Clinical Implications of Low Body Mass Index on Endovascular Lower Extremity Revascularization.

BACKGROUND: The epidemic of obesity and associated cardiovascular morbidity continues to grow, attracting public attention and healthcare resources. However, the impact of malnutrition and being underweight continues to be overshadowed by obesity, especially in patients with peripheral arterial disease (PAD). This study assesses the characteristics and outcomes of patients with low body mass index (BMI ≤ 18.5) compared to patients with nonobese BMI undergoing peripheral vascular interventions (PVI). METHODS: A retrospective analysis of patients undergoing PVI due to PAD registered in the Vascular Quality Initiative database. Patients were categorized into underweight (BMI ≤ 18.5) and nonobese BMI (BMI = 18.5-30). Patients in both groups were matched 3:1 for baseline demographic characteristics, comorbidities, medications, and indications. Kaplan-Meier analysis was done for long-term outcomes. RESULTS: A total of 337,926 patients underwent PVI, of whom 12,935 (4%) were underweight, 215,728 (64%) were nonobese, and 109,263 (32%) were obese. Underweight patients were more likely to be older, female, smokers, with chronic obstructive pulmonary disorder, and more likely to present with chronic limb-threatening ischemia than nonobese patients. After propensity matching, there were 18,047 nonobese patients and 6,031 underweight patients. There were no significant differences in matched characteristics. Perioperatively, underweight patients were more likely to require a longer hospital length of stay. Underweight patients had statistically significantly higher 30-day mortality compared to patients with nonobese BMI (3% vs. 1.6%, P < 0.001) and a higher rate of thrombotic complications. As for long-term outcomes, underweight patients had a higher rate of reintervention (20% vs. 18%, P < 0.001) and major adverse limb events (27% vs. 22%, P < 0.001). The 4-year rate of amputation-free survival was significantly lower in underweight patients (70% vs. 82%, P < 0.001), and the 2-year freedom from major amputation (90% vs. 94%, P < 0.001) showed similar trends with worse outcomes in patients who were underweight. CONCLUSIONS: Underweight patients with PAD are disproportionally more likely to be African American, females, and smokers and suffer worse outcomes after PVI than PAD patients with nonobese BMI. When possible, increased scrutiny and optimization of nutrition and other factors contributing to low BMI should be addressed prior to PVI.

Perioperative complications of minor and major reinterventions for peripheral arterial disease.

INTRODUCTION: Patients with peripheral arterial disease (PAD) frequently require reinterventions after lower-extremity revascularization (LER) to maintain perfusion. Current Society for Vascular Surgery guidelines define reinterventions as major or minor based on the magnitude of the procedure. While prior studies have compared primary LER procedures of different magnitudes, similar studies for reinterventions have not been performed. The objective of this study is to compare perioperative outcomes associated with major and minor reinterventions. METHODS: Patients undergoing LER for PAD at a tertiary care center from 2013 to 2017 were included. A retrospective review of electronic medical records was performed, and reinterventions were categorized as major or minor based on the procedure magnitude. Minor reinterventions included endovascular procedures and open revision with patch angioplasty, while major reinterventions were characterized by open surgical or endovascular LER with catheter-directed thrombolysis (CDT). Perioperative outcomes following LER were captured and compared for major and minor reinterventions. An additional subgroup analysis was performed comparing outcomes associated with major reinterventions stratified into open major surgical reinterventions and CDT. RESULTS: This study included 713 patients over a mean follow-up of 2.5 years. A total of 291 patients underwent 696 ipsilateral reinterventions (range = 1-12 reinterventions). Most reinterventions were minor (72.1%, N = 502) and 27.9% (N = 194) were major. Patients receiving reinterventions had an average age of 67.2 ± 11.5 and most were white (73.5%) males (60.1%) initially treated for claudication (58.2%) and CLTI (41.8%). There was significantly higher post-operative bleeding (9.8% vs 3.4%, p = .001), arterial thrombosis (3.1% vs 1.0%, p = .047), and acute renal failure (6.2% vs 2.4%, p = .014) after major reinterventions than minor. Additionally, major reinterventions had significantly higher return to the OR (17.0% vs 11.3%, p = .046) and longer hospital stays (7.5 vs 4.3 days, p = <.0001). Overall, major reinterventions were associated with significantly increased perioperative morbidity (37.6% vs 19.7%, p ≤ .001) with no difference in perioperative mortality. In the subgroup analysis, open reinterventions resulted in significantly longer hospital stays (8.6 days vs 5.5 days, p ≤ .001) and more wound infections than CDT (11.0% vs 0%, p = .017). However, there was no other significant difference in morbidity or mortality following treatment with open surgical reinterventions or CDT. CONCLUSIONS: In this study, major reinterventions after LER were associated with greater perioperative morbidity than minor reinterventions, with no difference in mortality. Major reinterventions performed via open surgery and CDT had similar morbidity and mortality.

