Determinants of Mortality and Mid-Term Outcomes After Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting.

OBJECTIVES: The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR. METHODS: Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors. RESULTS: A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke. CONCLUSIONS: Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal. CLINICAL IMPACT: The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.

Single Center Outcomes of Percutaneous Deep Vein Arterialization in Patients with End-Stage Peripheral Artery Disease.

Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate.

Neck radiation is not associated with increased risk of perioperative adverse events after transcarotid artery revascularization or transfemoral carotid artery stenting.

OBJECTIVE: It is unclear whether patients with prior neck radiation therapy (RT) are at high risk for carotid artery stenting (CAS). We aimed to delineate 30-day perioperative and 3-year long-term outcomes in patients treated for radiation-induced stenotic lesions by the transfemoral carotid artery stenting (TFCAS) or transcarotid artery revascularization (TCAR) approach to determine comparative risk and to ascertain the optimal intervention in this cohort. METHODS: Data were extracted from the Vascular Quality Initiative CAS registry for patients with prior neck radiation who had undergone either TCAR or TFCAS. The Student t-test and the χ2 test were used to compare baseline patient characteristics. Multivariable logistic regression and Cox Hazard Proportional analysis were used to compare perioperative and long-term differences between patients with and without prior neck radiation following TCAR and TFCAS. Kaplan-Meier estimator was used to determine the incidence of 3-year adverse events. RESULTS: A total of 72,656 patients (TCAR, 40,879; TFCAS, 31,777) were included in the analysis. Of these, 4151 patients had a history of neck radiation. Patients with a history of neck radiation were more likely to be younger, white, and have fewer comorbidities than patients with no neck radiation history. After adjustment for confounding factors, there was no difference in relative risk of 30-day perioperative stroke (P = .11), death (P = .36), or myocardial infarction (MI) (P = .61) between TCAR patients with or without a history of neck radiation. The odds of stroke/death (P = .10) and stroke/death/MI (P = .07) were also not statistically significant. In patients with prior neck radiation, TCAR had lower odds for in-hospital stroke/death/MI (odds ratio, 0.59; 95% confidence interval [CI], 0.35-0.99; P = .05) and access site complications than TFCAS. At year 3, patients with prior neck radiation had an increased hazard for mortality after TCAR (hazard ratio [HR], 1.24; 95% CI, 1.02-1.51; P = .04) and TFCAS (HR, 1.33; 95% CI, 1.12-1.58; P = .001). Patients with prior neck radiation also experienced an increased hazard for reintervention after TCAR (HR, 2.16; 95% CI, 1.45-3.20; P < .001) and TFCAS (HR, 1.67; 95% CI, 1.02-2.73; P<.001). CONCLUSIONS: Patients with prior neck radiation had a similar relative risk of 30-day perioperative adverse events as patients with no neck radiation after adjustment for baseline demographics and disease characteristics. In these patients, TCAR was associated with reduced odds of perioperative stroke/death/MI as compared with TFCAS. However, patients with prior neck radiation were at increased risk for 3-year mortality and reintervention.

Body Mass Index Impacts Indication But Not Outcomes of Thoracic Endovascular Aortic Repair.

