Workflow and Patient Satisfaction in Treating Peripheral Arterial Disease in the Office-Based Setting.

Contemporary concepts in health-care reform promote a shift in the provision of care away from hospitals in favor of the more cost-effective and efficient use of outpatient facilities including ambulatory surgery centers and office-based procedure centers particularly in the care of cardiovascular disease. This article reviews the experience of patients and specialists in caring for patients with peripheral arterial disease in an office-based care setting.

Initial experience with the ambulatory management of acute iliofemoral deep vein thrombosis with May-Thurner syndrome with percutaneous mechanical thrombectomy, angioplasty and stenting.

OBJECTIVE: Patients undergoing intervention for acute iliofemoral deep vein thrombosis (IFDVT) with May-Thurner syndrome (MTS) typically require inpatient (IP) hospitalization for initial treatment with anticoagulation and management with pharmacomechanical thrombectomy. Direct oral anticoagulants and percutaneous mechanical thrombectomy (PMT) devices offer the opportunity for outpatient (OP) management. We describe our approach with these patients. METHODS: Patients receiving intervention for acute IFDVT from January 2020 through October 2022 were retrospectively reviewed. Patients undergoing unilateral thrombectomy, venous angioplasty, and stenting for IFDVT with MTS comprised the study population and were divided into two groups: (1) patients admitted to the hospital and treated as IPs and (2) patients who underwent therapy as OPs. The two groups were compared regarding demographics, risk factors, procedural success, complications, and follow-up. RESULTS: A total of 92 patients were treated for IFDVT with thrombectomy, angioplasty, and stenting of whom 58 comprised the IP group and 34 the OP group. All 92 patients underwent PMT using the Inari ClotTriever (Inari Medical), intravascular ultrasound, angioplasty, and stenting with 100% technical success. Three patients in the IP group required adjuvant thrombolysis. There was no difference in primary patency of the treated IFDVT segment at 12 months between the two groups (IP, 73.5%; OP, 86.7%; P = .21, log-rank test). CONCLUSIONS: Patients with acute IFDVT and MTS deemed appropriate for thrombectomy and iliac revascularization can be managed with initiation of ambulatory direct oral anticoagulant therapy and subsequent return for ambulatory PMT, angioplasty, and stenting. This approach avoids the expense of IP care and allows for effective use of resources at a time when staffing and supply chain shortages have led to inefficiencies in the provision of IP care for nonemergent conditions.

Hybrid repair of aberrant right subclavian artery using open and endovascular techniques.

An aberrant right subclavian artery, the most common anatomic variant of the aortic arch, occurs in 0.5% of the population. Symptoms generally result from compression of the esophagus and/or trachea as the aberrant vessel passes posteriorly in the mediastinum. Treatment includes revascularization of the right subclavian artery from the right common carotid artery using a cervical approach combined with occlusion of the origin of the aberrant vessel from the thoracic aorta. We describe a hybrid treatment approach for a symptomatic aberrant right subclavian artery using cervical revascularization and branched thoracic stent graft coverage of the origin of the aberrant vessel.

Management with right atrium to jugular and brachiocephalic vein bypass for dialysis catheter-related superior vena cava syndrome.

Superior vena cava (SVC) syndrome is a spectrum of potentially life-threatening clinical manifestations resulting from either partial or complete obstruction of central venous blood flow. Approximately 70% of cases are caused by malignancy. The primary treatment end point for SVC syndrome is the achievement of long-term patency of the SVC. Malignant SVC syndrome is managed by either radiation therapy, open surgical intervention, or endovascular therapy with angioplasty and stenting. The current report describes an uncommon case of nonmalignant SVC syndrome resulting from complications of hemodialysis catheters that was managed with open revascularization between the right internal jugular and brachiocephalic veins and the right atrium.

Effect of Two Years of Doxycycline Treatment on Infrarenal Aortic Neck Diameter.