Long-term limb salvage and functional outcomes for patients undergoing partial calcanectomy.

INTRODUCTION: Partial calcanectomy (PC) can be performed to treat chronic heel ulcers in patients with calcaneal osteomyelitis. Patients undergoing PC often have multiple comorbidities, limited mobility, and face high risk of major limb amputation. This study examined the extent of vascular diagnostic testing and interventions as well as long-term outcomes in patients undergoing PC. METHODS: A retrospective analysis was performed on patients who underwent PC for non-healing calcaneal ulcer over a ten-year period. Demographics, comorbidities, vascular testing, and procedural data were recorded. Additional subgroup analysis was performed according to presence or absence of peripheral arterial disease (PAD). Primary outcomes were major limb amputation (above or below the knee) and mortality. Secondary outcomes included successful wound healing, time to complete wound healing, re-interventions, and change in ambulatory status. RESULTS: A total of 157 patients underwent partial calcanectomies on 162 limbs. 78.3% of patients had diabetes mellitus and 47.8% were diagnosed with PAD. Ankle brachial index with pulse volume recording (ABI/PVR) was performed for 46.5% (73/157) of patients, arterial duplex in 44.6% (70/157), and 19.7% (31/157) had a computed tomography angiogram. Lower extremity revascularization was performed in 28.4% of limbs (46/162). Independent ambulatory status was reported in 40.1% prior to PC and decreased to 17.9% by the time of last recorded follow-up (p < .00001). Long-term amputation-free survival was significantly higher in patients without PAD at 7 years (78.4% vs 57.1%, p = .02). Multivariate logistic regression analysis demonstrated that PAD and end-stage renal disease (ESRD) increased the odds of major limb amputation (OR 3.5 and 2.8, respectively), whereas ESRD and adjuvant podiatric procedures were associated with increased mortality (OR 4.8 and 4.8, respectively). CONCLUSION: Non-invasive vascular testing should be obtained in all patients undergoing PC, in order to stratify risk of amputation and identify candidates for revascularization. Over the long-term, patients undergoing PC face significant risk of prolonged wound healing, decline in ambulatory status, and major limb amputation.

Comparative Analysis of Mortality and Amputation Rates in Patients Undergoing Atherectomy for Infra-Popliteal Peripheral Arterial Disease: Insight From the VQI.

INTRODUCTION: Infra-popliteal peripheral arterial disease (IPPAD) poses challenges due to high restenosis and occlusion rates. The BASIL-2 trial demonstrated the superiority of endovascular treatment compared with surgical bypass in patients with IPPAD. However, the association between different endovascular modalities and clinical outcomes has not been conclusive. HYPOTHESIS: Combining plain old balloon angioplasty (POBA) with atherectomy is associated with improved clinical outcomes compared with POBA alone. METHODS: Patients who underwent POBA vs POBA+atherectomy for IPPAD from the Vascular Quality Initiative database were identified. To mitigate potential selection bias, we employed propensity score matching (PSM) to balance the distribution of confounding variables for mortality identified on multivariable logistic regression. Subsequently, we compared patient characteristics and long-term outcomes between the 2 treatment groups. RESULTS: Among patients who underwent endovascular intervention for IPPAD, 19 979 individuals (80.8%) were treated with POBA alone, while 4747 (19.2%) were treated with both POBA+atherectomy after PSM. Propensity score matching ensured minimal differences in baseline characteristics, such as indication for lower extremity revascularization (LER) and history of LER. After PSM, patients receiving POBA+atherectomy experienced higher rates of technical success and lower perioperative complications, such as renal complications and hematoma, compared with POBA alone. During long-term follow-up, patients who underwent atherectomy had lower rates of major amputation and major adverse limb events (MALE) but slightly lower freedom from reintervention. Nonetheless, there were no differences in mortality. CONCLUSION: Combining POBA with atherectomy appears to be a safe approach in patients with IPPAD, with lower rates of long-term amputation and MALE at the cost of a higher risk of reintervention. CLINICAL IMPACT: The use of adjunctive atherectomy is associated with improved long-term outcomes in patients with infra-popliteal disease.