BACKGROUND: There are limited studies looking at thoracic endovascular aortic repair (TEVAR) outcomes in obese and overweight patients. Our objective was to determine the rate of complications, reintervention, and short-term mortality in normal weight, overweight, and obese patients undergoing TEVAR. METHODS: Patients undergoing TEVAR at a large tertiary hospital from October 2007 to January 2020 were analyzed. Patients were stratified into 3 cohorts based on body mass index (BMI): normal (18.5-25 kg/m2), overweight (25-30 kg/m2), and obese (>30 kg/m2). Primary outcomes were 30-day and 1-year survival. Intraoperative, in-hospital, and postdischarge complications were assessed as secondary outcomes using the Clavian-Dindo classification system. In addition, reinterventions associated with the index TEVAR procedure as a secondary outcome. RESULTS: Among 204 patients fitting the study criteria, we identified 65 with normal BMI, 78 overweight, and 61 obese patients. Obese patients were younger than the overweight and normal BMI patients (mean age 62.2 vs. 66.7 vs. 70.7, respectively, P = 0.003). In terms of TEVAR indication, the obese cohort had the highest percentage of patients with type B aortic dissection (36.4%), while the normal BMI cohort had the higher proportion of patients undergoing TEVAR for isolated thoracic aortic aneurysm (63.9%). Intraoperative complications did not significantly differ between cohorts. Postoperatively, in-hospital complications, postdischarge complications and 30-day return to the operative room did not differ significantly between study cohorts. Odds of reintervention did not differ significantly between cohorts, both on univariate and multivariate analysis. Log-rank test of Kaplan Meier analysis revealed no difference in reintervention-free survival (P = 0.22). Thirty-day mortality and 1-year overall survival were similar across cohorts. Both univariate and multivariate logarithmic regression revealed no difference in likelihood of 30-day mortality between the obese and normal cohort. CONCLUSIONS: There were no measurable differences in complications, reinterventions, or mortality, suggesting that vascular surgeons can perform TEVAR across a spectrum of BMI without compromising outcomes.

Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair.

BACKGROUND: The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. METHODS: A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. RESULTS: A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7 years old. Patients undergoing SA were older with a mean age of 73.4 years versus 64.7 years for patients undergoing GA (P < 0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75 years old: 52.9% vs. 33.3%, P < 0.001; renal comorbidities: 20.6% vs. 10.6%, P = 0.03, and current smokers: 26.7% vs. 9.6%, P < 0.001). Length of stay (LOS) was decreased in the SA group (4.29 days vs. 9.70 days, P < 0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P = 0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P = 0.01), reintervention (19.2% vs. 26.8%, P = 0.02), and return to the operating room (6.8% vs. 12.7%, P = 0.02). Of the 19 patients that had SA + CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P = 0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA + CSFD patients versus SA + CSFD patients. Age >75 (P = 0.002), intraoperative complications (P < 0.001), and perioperative complications (P = 0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. CONCLUSIONS: Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.

SARS-CoV-2 infection triggers pro-atherogenic inflammatory responses in human coronary vessels.

Patients with coronavirus disease 2019 (COVID-19) present increased risk for ischemic cardiovascular complications up to 1 year after infection. Although the systemic inflammatory response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection likely contributes to this increased cardiovascular risk, whether SARS-CoV-2 directly infects the coronary vasculature and attendant atherosclerotic plaques remains unknown. Here we report that SARS-CoV-2 viral RNA is detectable and replicates in coronary lesions taken at autopsy from severe COVID-19 cases. SARS-CoV-2 targeted plaque macrophages and exhibited a stronger tropism for arterial lesions than adjacent perivascular fat, correlating with macrophage infiltration levels. SARS-CoV-2 entry was increased in cholesterol-loaded primary macrophages and dependent, in part, on neuropilin-1. SARS-CoV-2 induced a robust inflammatory response in cultured macrophages and human atherosclerotic vascular explants with secretion of cytokines known to trigger cardiovascular events. Our data establish that SARS-CoV-2 infects coronary vessels, inducing plaque inflammation that could trigger acute cardiovascular complications and increase the long-term cardiovascular risk.

Systems immunology-based drug repurposing framework to target inflammation in atherosclerosis.

The development of new immunotherapies to treat the inflammatory mechanisms that sustain atherosclerotic cardiovascular disease (ASCVD) is urgently needed. Herein, we present a path to drug repurposing to identify immunotherapies for ASCVD. The integration of time-of-flight mass cytometry and RNA sequencing identified unique inflammatory signatures in peripheral blood mononuclear cells stimulated with ASCVD plasma. By comparing these inflammatory signatures to large-scale gene expression data from the LINCS L1000 dataset, we identified drugs that could reverse this inflammatory response. Ex vivo screens, using human samples, showed that saracatinib-a phase 2a-ready SRC and ABL inhibitor-reversed the inflammatory responses induced by ASCVD plasma. In Apoe-/- mice, saracatinib reduced atherosclerosis progression by reprogramming reparative macrophages. In a rabbit model of advanced atherosclerosis, saracatinib reduced plaque inflammation measured by [18F] fluorodeoxyglucose positron emission tomography-magnetic resonance imaging. Here we show a systems immunology-driven drug repurposing with a preclinical validation strategy to aid the development of cardiovascular immunotherapies.

