months (IQR: 8-31) from amputation. Two patients (40%) who had undergone transhumeral amputation required revision of the amputation site for recurrent ulceration at 2 and 38 months. Of these, 1 patient underwent 3 transcatheter embolization procedures before revision and 1 underwent 1 embolization after revision. CONCLUSIONS: Although rare, successful amputation at the level of residual malformation can be performed in select patients with refractory complications of vascular malformations including intractable pain, bleeding, or nonhealing wounds. Specific preoperative and intraoperative measures may be critical to achieve satisfactory outcomes, and endovascular techniques continue to play a role after amputation.

Management of isolated femoropopliteal in-stent restenosis.

OBJECTIVE: The optimal catheter-directed therapy for femoropopliteal in-stent restenosis (ISR) remains controversial with limited durability. The natural history of untreated ISR is not well characterized. We evaluated the midterm outcomes of patients with asymptomatic isolated femoropopliteal ISR who were observed under a surveillance program. METHODS: Patients treated with isolated femoropopliteal stents from January 2009 to December 2013 were retrospectively investigated for the development of ISR. ISR was classified on the basis of duplex ultrasound criteria, with >50% defined as peak systolic velocity (PSV) twice that of the normal vessel and >75% as PSV >400 cm/s or four times the normal PSV. Asymptomatic patients with ISR of >50% were tracked for progression to high-grade (>75%) stenosis, occlusion, need for reintervention, and amputation. RESULTS: Asymptomatic ISR of >50% was identified in 62 (15.3%) of 402 patients with isolated femoropopliteal stents. The mean time for development of ISR was 22.1 (±20.1) months. The mean age was 72 (±9.7) years, and 34 (55.7%) patients were female. Thirty-one (50%) patients were diabetic, 18 (29.1%) were smokers, and 8 (12.9%) had chronic kidney disease. Indications for treatment were claudication in 49 (79.0%), tissue loss in 9 (14.5%), and rest pain in 4 (6.4%) patients. TransAtlantic Inter-Society Consensus (TASC) A lesions were treated in 13 (21%) patients, TASC B lesions in 24 (38.7%), and TASC C lesions in 25 (40.3%). Three-vessel runoff was identified in 25 (40.3%) patients, two-vessel runoff in 18 (29.0%), and one-vessel runoff in 19 (30.6%). Under surveillance, ISR of >50% progressed to >75% or occlusion in 20 (32.3%) patients. The mean time to progression was 17.4 months, and the mean overall follow-up was 33.1 months. Reintervention was required in 22 (35.0%) patients, with an average of 1.95 (range, 1-4) interventions per patient. Reintervention was undertaken in 19 (86%) patients for claudication and in 3 (18%) patients for critical limb ischemia. One patient required an amputation despite previous reintervention for progression. Progression to >75% stenosis was predictive of need for reintervention (P = .004). CONCLUSIONS: Under a surveillance program, asymptomatic patients with femoropopliteal ISR of >50% may be observed with a low risk of limb loss. Given the slow rate of progression and the poor durability of reintervention, surveillance with delayed intervention may be warranted.

Outcomes of thoracic endovascular aortic repair for chronic aortic dissections.

BACKGROUND: Open surgical repair remains the "gold standard" treatment for chronic type B aortic dissection (cTBD) with aneurysm. Thoracic endovascular aortic repair (TEVAR) has gained popularity in recent years for the treatment of thoracic aortic diseases, including cTBD. We assessed the effectiveness of TEVAR in the treatment of cTBD using the Vascular Quality Initiative (VQI) database. METHODS: The VQI registry identified 4713 patients treated with TEVAR from July 2010 to November 2015, including 125 repairs for cTBD. We analyzed TEVAR outcomes in this cohort per the Society for Vascular Surgery reporting standards for TEVAR. RESULTS: Median age was 65.0 years (interquartile range [IQR], 56.0-72.0 years), and 85 (68.0%) were male. Median aneurysm diameter was 5.5 cm (IQR, 4.8-6.3 cm). Sixty-two (49.6%) patients were asymptomatic on presentation, 57 (45.6%) were symptomatic, and 6 (4.8%) presented with rupture. Median length of stay was 8.0 days (IQR, 4.0-11.0 days). Fluoroscopy time was 17.3 minutes (IQR, 10.5-25.6 minutes). The distal landing zone was aortic zone 4 in 27 (21.6%) and aortic zone 5 and distal in 98 (78.4%) patients. Successful device delivery occurred in 123 (98.4%) patients. Conversion to open repair occurred in one (0.8%) patient. A type IA endoleak was present in 2 (1.6%), type IB endoleak in 2 (1.6%), and type II endoleak in 2 (1.6%) patients. Perioperative complications included stroke in 1 (0.8%), respiratory complications in 6 (4.8%), and spinal cord ischemia symptoms present at discharge in 3 (2.4%) patients. In-hospital mortality occurred in three (2.4%) patients. Reintervention was required in two (1.6%) patients for false lumen perfusion and in two (1.6%) patients for extension of the dissection. Follow-up was available for 43 patients at a median time of 239 days (IQR, 38-377 days). Median change in sac diameter was -0.2 cm (IQR, -0.5 to 0.1 cm). Sac shrinkage of 0.5 cm was noted in 12 (27.9%), with sac growth >0.5 cm in four (9.3%) patients. Extent of stent graft coverage did not affect sac shrinkage (P = .65). Patients with aneurysms ≥5.5 cm compared with <5.5 cm were more likely to demonstrate shrinkage (-0.6 cm vs 0.0 cm; 95% confidence interval, 0.3-11.7; P = .04). CONCLUSIONS: TEVAR for cTBD may be performed with acceptable rates of morbidity and mortality. Changes in sac diameter in the midterm are promising. Long-term data are needed to determine whether this approach is durable.