Systematic review of inferior vena cava atresia.

OBJECTIVE: Inferior vena cava (IVC) atresia is a rare venous anomaly characterized by absence of the IVC. It has been associated with deep vein thrombosis (DVT) and other congenital anomalies. The aim of the present study is to provide a comprehensive summary of the literature on IVC atresia and discuss the presentation and outcomes of patients with IVC atresia. METHODS: A systematic review of the English literature up to April 2020 was performed. The presentations and treatments reported were noted and compared between the two sexes. The IVC atresia cases were further stratified into isolated IVC atresia and IVC atresia associated with other congenital anomalies. RESULTS: A total of 412 abstracts were screened, with 178 reports included. A total of 376 patients were analyzed. Overall, males seem to be more affected than females, with a ratio of almost 2:1 (male, 227 [64.1%]; vs female, 127 [35.8%]). However, females were more likely to have congenital IVC atresia compared with males (46.1% vs 21.3%; P < .001). The mean age at presentation was 27.9 ± 18.0 years (range, 0-77 years), with no differences between the sexes. Most patients with IVC atresia presented with DVT (n = 242 of 376; 64.3%), with the iliac veins most often affected (n = 159 of 242; 65.7%). No difference was found in the reported proportion of patients presenting with DVT between the two sexes. The symptom presentation was similar, with leg pain and swelling the most common in both sexes. The patients were treated either medically with anticoagulation or surgically (open or endovascular). No mortality was reported with isolated IVC atresia in either treatment group. However, the mortality of patients with IVC atresia associated with other congenital anomalies was 11.7%. CONCLUSIONS: IVC atresia is more common in males but seems to have a predilection for females in the setting of other congenital anomalies. Most patients present with leg pain and swelling related to the development of DVT. Open and endovascular surgical interventions to treat IVC atresia have been reported in 18.3% of patients reviewed, with acceptable mid-term results in terms of patency and symptomatic relief.

Effect of inferior vena cava filter placement position on device complications.

BACKGROUND: Indwelling inferior vena cava (IVC) filters can cause complications, including penetration into surrounding structures, migration, and thrombosis of the vena cava. Computational fluid dynamics suggests juxtarenal placement of IVC filters decreases the risk of thrombosis; however, this has not been explored clinically. The present study examines the effect of filter placement position on long-term device complications with an emphasis on IVC thrombosis. We hypothesized that IVC filters placed further caudal to the renal veins were more likely to develop long-term thrombosis. METHODS: A retrospective review of the medical records of patients receiving IVC filters at a single tertiary center between 2008 and 2016 was performed. Patients missing follow-up or procedural imaging data were excluded. The placement procedure venograms were reviewed, and the distance from the filter apex to the more inferior renal vein was measured using reported IVC filter lengths for calibration. The patients were divided into three groups according to the tip position relative to the more inferior renal vein: at or superior (group A), 1 to 20 mm inferior (group B), and >20 mm inferior (group C). The patient and procedural characteristics and outcomes were compared between the three groups. The primary end points were IVC thrombosis and device-related mortality. RESULTS: Of 1497 eligible patients, 267 (17.8%) were excluded. The most common placement position was group B (64.0%). The mean age was lowest in group C, followed by groups A and B (age, 59.5 years, 64.6 years, and 62.2 years, respectively; P = .003). No statistically significant differences were found in the distribution of sex or the measured comorbidities. Group C was the most likely to receive jugular access (group C, 71.7%; group A, 48.3%; group B, 62.4%; P < .001) and received more first-generation filters (group C, 58.5%; group A, 46.6%; group B, 52.5%; P = .045). The short-term (<30-day) and long-term (≥30-day) outcomes, including access site hematoma, deep vein thrombosis, and pulmonary embolism, were uncommon, with no differences between the groups. Cases of symptomatic filter penetration, migration, and fracture were rare (one, one, and three cases, respectively). Although a pattern of increasing thrombosis with more inferior placement was found, the difference between groups was not statistically significant (group A, 1.5%; group B, 1.8%; group C, 2.5%; P = .638). No cases of device-related mortality occurred. All-cause mortality after a mean follow-up of 2.6 ± 2.3 years was 41.3% and did not vary significantly between the groups (P = .051). Multivariate logistic regression revealed that placement position did not predict for short- or long-term deep vein thrombosis, pulmonary embolism, IVC thrombosis, or all-cause mortality after adjustment for the baseline patient characteristics. CONCLUSIONS: IVC filters have low rates of short- and long-term complications, including IVC thrombosis. The placement position did not affect the occurrence of device complications in this study.