SARS-CoV-2 infection triggers pro-atherogenic inflammatory responses in human coronary vessels.

COVID-19 patients present higher risk for myocardial infarction (MI), acute coronary syndrome, and stroke for up to 1 year after SARS-CoV-2 infection. While the systemic inflammatory response to SARS-CoV-2 infection likely contributes to this increased cardiovascular risk, whether SARS-CoV-2 directly infects the coronary vasculature and attendant atherosclerotic plaques to locally promote inflammation remains unknown. Here, we report that SARS-CoV-2 viral RNA (vRNA) is detectable and replicates in coronary atherosclerotic lesions taken at autopsy from patients with severe COVID-19. SARS-CoV-2 localizes to plaque macrophages and shows a stronger tropism for arterial lesions compared to corresponding perivascular fat, correlating with the degree of macrophage infiltration. In vitro infection of human primary macrophages highlights that SARS-CoV-2 entry is increased in cholesterol-loaded macrophages (foam cells) and is dependent, in part, on neuropilin-1 (NRP-1). Furthermore, although viral replication is abortive, SARS-CoV-2 induces a robust inflammatory response that includes interleukins IL-6 and IL-1ß, key cytokines known to trigger ischemic cardiovascular events. SARS-CoV-2 infection of human atherosclerotic vascular explants recapitulates the immune response seen in cultured macrophages, including pro-atherogenic cytokine secretion. Collectively, our data establish that SARS-CoV-2 infects macrophages in coronary atherosclerotic lesions, resulting in plaque inflammation that may promote acute CV complications and long-term risk for CV events.

Surgical External Iliac Artery Access for Transcatheter Aortic Valve Replacement Is a Safe, Suitable Alternative to Common Femoral Artery Access.

Background Many patients undergoing transcatheter aortic valve replacement (TAVR) have peripheral artery disease necessitating surgical access. This study reviews the preoperative risk factors, procedural characteristics, and outcomes in patients undergoing surgical common femoral artery (CFA) and external iliac artery (EIA) access through a retro-inguinal groin incision for TAVR. Methods A single-center TAVR database was retrospectively analyzed for patients undergoing surgical cutdown (January 1, 2016 - December 31, 2020). Access sites were evaluated on preoperative imaging. Data on demographics, imaging, procedural characteristics, and outcomes were collected. The vascular surgeon selected the cutdown site. Results A hundred and thirty TAVR patients had surgical cutdown. The choice of access site was either the common femoral artery (82 patients, 63%) or the iliac artery (48 patients, 37%). There was no difference in age, BMI, or medical risk factors. There was no difference in iliac diameter or circumferential iliac calcium. In the iliac group, there was a smaller mean CFA size and a higher incidence of circumferential CFA calcium. In the femoral group, there was: a lower mean sheath-to-CFA ratio, a trend toward increased unplanned endarterectomy, and a higher incidence of 30-day readmission. There was no difference in adjunct procedure use. Conclusion EIA surgical access had similar complication rates and length of stay with a reduced tendency for unplanned endarterectomy when compared to CFA access. The EIA is a suitable access site for TAVR in select patients.

External iliac vein dimensions can change after placement of a more proximal iliac vein stent.