Objective: Endovascular aneurysm repair (EVAR) is a widely used option for patients with suitable vascular anatomy who have a large infrarenal abdominal aortic aneurysm (AAA). Neck diameter is the primary anatomical determinant of EVAR eligibility and device durability. Doxycycline has been proposed to stabilise the proximal neck after EVAR. This study explored doxycycline mediated aortic neck stabilisation in patients with small AAA, monitored by computed tomography over two years. Methods: This was a multicentre prospective randomised clinical trial. Subjects from the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT, NCT01756833) were included in this secondary a priori analysis. Female baseline AAA maximum transverse diameter was between 3.5 and 4.5 cm, and male was between 3.5 and 5.0 cm. Subjects were included if they completed pre-enrolment and two year follow up computed tomography (CT) imaging. Proximal aortic neck diameter was measured at the lowest renal artery, and 5, 10, and 15 mm caudal to this point; mean neck diameter was calculated from these values. Unpaired, two tailed parametric t test analysis with post hoc Bonferroni correction was used to detect differences between neck diameters in subjects treated with placebo vs. doxycycline at baseline and two years. Results: One hundred and ninety-seven subjects (171 male, 26 female) were included in the analysis. All patients, regardless of treatment arm, demonstrated larger neck diameter caudally, a slight increase in diameter at all anatomical levels over time, and greater growth caudally. There was no statistically significant difference in infrarenal neck diameter between treatment arms at any anatomical level at any time point, nor mean change in neck diameter over two years. Conclusion: Doxycycline does not demonstrate infrarenal aortic neck growth stabilisation in small AAA followed for two years by thin cut CT imaging using a standardised acquisition protocol and cannot be recommended for mitigation of growth of the aortic neck in patients with untreated small abdominal aortic aneurysms.

Outcomes of upper arm axillary artery and brachial artery arteriovenous grafts.

BACKGROUND: We compared the outcomes of upper arm arteriovenous grafts (AVGs) in a large, prospectively collected data set to determine if there are clinically significant differences in axillary artery-based and brachial artery-based AVGs. METHODS: Patients who received upper arm AVGs within the Society of Vascular Surgery Vascular Quality Initiative (VQI) dataset were identified. The primary outcome measures were primary and secondary patency loss at 12-month follow-up. Other outcomes included were wound infection, steal syndrome, and arm swelling at 6-month follow-up. The log-rank test was used to evaluate patency loss using Kaplan-Meier analysis, and Cox proportional hazards models were used to examine adjusted association between inflow artery (brachial artery vs axillary artery) and outcomes, adjusting for configuration (straight vs looped). RESULTS: Among 3637 upper extremity AVGs in the VQI (2010-2017), there were 510 upper arm brachial artery AVGs and 394 upper arm axillary artery AVGs. Patients with axillary artery AVGs were more likely to be female (72% vs 56%, p < 0.001) and underwent general anesthesia (61% vs 57%, p < 0.05). In univariable analysis, the 12-month primary patency (54% vs 63%, p = 0.03) and secondary patency (81% vs 89%, p = 0.007) were lower for axillary artery AVGs than upper arm brachial artery AVGs. In multivariable analysis, although wound infection and arm swelling were similar at 6-month follow up, axillary artery AVGs were more likely to have steal syndrome (adjusted Hazard Ratio (aHR) = 2.6, 95% Confidence Interval (CI) 1.2,5.6, p = 0.017). In addition, axillary artery AVGs were associated with higher rates of 12-month primary patency loss (aHR = 1.6, 95% CI 1.2-2.2, p = 0.002) and 12-month secondary patency loss (aHR = 2.0, 95% CI 1.3-3.3, p = 0.005). CONCLUSIONS: From this observational study analyzing the outcomes of upper extremity hemodialysis access, axillary artery AVGs were associated with significantly lower patency rates and higher risk of steal syndrome than brachial artery AVGs.

Acute Limb Arterial Ischemia Following Iliac Vein Stenting in the Setting of a Frozen Pelvis.

The authors report on a young patient with previous radiation to her pelvis who presented with acute limb ischemia following iliac vein stenting believed to be secondary to extrinsic iliac artery compression in the setting of a frozen pelvis. She underwent revascularization and a trans-femoral amputation, ultimately needing a femoral to femoral artery crossover bypass in order to achieve amputation stump healing. This case describes a potential arterial complication of venous stenting in a previously irradiated field.

The Use of Re-Entry Devices Through Pedal Arterial Access in the Management of Chronic Limb-Threatening Ischemia.

Infra-inguinal arterial chronic total occlusions remain a challenging scenario for the endovascular practitioner. Retrograde access has quickly become an essential tool in approaching such lesions, increasing the chances of crossing success. When antegrade and retrograde access techniques fail in achieving lesion crossing, re-entry devices have proven to be useful. Their use is however, somewhat limited by the size of the sheaths required to accommodate their passage. As newer and slimmer profiled sheaths become available, the possibilities of interventions available from minimally invasive approaches increases. We present 2 complex arterial revascularization cases that required intravascular ultrasound-based re-entry devices utilizing a pedal retrograde access.