Arterial Diameter and Percentage of Monocytes are Sex-Dependent Predictors of Early Arteriovenous Fistula Maturation.

BACKGROUND: Arteriovenous fistulae mature less frequently in women than in men, leading to inferior patency and decreased fistula utilization in women. We hypothesized that both anatomic and physiologic sex differences explain reduced maturation. METHODS: The electronic medical records of patients who had a primary arteriovenous fistula created from 2016 to 2021 at a single center were reviewed; sample size was determined using a power calculation. Postoperative ultrasound and laboratory tests were obtained at least 4 weeks after fistula creation. Primary unassisted fistula maturation was determined up to 4 years postprocedure. RESULTS: A total of 28 women and 28 men with a brachial-cephalic fistula were analyzed. The inflow brachial artery diameter was smaller in women than in men, both preoperatively (4.2 ± 0.9 vs. 4.9 ± 1.0 mm, P = 0.008) and postoperatively (4.8 ± 0.8 vs. 5.3 ± 0.9 mm, P = 0.039). Despite similar preoperative brachial artery peak systolic velocity, women had significantly lower postoperative arterial velocity (P = 0.027). Fistula flow was reduced in women, particularly in the midhumerus (747.0 ± 570.4 vs. 1,117.1 ± 471.3 cc/min, P = 0.003). Percentages of neutrophils and lymphocytes were similar among women and men 6 weeks after fistula creation. However, women had reduced monocytes (8.5 ± 2.0 vs. 10.0 ± 2.6%, P = 0.0168). Among 28 men, 24 of 28 (85.7%) achieved unassisted maturation, whereas only 15 of 28 (53.6%) women had fistulae that matured without intervention. Secondary analysis using logistic regression suggested that postoperative arterial diameter was associated with maturation in men, while postoperative monocyte percentage was associated with maturation in women. CONCLUSIONS: Sex differences during arteriovenous fistula maturation are present in arterial diameter and velocity, suggesting that both anatomic and physiologic differences in arterial inflow contribute to sex differences in fistula maturation. In men, postoperative arterial diameter is correlated with maturation, whereas in women, the significantly lower proportion of circulating monocytes suggests a role for the immune response in fistula maturation.

A RIETE registry analysis of patients with upper extremity deep vein thrombosis and thoracic outlet syndrome.

BACKGROUND: Upper extremity deep vein thrombosis (UEDVT) related to thoracic outlet syndrome (TOS) is rare, and the literature is limited to institutional case series. METHODS: We used data from the RIETE Registry to compare outcomes (recurrences, major bleeding and signs and symptoms of post-thrombotic [PTS] syndrome) in patients with UEDVT and TOS undergoing first rib resection vs. those not undergoing surgery. RESULTS: From March 2001 to March 2021, there were 4214 patients with UEDVT, of whom 209 (4.96%) had TOS. Of these, 55 (26%) underwent first rib resection. Patients with TOS were younger and less likely to have comorbidities than those without TOS. There were no differences between patients with TOS undergoing surgery and those who did not. During anticoagulation, patients with TOS had a non-statistically significant lower rate of VTE recurrences than those without TOS (hazard ratio [HR]: 0.46; 95%CI: 0.14-1.12) and a lower bleeding rate (HR: 0.16; 95%CI: 0.01-0.83). No patient with TOS developed pulmonary embolism or died. Patients with TOS undergoing surgery had fewer PTS symptoms (odds ratio [OR]: 0.21; 95%CI: 0.06-0.68) or signs (OR: 0.11; 95%CI: 0.02-0.42) after one year than patients who did not have surgery. At two years, the differences in symptoms (OR: 0.25; 95%CI: 0.06-0.94) and signs (OR: 0.04; 95%CI: 0.002-0.33) persisted. CONCLUSIONS: Patients with UEDVT and TOS were younger and had less comorbidities than those without. Surgical resection of the first rib was associated with a lower proportion of patients developing PTS one and two years later.

A rare presentation and management of thrombosis of an aberrant right subclavian artery related to thoracic outlet syndrome.