OBJECTIVE: We have occasionally observed during vein stenting for proximal iliac vein stenosis, the appearance of a more distal stenosis in the iliac vein that had not been initially observed before placement of the more proximal vein stent. In the present retrospective study, we aimed to document this observation. METHODS: We identified patients in whom changes in the area measurement and linear dimensions of the external iliac vein (EIV) were observed on venography and/or intravascular ultrasound (IVUS) after stent placement for chronic nonthrombotic iliac stenosis in the common iliac vein (CIV). The images of these IVUS scans were subsequently analyzed to determine the cross-sectional area, major axis, and minor axis measurements in the EIV, before and after placement of a proximal CIV stent. RESULTS: A total of 32 limbs with complete and quality IVUS and venography images available that allowed for measurement of the EIV before and after vein stent placement in the CIV were evaluated. The patient cohort was 55% men, with a mean age of 63.8 ± 9.9 years and a mean body mass index of 27.8 ± 7.8 kg/m2. Of the 32 limbs, 18 were left sided and 14 were right sided. Most (n = 12 [60%]) of the limbs had presented with venous-related skin changes (C4 disease). The remainder of the cohort had had active (C6 disease; n = 4 [20%]) or recently healed (C5 disease; n = 1 [5%]) venous ulceration and isolated venous-related edema (C3; n = 3 [15%]). The minimal CIV area before and after CIV stenting was 28.47 ± 23.53 mm2 and 196.34 ± 42.62 mm2, respectively. The minimal mean EIV cross-sectional area before and after CIV stenting was 87.44 ± 38.55 mm2 and 50.69 ± 24.32 mm2, respectively, a statistically significant reduction of 36.75 mm2 (P < .001). The mean EIV major axis and minor axis had both decreased similarly. The minimal mean EIV major axis before and after CIV stenting was 15.22 ± 3.13 mm and 11.13 ± 3.58 mm, respectively (P < .001). The minimal mean EIV minor axis before and after CIV stenting was 7.26 ± 2.40 mm and 5.84 ± 1.42 mm, respectively (P < .001). CONCLUSIONS: The results from the present study have shown that the dimensions of the EIV can change significantly after placement of a proximal CIV stent. Possible explanations include masked stenosis due to distal venous distention resulting from the more proximal stenosis, vascular spasm, and anisotropy. The presence of proximal CIV stenosis can potentially lessen the appearance, or completely mask the presence, of an EIV stenosis. This phenomenon appears unique to venous stenting, and the prevalence is unknown. These findings underscore the importance of completion IVUS and venography after venous stent placement.

The Venous Thrombectomy Armamentarium: An Expanding World.

Acute deep venous thrombosis (DVT) is a common and important public health problem. It affects more than 350,000 people in the United States annually and has a substantial economic impact. Without adequate treatment, there is significant risk of development of post-thrombotic syndrome (PTS) resulting in patient morbidity, worse quality of life, and costly long-term medical care. Over the past decade, the treatment algorithm for patients with acute DVT has significantly changed. Prior to 2008, the treatment recommendation for patients with acute DVT was limited to anticoagulation and conservative management. In 2008, national clinical practice guidelines were updated to include interventional strategies such as surgical- and catheter-based techniques for the treatment of acute DVT. Early strategies for debulking of extensive acute DVT primarily consisted of open surgical thrombectomy and administration of thrombolytics. In the intervening period, a plethora of advanced endovascular techniques and technologies have been developed which reduced the morbidity of operative intervention and risks of hemorrhage associated with thrombolysis. This review will focus on the novel technologies commercially available for management of acute DVT, denoting unique features inherent to each device. This expanded armamentarium gives vascular surgeons and proceduralists the opportunity to individualize their treatment approach to the specific patient's anatomy, lesion, and history.

Women are Not at Higher Risk for Reintervention or Major Amputation after Lower Extremity Atherectomy for Peripheral Artery Disease.