Mycotic infrarenal aortic aneurysm due to mycobacterium after intravesical treatment for bladder cancer.

Intravesical instillation of Bacillus Calmette-Guerin, a live-attenuated strain of Mycobacterium bovis, is a common adjuvant therapy for bladder cancer with a low incidence of serious adverse events. The case described herein illustrates a rare complication of intravesical Bacillus Calmette-Guerin instillation that resulted from invasion of the mycobacterium into tissue outside of the bladder lining, also known as microbial dissemination, leading to infection of the aortic wall and development of a mycotic aneurysm, and highlights the therapeutic challenges presented by the aortic pathology in this clinical scenario.

A case of leiomyosarcoma of the common femoral artery.

Leiomyosarcomas are rare malignant tumors of smooth muscle cell origin with those originating from blood vessels accounting for <1%. We report the unusual case of a leiomyosarcoma originating in the wall of the common femoral artery, highlighting the management decisions for vascular tumors and providing a brief literature review for these unusual malignancies.

Hybrid Approach with Angiography and Limited Open Exposure to Treat Type Ia Endoleaks after Endovascular Aortic Aneurysm Repair.

BACKGROUND: Type Ia endoleaks after endovascular aortic repair (EVAR) almost always mandate secondary percutaneous reinterventions. Several patients, however, will require conversion to open surgical repair with complete graft explant, which is associated with significant morbidity and mortality. We herein present 3 cases of hybrid surgical repair for type Ia endoleaks, using a limited open exposure for proximal stent graft edge revision to achieve graft preservation and effective aneurysm sac exclusion. METHODS: Angiography was used to confirm type Ia endoleak in 3 patients (2 males) who had previous EVAR between October 2017 and October 2019. Time to the endoleak after the index EVAR was immediate in 1 patient during repair of a ruptured aneurysm, 2 months in 1 patient and 2 years in 1 patient. The aorta was exposed through a limited transabdominal (n = 1) or retroperitoneal (n = 2) approach and circumferential aortic control was achieved below the renal arteries. A row of interrupted horizontal mattress sutures of 3-0 polypropylene reinforced with Teflon pledgets was placed along the aortic neck circumference. Multi-planar angiography was then repeated to verify the absence of sac filling and successful type Ia endoleak exclusion. Follow-up abdominal duplex was obtained for all 3 patients after discharge to monitor the stent graft and confirm endoleak resolution. Furthermore, there were no instances of acute renal failure. RESULTS: In the period of review, 77 patients underwent EVAR. In the 3 patients described, we were able to achieve complete aneurysm sac exclusion and stent graft preservation in all cases. Follow-up imaging was available on 2 patients at 4-6 weeks after surgery demonstrating sustained exclusion of the endoleak. Two patients died during follow-up: one from a myocardial infarction 7 weeks after surgery and one from metastatic lung cancer at 8 months after surgery. Follow up duplex imaging at one year on the single survivor demonstrated sac shrinkage and absence of endoleak. CONCLUSIONS: Type Ia endoleaks represent a significant source of morbidity and mortality after EVAR and typically require repair to avoid aneurysm rupture. Our use of limited proximal revision without explant provides an alternative approach to resolve the endoleaks while reducing the magnitude of physiological stress when compared to an open explant. It represents a feasible option for high-risk patients.

The impact of hemoglobin A1c on outcomes after lower extremity bypass.