OBJECTIVES: We present a case in which a 44-year-old female smoker with a complex medical and surgical history presented with acute upper limb ischemia. METHODS: The patient was diagnosed with thoracic outlet syndrome causing symptomatic thrombosis of an aberrant right subclavian artery associated with diverticulum of Kommerell. The patient had history of extensive surgeries and radiation in the right chest with fibrotic changes, so surgical dissection in the area was associated with significant risk of nerve injury. Therefore, revascularization of the arm was performed via carotid to brachial artery bypass with reversed saphenous vein and the thoracic outlet was decompressed with segmental clavicular resection. RESULTS: Patient has been symptom free for 3 years with patent bypass. CONCLUSIONS: This case demonstrates a unique presentation of distal thrombosis of a symptomatic aberrant right subclavian artery related to thoracic outlet syndrome. The combined claviculectomy-vein bypass is a safe and efficacious surgical approach that provides durable relief.

Reinterventions in Patients with Claudication and Chronic Limb Threatening Ischemia.

BACKGROUND: Patients with peripheral artery disease (PAD) present with claudication or chronic limb threatening ischemia (CLTI). CLTI patients have a more advanced stage of atherosclerosis and increased comorbidities compared to claudicants, and are at an elevated risk of major amputation and mortality after lower extremity revascularization (LER). However, the frequency of reinterventions for claudication and CLTI have not been compared. Our hypothesis is that patients with CLTI undergo more frequent reinterventions to prevent major amputation. METHODS: A single-center retrospective chart review of consecutive patients undergoing lower extremity revascularization (LER) for PAD in 2013-2015 was performed. Patients were stratified based on indication for revascularization into claudication or CLTI. Patient characteristics, outcomes, and reinterventions were compared between the 2 groups. RESULTS: There were 826 patients undergoing LER and 44% (N = 361) had CLTI. Patients treated for CLTI were more likely to be smokers (P < 0.001), to have diabetes (P< 0.001), chronic renal insufficiency (P< 0.001), end stage renal disease (P< 0.001), and cardiac disease (P< 0.001). CLTI patients were less likely to be on optimal medical management as reflected by decreased rate of aspirin (P< 0.001), ADP receptor/P2Y12 inhibitors (P< 0.001), and statins (P< 0.001) compared to patients with claudication. Patients with CLTI had significantly higher major amputation (3.7% vs. 0.2%, P< 0.001) and mortality (1.4% vs. 0.2%, P = 0.092) at 30 days. At long-term follow up, patients with CLTI had higher rates of major amputation (15.5% vs. 1.3%, P < 0.001) and mortality (37.1% vs. 18.1%, P < 0.001) compared to patients with claudication. There was a significant difference in mean follow-up time between the 2 cohorts (claudication: 3.7 ± 1.5 years versus CLTI: 2.6 ± 1.8 years, P < 0.001). There was no significant difference in the ipsilateral reintervention rate between the 2 groups (claudication: 39.6% vs. CLTI: 42.7%, P = 0.37) or the mean number of ipsilateral reinterventions (claudication: 2.0 ± 1.6 vs. CLTI: 2.0 ± 1.7). However, after adjusting for follow-up time, the mean number of reinterventions per year was significantly higher for CLTI patients compared to patients with claudication (1.4 ± 2.2 vs. .6 ± 0.7 intervention per year, P < 0.001). CONCLUSIONS: Patients undergoing LER for CLTI undergo more frequent reinterventions over time compared to patients treated for claudication. Research on reinterventions after LER should include reporting of the frequency of reintervention adjusted for the follow up period in addition to the reintervention rate defined as the percentage of patients undergoing reintervention.

Trends in Utilization and Outcomes of Orbital, Laser, and Excisional Atherectomy for Lower Extremity Revascularization.