BACKGROUND: Our objective was to compare short-term and long-term differences in reintervention-free and major amputation-free survival between female and male patients undergoing lower extremity atherectomy for peripheral artery disease. METHODS: We analyzed lower extremity atherectomy procedures performed on 294 patients between January 2014 and September 2019. Reintervention was defined as either open bypass or endovascular procedure to the same region following the index operation. Kaplan-Meier (KM) survival analysis was performed to compare reintervention-free and major amputation-free survival between sexes. Multivariate logistic regression analyses were performed to determine the adjusted odds of reintervention and major amputation based on sex. We conducted subgroup analyses by anatomic region (femoropopliteal vs. tibial), indication (claudication vs. chronic limb-threatening ischemia (CLTI)), and balloon type (drug-coated balloon (DCB) versus plain balloon angioplasty (POBA)) across sexes. RESULTS: Of the 294 patients, 125 (42.5%) were female. Compared to men, women receiving atherectomy were more likely to be Black (28.0% vs. 16.6%; P = 0.018), a nonsmoker (44.8% vs. 21.3%; P < 0.001), and present with CLTI (55.2% vs. 43.2%; P = 0.042). There were no differences in atherectomy region, lesion type, or balloon type between sexes. KM analysis showed similar 4-year reintervention-free survival (68.8% vs. 75.1%; P = 0.88) and major amputation-free survival (97.6% vs. 97.6%; P = 0.41) between sexes. Women and men had similar reintervention-free survival when grouped by femoropopliteal (67.9% vs. 70.8%; P = 0.69) or tibial (76.2% vs. 83.9%; P = 0.68) atherectomy region. Indication (claudication versus CLTI) did not affect reintervention-free survival in either women (64.5% vs. 69.6%; P = 0.28) or men (68.5% vs. 76.7%; P = 0.84). KM curves for DCB versus POBA were also similar between sexes and showed an early benefit in reintervention rate favoring DCB, which dissipated in both women (65.4% vs. 72.7%; P = 0.61) and men (75.5% vs. 78.4%; P = 0.18) by 3 years. CONCLUSIONS: Compared to men, women demonstrate commensurate benefit from atherectomy for lower extremity revascularization. There were no differences seen in long-term reintervention or major amputation between sexes.

Periprocedural P2Y12 inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes.

OBJECTIVE: The continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y12 inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y12 inhibitors for CAS. METHODS: The Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y12 inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. RESULTS: A total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y12 inhibitor. P2Y12 inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y12 inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P < .001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y12 inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P < .001) and mortality (0.6% vs 2.1%; P < .001) than those who were not on a P2Y12 inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y12 inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. CONCLUSIONS: The use of perioperative P2Y12 inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y12 inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y12 inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y12 inhibitors in the periprocedural period, leaving room for significant improvement.

High Thoracic Tortuosity Is Associated With CT-Markers of Degeneration of the Descending Thoracic Aortic Wall.

OBJECTIVE/INTRODUCTION: Increased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following EVAR in AAA patients. METHODS: Patients who underwent elective EVAR between 2004 and 2018 were reviewed. Thoracic tortuosity index (TTI) was measured using 3D reconstruction software. Patients were dichotomized across the median TTI into high tortuosity [HT] (TTI >1.27, Figure1(a)) and low tortuosity [LT] (TTI ≤1.27, Figure 1(b)) groups. Perioperative complications, postoperative outcomes, and CT-based features of thoracic aortic wall degeneration (Figure 1(c)-(e)) were collected and analyzed. RESULTS: 136 patients underwent treatment: 70 HT patients, including 54 males and 16 females (mean age: 77 years), and 66 LT patients, including 62 males and 4 females (mean age: 70 years) (age; P < .001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P = .045, P = .01). Presence of degenerative aortic wall markers was greater in HT patients (P = .045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P = .002). Frequency of AAA rupture/dissection was 4.3% for HT and 1.5% for LT (P = .339). A trend was observed in all cause 30-day mortality in the HT group (P = .061). Other perioperative complications and postoperative outcomes were similar between groups. CONCLUSION: High TTI was associated with older age at time of EVAR, greater prevalence of degenerative markers in the descending thoracic aortic wall, and widespread aorto-iliac dilation. While not predictive of EVAR outcomes, TTI can provide valuable information regarding aneurysm pathophysiology.

Erratum: Publisher Correction: Systems immunology-based drug repurposing framework to target inflammation in atherosclerosis.

[This corrects the article DOI: 10.1038/s44161-023-00278-y.].

Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.