Occluded Superficial Femoral and Popliteal Artery Stents Can Have a Negative Impact on Bypass Target.

PURPOSE: To identify whether occluded femoropopliteal stents influence previously available lower extremity bypass (LEB) targets. METHODS: Among 621 consecutive patients who had undergone stenting of a superficial femoral artery or popliteal artery lesion from January 2009 to December 2013, 30 patients (mean age 69.9±10.2 years; 16 women) were found to have occluded stents. Angiograms before stent placement were analyzed to determine what would have been the optimal distal bypass site, which was compared with the angiogram following stent occlusion. RESULTS: Seven (22%) limbs lost the bypass target. In one limb, the target changed from above-knee to below-knee popliteal, in 2 limbs from above-knee popliteal to tibial, and in 4 limbs from below-knee popliteal to tibial artery. Eleven (34%) limbs required LEB during follow-up. Chronic obstructive pulmonary disease (p=0.007), chronic renal insufficiency (p=0.026), a popliteal artery stent (p=0.001), and the below-knee popliteal artery as an optimal bypass target (p=0.026) were associated with loss of bypass target following stent occlusion. CONCLUSION: Superficial femoral artery and popliteal artery stent occlusion can affect target vessels in patients who may require subsequent LEB. This should be considered when performing stenting.

Outcomes of open surgical repair for chronic type B aortic dissections.

OBJECTIVE: Open surgical repair (OSR) for chronic type B aortic dissection (CTBAD) has an associated morbidity and mortality. The role of thoracic endovascular aortic repair (TEVAR) in CTBAD has not been determined. We analyzed our contemporary experience of CTBAD undergoing OSR to identify high-risk patients who may be considered for TEVAR. METHODS: From 1999 to 2010, 221 patients had repair of descending thoracic and thoracoabdominal aortic aneurysms, including 86 patients with CTBADs. We analyzed this cohort for mortality, complications, length of stay, and reinterventions. RESULTS: OSR was performed in 25 (29%) and 61 (71%) patients for descending thoracic and thoracoabdominal CTBAD, respectively. Median age was 57.0 years (interquartile range [IQR], 52.0-64.2 years), and median diameter was 6.0 cm (IQR, 5.0-6.9 cm). Fifty-nine patients (69%) were male. Eight (9%) were treated for rupture. Follow-up duration was 4.6 years (IQR, 2.8-6.9 years). Hospital mortality occurred in five patients (5.8%). Cardiopulmonary bypass was used in 83 patients (97%) and deep hypothermic arrest in 36 (42%). Two patients (2.3%) each developed paraplegia, stroke, and renal failure requiring permanent hemodialysis in the postoperative period. Length of stay was 13.5 days (IQR, 10.0-21.0 days). Univariate predictors of hospital death included redo operations and prolonged pump time (P < .05). Six patients (7%) had aortic-related reoperations at 4.3 years (IQR, 2.7-5.2 years): one for an ascending aortic aneurysm and five for descending aortic aneurysms. Overall survival at 1, 5, and 7 years was 92%, 83%, and 70%, respectively, and freedom from reoperation was 99%, 90%, and 86%, respectively. CONCLUSIONS: OSR of CTBAD is a durable option with low mortality. Patients requiring redo operations or anticipated prolonged pump time need further evaluation to determine whether conventional OSR or TEVAR, if feasible, is the optimal treatment option.

Stent-graft limb deployment in the external iliac artery increases the risk of limb occlusion following endovascular AAA repair.