PURPOSE: The aim of this study is to analyze the utilization pattern of atherectomy modalities and compare their outcomes. MATERIALS AND METHODS: All patients undergoing atherectomy in the 2010-2016 Vascular Quality Initiative Database were identified. Utilization of orbital, laser, or excisional atherectomy was obtained. Characteristics and outcomes of patients treated for isolated femoropopliteal and isolated tibial disease by different modalities were compared. RESULTS: Atherectomy use increased from 10.3% to 18.3% of all peripheral interventions (n = 122 938). Orbital atherectomy was most commonly used and increased from 59.4% in 2010 to 63.2% of all atherectomies in 2016, while laser atherectomy decreased from 19.2% to 13.1%. Atherectomy was mostly used for treatment of isolated femoropopliteal disease (51.1%), followed by combined femoropopliteal and tibial disease (25.8%) and isolated tibial disease (11.7%). In isolated femoropopliteal revascularization, excisional atherectomy was associated with higher rate of perforation (1.2%) compared with laser (0.4%) and orbital atherectomy (0.5%). The technical success of orbital atherectomy (96.7%) was lower compared with excisional atherectomy (98.7%). Concomitant stenting was significantly higher with laser atherectomy (43.0%) compared with orbital (27.2%) and excisional (26.1%) atherectomy. Nevertheless, there was no difference in 1-year primary patency, reintervention, major amputation, improvement in ambulatory status, or mortality. Multivariable analysis also demonstrated no difference in 1-year primary patency and major ipsilateral amputation among the modalities. In isolated tibial revascularization, there were no differences in perioperative outcomes among the modalities. Excisional atherectomy was associated with the highest 1-year primary patency (88.1%). After adjusting for confounders, excisional atherectomy remained associated with superior 1-year primary patency compared with orbital atherectomy (odds ratio [OR] = 2.59, 95% confidence interval [CI] = [1.18-5.68]), and excisional atherectomy remained associated with a lower rate of 1-year major ipsilateral amputation compared with laser atherectomy (OR = 0.29, 95% CI = [0.09-0.95]). CONCLUSION: Atherectomy use has increased, driven primarily by orbital atherectomy. Despite significant variation in perioperative outcomes, there were no differences in 1-year outcomes among the different modalities when used for treating isolated femoropopliteal disease. In isolated tibial disease treatment, excisional atherectomy was associated with higher 1-year primary patency compared with orbital atherectomy and decreased major ipsilateral amputation rates compared with laser atherectomy. These differences warrant further investigation into the comparative effectiveness of atherectomy modalities in various vascular beds.

Alternative Endograft Aortoiliac Reconstruction for Iliac Branch Endoprostheses.

BACKGROUND: Endovascular treatment of complex common iliac artery (CIA) and internal iliac artery (IIA) aneurysms using iliac branch endoprostheses (IBE) has proven safe and effective. Instructions for use (IFU) require deployment of current IBE technology with the corresponding manufacturer's modular bifurcated aortic endograft. Concomitant aortoiliac occlusive disease, inadequate renal artery-iliac bifurcation length, and unfavorable aortic anatomy preclude on-label IBE deployment. This study aimed to evaluate the technical feasibility and safety of Alternative Endograft Aortoiliac Reconstruction (AEGAR) for branched endovascular treatment of complex iliac artery aneurysms. METHODS: In 7 consecutive patients with CIA or IIA aneurysms, computed tomography angiography (CTA) and center-line reconstruction revealed aortoiliac anatomy incompatible with the current IBE IFU due to inadequate proximal CIA landing zone (n = 7), inadequate renal artery to iliac bifurcation length (n = 2), compromised aortic anatomy (n = 3), or short infrarenal neck <15 mm (n = 1), either alone or in combination. To overcome these restrictions and facilitate IBE deployment, aortoiliac reconstruction was performed using the Endologix AFX, Endologix Ovation limbs or the Medtronic Endurant II platforms (AEGAR technique). All internal iliac artery reconstructions and external iliac artery extensions were performed using the Gore VBX or Viabahn stent grafts. Technical success was defined as successful delivery of all endograft components without migration or endoleak. RESULTS: The mean patient age was 69 years (range 52-82 years; 6 male). Four patients had bilateral CIA aneurysms and 3 patients had unilateral CIA aneurysms (mean diameter 4.3cm; range 2.2-7 cm). There were 13 IIA VBX stent grafts used for a total of 9 IIAs treated with IBE (bilateral IBE = 2 patients). The mean fluoroscopy time was 38.8 min (range 21.3-64.3 min) and the mean contrast volume was 168.5 mL (range 122-226 mL). Technical success was achieved in all patients and there were no perioperative complications. Mean hospital-stay was 2.2 days (range 1-3 days). Follow-up ranged from 82-957 days (mean = 487 days). At last follow-up, all patients were alive without cardiovascular morbidity; and CTA revealed stable or decreased aneurysm size, patent endografts, and no evidence of endoleak or migration. CONCLUSIONS: The AEGAR technique can be used to safely and effectively overcome certain aortoiliac anatomic constraints that preclude use of current IBE technology. We encourage broader use of these alternative endografts in pertinent anatomic configurations.