INTRODUCTION: Asymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. METHODS: Data from patients in the Vascular Quality Initiative database who underwent TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke occurring within 180 days before the procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic) and patients with a history of TIA/stroke occurring more than 180 days before the procedure (remote history of neurologic symptoms). The Student t-test and Pearson χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. RESULTS: There were 7158 patients who underwent TCAR (symptomatic: 2574, asymptomatic: 3689, and asymptomatic with a remote history of neurologic symptoms: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195, asymptomatic: 10,333, and asymptomatic with a remote history of neurologic symptoms: 1495). Regardless of symptom status, the mean patient age was 73 years for TCAR and 69 years for TFCAS. A total of 64% of patients in the study were male and 36% of patients were female. The mean long-term follow-up data ranged between 208 and 331 days within the three patient groups. Carotid stenosis patients with a remote history of neurologic symptoms had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic patients, and these rates were similar to those of symptomatic patients. Comparing TCAR and TFCAS among patients with a remote history of neurologic symptoms, there were statistically significant reductions in the odds of stroke/death (odds ratio: 0.46, 95% confidence interval: 0.27-0.84, P = .011) and stroke/death/myocardial infarction (odds ratio: 0.51, 95% confidence interval: 0.30-0.87, P = .013) after TCAR. This was likely driven by the increased rate of death after TFCAS in patients with a remote history of neurologic symptoms (0.9%) compared with asymptomatic patients (0.6%). CONCLUSIONS: Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.

Comparison of Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting Based on High Risk Anatomic Characteristics.

BACKGROUND: Anatomic details affecting the adverse outcomes following carotid artery stenting have not been well characterized. We compared in-hospital outcomes following transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic and asymptomatic patients stratified by degree of lesion calcification and aortic arch type. METHODS: Data from patients in the Society for Vascular Surgery's Vascular Quality Initiative database undergoing TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) and had non-missing grading on carotid artery calcification or aortic arch type was analyzed. Degree of calcification was stratified into 3 groups: none, ≤ 50% calcification, and >50% calcification. Arch type was stratified as Type I, Type II, and Type III. RESULTS: A total of 9,868 patients (TCAR: 4,224; TFCAS: 5,644) were included in the calcification analysis. TCAR patients were generally older, white, smokers, and had more comorbidities than TFCAS patients. Among the symptomatic patients, there was no difference in rates of stroke, stroke/transient ischemic attack (TIA), and myocardial infarction (MI) by calcification severity between TCAR and TFCAS. However, there was a trend towards increased risk in all 3 events with higher calcification only after TFCAS. Symptomatic patients with severe (>50%) calcification had lower rates of death (TCAR: 0.9% vs. TFCAS: 2.8%, P = 0.013), stroke/death (TCAR: 2.7% vs. TFCAS: 5.8%, P = 0.006), stroke/death/MI (TCAR: 3.3% vs. TFCAS: 6.5%, P = 0.007), and postop complications (TCAR: 6.0% vs. TFCAS: 12.4%, P < 0.001) after TCAR compared to TFCAS. Furthermore, TCAR had lower risk of mortality at all degrees of calcification compared to TFCAS. Similar findings were noted among asymptomatic TCAR patients with >50% calcification, in which the rates of death (TCAR: 0.4% vs. TFCAS: 1.1%, P = 0.080) and stroke/death (TCAR: 1.5% vs. TFCAS: 3.1%, P = 0.029) were reduced. A comparison of TCAR to TFCAS by arch type showed that rates of stroke/death after TCAR were similar regardless of arch complexity (Type I: 2.6% vs. Type II: 2.8%), but increased after TFCAS with complex, high risk anatomy (Type I: 4.2% vs. Type II: 5.2%). CONCLUSIONS: While increased calcification increased rates of adverse events after TFCAS, this trend was not observed after TCAR, which also had lower rates of death and stroke/death among patients with severe calcification. Furthermore, TCAR had lower risk of mortality than TFCAS across all degrees of calcification. TFCAS was associated with increased risk of stroke/death with complex aortic arch anatomy, however, rates of stroke/death after TCAR were similar regardless of arch complexity. Our results suggests that TCAR should be preferentially considered in revascularization of patients with anatomy considered high-risk for TFCAS.

The Feasibility and Applicability of Percutaneous Deep Vein Arterialization in Peripheral Artery Disease.