PURPOSE: To assess whether deployment of an endograft limb in the external iliac artery (EIA) increases the rate of limb occlusion following endovascular aneurysm repair (EVAR). METHODS: Interrogation of a prospectively maintained database identified 661 patients (596 men; median age 73 years, range 37-93) with infrarenal abdominal aortic aneurysm who underwent EVAR between 1996 and 2010 using Zenith stent-grafts predominately. Of these, 567 patients [56 (9.9%) women] had both endograft limbs deployed in the CIA (1203 limbs at risk), while 94 patients [9 (9.6%) women] had at least 1 limb in the EIA (22 bilateral; 116 limbs at risk). An adjunctive bare metal stent was used in 8 (9%) limbs deployed in the EIA. RESULTS: There were 31 limb occlusions, all unilateral: 17 (3%) patients in the CIA group had an occluded limb (1% of limbs at risk) vs. 14 (15%) patients in the EIA group (12% of limbs at risk; p<0.0001). The median time to occlusion was 3 months (0-60) in the CIA group and 1 month (0-36) in the EIA group. The majority of occlusions were treated by extra-anatomical revascularization, most often a femorofemoral crossover bypass. No legs were amputated following occlusion of a limb placed in the CIA, but there were 3 amputations in the EIA group (p=0.003). CONCLUSION: Deployment of endograft limbs into the EIA led to a higher rate of occlusion and leg amputation. Increased tortuosity of the EIA and a smaller caliber vessel are likely to account for the increased risk.

Single versus Multiple Vessel Endovascular Tibial Artery Revascularization for Critical Limb Ischemia: A Review of the Literature.

Vascular interventionalists have long debated on whether one or multiple patent tibial arteries (run-off) are necessary to treat critical limb ischemia, including ischemic rest pain and tissue loss. This review article seeks to clarify data surrounding this topic by including literature from retrospective studies, prospective studies, meta-analyses, and randomized controlled trials. Our conclusion is that revascularizing a single tibial artery to the foot is adequate for wound healing.

Management of the Left Subclavian Artery in TEVAR for Chronic Type B Aortic Dissection.

OBJECTIVES: Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD. METHODS: The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards. RESULTS: Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident (P = .16), spinal cord ischemia (P = 1.00), or death (P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04). CONCLUSIONS: Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.

Extreme obesity is associated with angulation during inferior vena cava filter placement.

BACKGROUND: Placement of inferior vena cava (IVC) filters can be complicated by venous injury, filter misplacement, angulation, insertion site injury, and procedure-related death. Currently, no studies exist evaluating the correlation between obesity and adverse outcomes of IVC filters. We aimed to assess the outcomes of IVC filter placement in the obese population using the Vascular Quality Initiative database. METHODS: The Vascular Quality Initiative registry identified 7258 patients who underwent IVC filter placement from January 2013 to June 2017. Patients were divided into three groups based on their body mass index (BMI): normal/overweight (BMI <30), obese (BMI 30-40), and extremely obese (BMI >40). Periprocedural outcomes were analyzed. RESULTS: The mean age was 63.6 ± 16.6 years and 3444 patients (47%) were female. BMI was less than 30 in 4115 (56.7%), 30 to 40 in 2148 (29.6%), and greater than 40 in 995 (13.7%) patients. A complication or IVC filter-related death occurred in 142 patients (2.6%). Adverse events included angulation (1.3%), IVC filter misplacement (0.5%), insertion site injury (0.3%), IVC filter-related death (0.1%), and venous injury (0.06%). In multivariable analysis, increased BMI was found to be associated with angulation (P = .03), but was not associated with IVC filter misplacement (P = .43), or any complication or IVC filter-related death (P = .22). A subgroup analysis of IVC filter placements using only fluoroscopy demonstrated that the risk of angulation was significantly higher in patients with a BMI of greater than 40 compared with a BMI of less than 30 (odds ratio, 2.12; 95% confidence interval, 1.07-4.21; P = .03). There was not enough evidence to conclude that BMI was associated with any other outcome. CONCLUSIONS: IVC filter insertion has low complication rates. Increased BMI is associated with an increased risk of IVC filter angulation; there is no evidence of association between BMI and other periprocedural complications.

Arteriovenous Malformations: Syndrome Identification and Vascular Management.

PURPOSE OF REVIEW: Vascular malformations represent a poorly understood set of conditions that create considerable diagnostic and therapeutic confusion. Historically, extensive surgical resections yielded poor results. More recently, the treatment paradigm has shifted to endovascular therapy such that embolization and sclerotherapy are now considered the first line of treatment. Although there is still a role for traditional surgical techniques, it is now most commonly integrated with endovascular therapies in a hybrid fashion. The goal of this review is to provide a greater understanding of the diagnosis and treatment of vascular malformations. RECENT FINDINGS: Vascular malformations can be high-flow (arteriovenous shunting) or low-flow (venous or lymphatic). Clinical presentation and treatment is different for each. Treatment of high-flow lesions must be directed at reducing or eliminating the nidus, usually via super-selective catheterization and embolization. Low-flow lesions are usually treated by direct injection of sclerosing agents under fluoroscopic or ultrasound guidance. The cornerstone of managing patients with vascular malformations is making the proper diagnosis, which is often challenging. Even after a diagnosis is made, therapy itself may be challenging and generate frustration among patients and providers. Frequently, the treatment of vascular malformations is characterized by only slow and incremental improvements without complete lesion eradication. By combining a thorough understanding of the vascular malformation disease process with an array of endovascular techniques, vascular interventionalists may contribute greatly to the care of these patients.