Strategies to Minimize Iodinated Contrast Volume in Patients with Chronic Kidney Disease Undergoing Peripheral Vascular Interventions.

Peripheral vascular interventions (PVI) utilize iodinated contrast medium (ICM) to visualize intravascular lesions and guide therapy. The use of ICM carries a risk of postcontrast acute kidney injury (PC-AKI), which is increased in the elderly and in patients with chronic kidney disease (CKD). Furthermore, the risk of PC-AKI increases with the volume of ICM used. This paper reports a 94-year-old patient with CKD stage 4 who presented with chronic limb threatening ischemia. He underwent successful endovascular revascularization using a combination of CO2 and dilute ICM (total volume = 6.5 mL). The case demonstrates strategies to minimize ICM during PVIs.

Diagnostic and Technical Challenges in the Care of a Complex Patient With Post-Thrombotic Syndrome.

Iliofemoral deep vein thrombosis can lead to post-thrombotic syndrome, a costly and morbid condition. Endovascular treatment is increasingly used for symptomatic relief, but clinical success depends on accurate patient evaluation and selection. This case describes the diagnostic and technical challenges in the care of a complex patient with post-thrombotic syndrome following stroke and extensive deep vein thrombosis. It highlights the multi-disciplinary work-up for a patient with post-thrombotic syndrome presenting with confounding symptoms, as well as the importance of considering alternative access for successful lower extremity venous recanalization.

Intermediate-dose anticoagulation, aspirin, and in-hospital mortality in COVID-19: a propensity score-matched analysis.

Background: Thrombotic complications occur at high rates in hospitalized patients with COVID-19, yet the impact of intensive antithrombotic therapy on mortality is uncertain. Research Question: How does in-hospital mortality compare with intermediate- versus prophylactic-dose anticoagulation, and separately with in-hospital aspirin versus no antiplatelet therapy, in treatment of COVID-19? Study Design and Methods: Using data from 2785 hospitalized adult COVID-19 patients, we established two separate, nested cohorts of patients (1) who received intermediate- or prophylactic-dose anticoagulation ("anticoagulation cohort", N = 1624), or (2) who were not on home antiplatelet therapy and received either in-hospital aspirin or no antiplatelet therapy ("aspirin cohort", N = 1956). Propensity score matching utilizing various markers of illness severity and other patient-specific covariates yielded treatment groups with well-balanced covariates in each cohort. The primary outcome was cumulative incidence of in-hospital death. Results: Among propensity score-matched patients in the anticoagulation cohort (N = 382), in a multivariable regression model, intermediate- compared to prophylactic-dose anticoagulation was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.518 [0.308-0.872]). Among propensity-score matched patients in the aspirin cohort (N = 638), in a multivariable regression model, in-hospital aspirin compared to no antiplatelet therapy was associated with a significantly lower cumulative incidence of in-hospital death (hazard ratio 0.522 [0.336-0.812]). Interpretation: In this propensity score-matched, observational study of COVID-19, intermediate-dose anticoagulation and aspirin were each associated with a lower cumulative incidence of in-hospital death.

Multiple duplications of the superficial femoral artery - Case report and review of the literature.

OBJECTIVES: Lower extremity arterial anatomic variations are rare, with duplication of the superficial femoral artery being an extremely uncommon variant with few prior reports in the literature.Methods/Results: We report the case of a 68-year-old male with calf claudication who underwent angiography and was found to have two separate areas of vessel duplication along the superficial femoral artery, which has not previously been described in the literature. CONCLUSION: Although uncommon, recognition of a duplicated superficial femoral artery is important to avoid difficulties and complications that may arise during open or endovascular procedures.

A survey of vascular specialists' practice patterns of inferior vena cava filter placement and retrieval.