OBJECTIVE: Diabetes has been shown to be associated with increased risk of postoperative complications after lower extremity bypass (LEB), although it is unclear whether medium-term glucose control affects outcomes. This study aimed to assess the association of perioperative hemoglobin A1c (HbA1c) level on perioperative outcomes after LEB. METHODS: We examined consecutive infrainguinal LEBs for chronic limb-threatening ischemia (CLTI) using the Vascular Quality Initiative database (2007-2018). Perioperative HbA1c levels were stratified into <5.7%, 5.7% to 6.5%, and >6.5%. Propensity score matching on demographics, medical history, and procedural characteristics was used to select comparable patients across HbA1c groups. The primary outcome was postoperative wound infection. Multivariable analyses were performed for matched and unmatched groups using Cox proportional hazards models for survival outcomes and logistic regression for binary outcomes with association expressed by adjusted hazard ratio (aHR) or adjusted odds ratio (aOR) and corresponding 95% confidence intervals (CIs). RESULTS: The CLTI cohort included 8171 infrainguinal LEBs: 631 (7.7%) had HbA1c <5.7%; 1691 (20.6%), 5.7% to 6.5%; and 5849 (71.6%), >6.5%. There was no difference in rates of wound infection in the CLTI cohort (HbA1c ≤5.7%, 3.8%; HbA1c 5.7%-6.5%, 3.7%; HbA1c >6.5%, 3.2%; P = .53) or matched cohort (4.3%, 4.5%, 3.4%; P = .62). There were no differences in perioperative mortality in the CLTI cohort (2.5%, 1.7%, 1.5%; P = .16) or the matched cohort (2.7%, 2.3%, 2.2%; P = .84). In multivariable analysis, there was no significant association between HbA1c and wound infection in the CLTI cohort (HbA1c 5.7%-6.5% vs <5.7%: aOR, 0.91 [95% CI, 0.56-1.50; P = .72]; HbA1c >6.5% vs <5.7%: aOR, 0.81 [95% CI, 0.52-1.26; P = .35]). There was, however, a significant association between decreased HbA1c and mortality (HbA1c 5.7%-6.5% vs <5.7%: aHR, 0.77 [95% CI, 0.61-0.97; P = .03]; HbA1c >6.5% vs <5.7%: aHR, 0.75 [95% CI, 0.61-0.93; P = .01]). CONCLUSIONS: Our study suggests no significant association of increased HbA1c level and perioperative complications. Additional investigation is required to further evaluate the impact of short-term glycemic control and long-term outcomes of patients undergoing LEB.

Upper Arm Arteriovenous Grafts are Superior over Forearm Arteriovenous Grafts in Upper Extremity Dialysis Access.

BACKGROUND: In this study, we compared the outcomes of forearm arteriovenous grafts (AVGs) and upper arm AVGs in a large, prospectively collected data set, which represents real-world experience with upper extremity prosthetic dialysis access, to determine if there are clinically significant differences in the upper arm and forearm positions. METHODS: We identified 2,063 patients who received upper extremity AVGs within the Vascular Quality Initiative data set (2010-2018). Axillary to axillary upper arm AVGs were excluded (n = 394) from the analysis. The main outcome measures were primary and secondary patency rates at 12 months. Other outcomes were 6-month wound infection, steal syndrome, and arm swelling. The log-rank test was used to evaluate patency loss using a Kaplan-Meier analysis. Cox proportional hazards models were used to examine adjusted association between locations (forearm and upper arm) and outcomes. RESULTS: There were 1,160 forearm AVGs and 509 upper arm brachial artery AVGs in the study cohort. Patients with forearm AVGs were more likely to have a body mass index > 30 (45% vs. 38%, P = 0.013), no history of previous access (73% vs. 63%, P < 0.001), and underwent local-regional anesthesia (56% vs. 43%, P < 0.001). The 12-month primary patency (51.5% vs. 62.9%, P < 0.001) and secondary patency (76.4% vs. 89.1%, P < 0.001) were significantly lower for forearm AVGs. Wound infection, steal syndrome, and arm swelling were similar between forearm AVGs and upper arm AVGs at the 6-month follow-up. In multivariable analysis, the primary patency loss (adjusted hazard ratio (aHR) 1.66, 95% confidence interval (CI) 1.33-2.01, P < 0.001) and 12-month secondary patency loss (aHR 2.71, 95% CI 1.84-3.98, P < 0.001) were significantly higher for forearm AVGs at 12 months. CONCLUSIONS: From this observational study of the Vascular Quality Initiative data set, the primary and secondary patency rates were superior for upper arm brachial artery AVGs compared with forearm AVGs.

Mycotic aneurysm of the distal thoracic aorta after botulinum toxin injection for esophageal dysmotility.

Endoscopic injection of botulinum toxin is a common method to treat esophageal dysmotility and achalasia. Patients undergoing this procedure who subsequently present with abdominal or back pain and constitutional symptoms should be evaluated for possible complications of the procedure, including occult esophageal perforation, mediastinitis, and mycotic aneurysm of the thoracic aorta. The case described herein illustrates the importance of serial imaging in a patient with persistent symptoms after botulinum toxin injection to identify and to treat occult aortic inoculation leading to mycotic aneurysm before sepsis and aortic rupture ensue with their attendant morbidity and mortality risks.