Peripheral artery disease (PAD) can often present with chronic limb threatening ischemia (CLTI), including ischemic rest pain and severe tissue loss. Progression of PAD can lead to "no option" or end-stage disease in which there are no traditional open or endovascular interventions available for revascularization. This cohort of patients have a poor prognosis, with a major amputation rate of 40% and mortality of up to 20% at six months. For this patient population, surgical deep vein arterialization (DVA) is offered as an attempt to provide blood flow to the distal preserved venous bed and reverse the ischemic process. Surgical DVA has traditionally been offered as an option and was pioneered by Herb Dardik. The evolution of endovascular technology has allowed for percutaneous DVA (pDVA). Using ultrasound and fluoroscopic guidance, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts to increase distal limb perfusion with the goals of improving wound healing and amputation-free survival. Lysis of venous valves with a valvulotome also aids with reversal of flow into the distal venous system. Investigations of percutaneous deep vein arterialization are underway with one device, the LimFlow System (LimFlow SA, Paris, France), which is undergoing feasibility trials. Here we present the current clinical indications, feasibility, results, and our institutional experience with the use of percutaneous deep vein arterialization.

No Mortality Signal With Stellarex Low-Dose Paclitaxel DCB: ILLUMENATE Pivotal 4-Year Outcomes.

BACKGROUND: Paclitaxel-coated balloons have shown safety and efficacy in the short- to intermediate-term; however, long-term data remain limited. OBJECTIVES: To report late safety and efficacy outcomes for a low-dose paclitaxel drug-coated balloon (DCB) compared with percutaneous transluminal angioplasty (PTA) in femoropopliteal lesions from a large randomized controlled trial (RCT). METHODS: ILLUMENATE Pivotal is a multicenter, single-blind RCT conducted across 43 US and EU centers to examine the safety and efficacy of the Stellarex DCB for the treatment of femoropopliteal disease. Assessments were recorded for all active patients at 36 and 48 months. Vital status of patients formally exited from the study was also collected. RESULTS: Primary patency through 36 months for patients treated with DCB was significantly higher compared with PTA (p=0.016). The primary safety endpoint through 36 months was 77.4% and 72.4%, respectively (p=0.377). Kaplan-Meier analysis indicated that a higher proportion of DCB subjects were event-free compared with PTA at all study visits. The rate of major adverse event (MAE) through 48 months was 32.9% in the DCB group and 37.9% in the PTA group (p=0.428). No differences in the rate of mortality were evident through 48 months of follow-up with 15.6% in the DCB group and 15.2% in the PTA group (p=0.929). CONCLUSIONS: Stellarex DCB was associated with significantly higher patency compared with PTA through 3 years with no mortality difference detected through 4 years. The data from the ILLUMENATE Pivotal RCT support the long-term safety and efficacy of the low-dose Stellarex DCB.

Follow-up after acute thrombotic events following COVID-19 infection.

OBJECTIVE: COVID-19 infection results in a hypercoagulable state predisposing patients to thrombotic events. We report the 3- and 6-month follow-up of 27 patients who experienced acute arterial thrombotic events in the setting of COVID-19 infection. METHODS: Data were prospectively collected and maintained for all vascular surgery consultations in the Mount Sinai Health System from patients who presented between March 16 and May 5, 2020. RESULTS: Twenty-seven patients experienced arterial thrombotic events. The average length of stay was 13.3 ± 15.4 days. Fourteen patients were treated with open surgical intervention, six were treated with endovascular intervention, and seven were treated with anticoagulation only. At 3-month follow-up, 11 patients (40.7%) were deceased. Nine patients who expired did so during the initial hospital stay. The 3-month cumulative primary patency rate for all interventions was 72.2%, and the 3-month primary patency rates for open surgical and endovascular interventions were 66.7 and 83.3, respectively. There were 9 (33.3%) readmissions within 3 months. Six-month follow-up was available in 25 (92.6%) patients. At 6-month follow-up, 12 (48.0%) patients were deceased, and the cumulative primary patency rate was 61.9%. The 6-month primary patency rates of open surgical and endovascular interventions were 66.7% and 55.6%, respectively. The limb-salvage rate at both 3 and 6 months was 89.2%. CONCLUSIONS: Patients with COVID-19 infections who experienced thrombotic events saw high complication and mortality rates with relatively low patency rates.