OBJECTIVES: The placement of inferior vena cava filters (IVCF) continues to rise. Vascular specialists adopt different practices based on local expertise. This study was performed to assess the attitudes of vascular specialists towards the placement and retrieval of IVCF. METHODS: An online survey of 28 questions related to practice patterns regarding IVCF was administered to 1429 vascular specialists. Vascular specialists were categorized as low volume if they place less than three IVCF per month and high volume if they place at least three IVCF per month. The responses of high volume and low volume were compared using two-sample t-tests and Chi-square tests. RESULTS: A total of 259 vascular specialists completed the survey (18% response rate). There were 191 vascular surgeons (74%) and 68 interventional radiologists (26%). The majority of responders were in academic practice (67%) and worked in tertiary care centers (73%). The retrievable IVCF of choice was Celect (27%) followed by Denali (20%). Forty-two percent used a temporary IVCF and left it in situ instead of using a permanent IVCF. Eighty-two percent preferred placing the tip of the IVCF at or just below the lowest renal vein. Thirty-one percent obtained a venous duplex of the lower extremities prior to retrieval while 24% did not do any imaging. There were 132 (51%) low volume vascular specialists and 127 (49%) high volume vascular specialists. Compared to low volume vascular specialists, significantly more high volume vascular specialists reported procedural times of less than 30 min for IVCF retrieval (57% vs. 42%, P = 0.026). There was a trend for high volume to have fewer unsuccessful attempts at IVCF retrieval but that did not reach statistical significance ( P = .061). High volume were more likely to have attempted multiple times to retrieve an IVCF (66% vs. 33%, P < .001), and to have used bronchoscopy forceps (32% vs. 14%, P = .001) or a laser sheath (14% vs. 2%, P < .001) for IVCF retrieval. In general, vascular specialists were not comfortable using bronchoscopy forceps (65%) or a laser sheath (82%) for IVCF retrieval. CONCLUSIONS: This study underscores significant variability in vascular specialists practice patterns regarding IVCF. More studies and societal guidelines are needed to define best practices.

Whole-exome sequencing in evaluation of patients with venous thromboembolism.

Genetics play a significant role in venous thromboembolism (VTE), yet current clinical laboratory-based testing identifies a known heritable thrombophilia (factor V Leiden, prothrombin gene mutation G20210A, or a deficiency of protein C, protein S, or antithrombin) in only a minority of VTE patients. We hypothesized that a substantial number of VTE patients could have lesser-known thrombophilia mutations. To test this hypothesis, we performed whole-exome sequencing (WES) in 64 patients with VTE, focusing our analysis on a novel 55-gene extended thrombophilia panel that we compiled. Our extended thrombophilia panel identified a probable disease-causing genetic variant or variant of unknown significance in 39 of 64 study patients (60.9%), compared with 6 of 237 control patients without VTE (2.5%) (P < .0001). Clinical laboratory-based thrombophilia testing identified a heritable thrombophilia in only 14 of 54 study patients (25.9%). The majority of WES variants were either associated with thrombosis based on prior reports in the literature or predicted to affect protein structure based on protein modeling performed as part of this study. Variants were found in major thrombophilia genes, various SERPIN genes, and highly conserved areas of other genes with established or potential roles in coagulation or fibrinolysis. Ten patients (15.6%) had >1 variant. Sanger sequencing performed in family members of 4 study patients with and without VTE showed generally concordant results with thrombotic history. WES and extended thrombophilia testing are promising tools for improving our understanding of VTE pathogenesis and identifying inherited thrombophilias.

Management of isolated calf vein thrombosis in cancer patients.

The treatment of isolated calf vein thrombosis remains widely debated. This study highlights the characteristics of isolated calf vein thrombosis in cancer patients and compares to isolated calf vein thrombosis in patients without history of cancer. Between July 2013 and April 2014, a retrospective chart review of consecutive patients with isolated calf vein thrombosis was performed recording patient risk factors, ultrasound characteristics of the thrombus, treatment modalities, long-term recurrence of venous-thromboembolism, incidence of bleeding, and mortality. Of 131 patients with isolated calf vein thrombosis, 53 (40.1%) had history of cancer. Isolated calf vein thrombosis occurred at an older age in cancer patients (66.7 vs 58.5 years, p = 0.004). The anatomical characteristics of isolated calf vein thrombosis on ultrasound were comparable in both groups. Isolated calf vein thrombosis in cancer patients was less likely to be treated with anticoagulation (60.4% vs 80.8%, p = 0.018). However, a trend towards higher incidence of bleeding after initiation of anticoagulation for isolated calf vein thrombosis in cancer patients (11.3% vs 6.4%, p = 0.351) was noted. Mortality in cancer patients was higher (37.7% vs 9.00%, p < 0.001) but was unrelated to isolated calf vein thrombosis or its treatment. In conclusion, the risks of bleeding seem to exceed the benefits of anticoagulation in approximately 50% of cancer patients with isolated calf vein thrombosis. The management of isolated calf vein thrombosis does not seem to impact the survival of cancer patients.