Endothelial vascular cell adhesion molecule 1 is a marker for high-risk carotid plaques and target for ultrasound molecular imaging.

BACKGROUND: Molecular imaging of carotid plaque vulnerability to atheroembolic events is likely to lead to improvements in selection of patients for carotid endarterectomy (CEA). The aims of this study were to assess the relative value of endothelial inflammatory markers for this application and to develop molecular ultrasound contrast agents for their imaging. METHODS: Human CEA specimens were obtained prospectively from asymptomatic (30) and symptomatic (30) patients. Plaques were assessed by semiquantitative immunohistochemistry for vascular cell adhesion molecule 1 (VCAM-1), lectin-like oxidized low-density lipoprotein receptor 1, P-selectin, and von Willebrand factor. Established small peptide ligands to each of these targets were then synthesized and covalently conjugated to the surface of lipid-shelled microbubble ultrasound contrast agents, which were then evaluated in a flow chamber for binding kinetics to activated human aortic endothelial cells under variable shear conditions. RESULTS: Expression of VCAM-1 on the endothelium of CEA specimens from symptomatic patients was 2.4-fold greater than that from asymptomatic patients (P < .01). Expression was not significantly different between groups for P-selectin (P = .43), von Willebrand factor (P = .59), or lectin-like oxidized low-density lipoprotein receptor 1 (P = .99). Although most plaques from asymptomatic patients displayed low VCAM-1 expression, approximately one in five expressed high VCAM-1 similar to plaques from symptomatic patients. In vitro flow chamber experiments demonstrated that VCAM-1-targeted microbubbles bind cells that express VCAM-1, even under high-shear conditions that approximate those found in human carotid arteries, whereas binding efficiency was lower for the other agents. CONCLUSIONS: VCAM-1 displays significantly higher expression on high-risk (symptomatic) vs low-risk (asymptomatic) carotid plaques. Ultrasound contrast agents bearing ligands for VCAM-1 can sustain high-shear attachment and may be useful for identifying patients in whom more aggressive treatment is warranted.

The Influence of Temperature on Chytridiomycosis In Vivo.

Chytridiomycosis, an amphibian disease caused by the fungal pathogen Batrachochytrium dendrobatidis (Bd), is an ideal system for studying the influence of temperature on host-pathogen relationships because both host and pathogen are ectothermic. Studies of Bd in culture suggest that optimal growth occurs between 17 and 23°C, and death of the fungus occurs above 29 or below 0°C. Amphibian immune systems, however, are also temperature dependent and often more effective at higher temperatures. We therefore hypothesized that pathogen load, probability of infection and mortality in Bd-exposed frogs would peak at a lower temperature than that at which Bd grows best in vitro. To test this, we conducted a study where Bd- and sham-exposed Northern cricket frogs (Acris crepitans) were incubated at six temperatures between 11 and 26°C. While probability of infection did not differ across temperatures, pathogen load and mortality were inversely related to temperature. Survival of infected hosts was greatest between 20 and 26°C, temperatures where Bd grows well in culture. These results demonstrate that the conditions under which a pathogen grows best in culture do not necessarily reflect patterns of pathogenicity, an important consideration for predicting the threat of this and other wildlife pathogens.

Stent graft versus balloon angioplasty for failing dialysis-access grafts.

BACKGROUND: The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis. Balloon angioplasty, the first-line therapy, has a tendency to lead to subsequent recoil and restenosis; however, no other therapies have yet proved to be more effective. This study was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous anastomotic stenosis in failing hemodialysis grafts. METHODS: We conducted a prospective, multicenter trial, randomly assigning 190 patients who were undergoing hemodialysis and who had a venous anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft. Primary end points included patency of the treatment area and patency of the entire vascular access circuit. RESULTS: At 6 months, the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group (51% vs. 23%, P<0.001), as was the incidence of patency of the access circuit (38% vs. 20%, P=0.008). In addition, the incidence of freedom from subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32% vs. 16%, P=0.03 by the log-rank test and P=0.04 by the Wilcoxon rank-sum test). The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than in the stent-graft group (78% vs. 28%, P<0.001). The incidences of adverse events at 6 months were equivalent in the two treatment groups, with the exception of restenosis, which occurred more frequently in the balloon-angioplasty group (P<0.001). CONCLUSIONS: In this study, percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use of a stent graft, which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty. (ClinicalTrials.gov number, NCT00678249.)