Paradigm Shifts in Vascular Surgery: Analysis of the Top 100 Innovative and Disruptive Academic Publications.

BACKGROUND: Disruption score (DS) is a novel bibliometric created to identify research that shifts paradigms, which may be overlooked by citation count (CC). We analyzed the most disruptive, compared to the most cited, literature in vascular surgery, and hypothesized that DS and CC would not correlate. METHODS: A PubMed search identified vascular surgery publications from 1954 to 2014. The publications were linked to the iCite NIH tool and DS algorithm to identify the top 100 studies by CC and DS, respectively. The publications were reviewed for study focus, design, and contribution, and subsequently compared. RESULTS: A total of 56,640 publications were identified. The top 100 DS papers were frequently published in J Vasc Sur (43%) and Eur J Vasc Endovasc Surg (13%). The top 100 CC papers were frequently published in N Engl J Med (32%) and J Vasc Sur (20%). The most cited article is the fifth most disruptive; the most disruptive article is not in the top 100 cited papers. The DS papers had a higher mean DS than the CC papers (.17 vs .0001, P < .0001). The CC papers had a higher mean CC than the DS papers (866 vs 188, P < .0001). DS and CC are weakly correlated metrics (r = .22, P = .03). DISCUSSION: DS was weakly correlated with CC and captured a unique subset of literature that created paradigm shifts in vascular surgery. DS should be utilized as an adjunct to CC to avoid overlooking impactful research and influential researchers, and to measure true academic productivity.

Epidemiology, repair technique, and predictors of stroke and mortality in penetrating carotid artery injuries.

OBJECTIVE: Penetrating carotid artery injuries (PCAI) are significantly morbid and deadly, often presenting in extremis with associated injuries and central nervous system deficit. Repair may be challenging with arterial reconstruction vs ligation role poorly defined. This study evaluated contemporary outcomes and management of PCAI. METHODS: PCAI patients in the National Trauma Data Bank from 2007 to 2018 were analyzed. Outcomes were compared between repair and ligation groups after additionally excluding external carotid injuries, concomitant jugular vein injuries, and head/spine Abbreviated Injury Severity score of ≥3. Primary end points were in-hospital mortality and stroke. Secondary end points were associated injury frequency and operative management. RESULTS: There were 4723 PCAI (55.7% gunshot wounds, 44.1% stab wounds). Gunshot wounds more frequently had associated brain (73.8% vs 19.7%; P < .001) and spinal cord (7.6% vs 1.2%; P < .001) injuries; stab wounds more frequently had jugular vein injuries (19.7% vs 29.3%; P < .001). The overall in-hospital mortality was 21.9% and the stroke rate was 6.2%. After exclusion criteria, 239 patients underwent ligation and 483 surgical repair. Ligation patients had lower presenting Glasgow Coma Scale (GCS) than repair patients (13 vs 15; P = .010). Stroke rates were equivalent (10.9% vs 9.3%; P = .507); however, in-hospital mortality was higher after ligation (19.7% vs 8.7%; P < .001). In-hospital mortality was higher in ligated common carotid artery injuries (21.3% vs 11.6%; P = .028) and internal carotid artery injuries (24.5% vs 7.3%; P = .005) compared with repair. On multivariable analysis, ligation was associated with in-hospital mortality, but not with stroke. A history of neurological deficit before injury lower GCS, and higher Injury Severity Score (ISS) were associated with stroke; ligation, hypotension, higher ISS, lower GCS, and cardiac arrest were associated with in-hospital mortality. CONCLUSIONS: PCAI are associated with a 22% rate of in-hospital mortality and a 6% rate of stroke. In this study, carotid repair was not associated with a decreased stroke rate, but did have improved mortality outcomes compared with ligation. The only factors associated with postoperative stroke were low GCS, high ISS, and a history of neurological deficit before injury. Beside ligation, low GCS, high ISS, and postoperative cardiac arrest were associated with in-hospital mortality.

International Multi-Institutional Experience with Presentation and Management of Aortic Arch Laterality in Aberrant Subclavian Artery and Kommerell's Diverticulum.

BACKGROUND: Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch. METHODS: Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions. RESULTS: 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change. CONCLUSIONS: In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.

Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell's diverticulum.

OBJECTIVE: Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset. METHODS: Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak. RESULTS: Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms. CONCLUSIONS: Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate.

Functional performance status and risk of cardiovascular events and mortality following endovascular repair of thoracic and abdominal aortic pathology.

OBJECTIVE: To characterize the association of preoperative functional performance status based on Eastern Cooperative Oncology Group (ECOG) scoring with the risk of adverse cardiovascular events, vascular events, and mortality in patients undergoing EVAR and TEVAR. METHODS: Retrospective review of the Society for Vascular Surgery Vascular Quality Initiative, a large, multi-center, registry database was performed. All individuals undergoing EVAR (n = 18,730) and TEVAR (n = 6595) for non-ruptured aortic pathologies between 2014 and 2018 were eligible for analysis. Multivariable logistic regression was used to determine the association of pre-procedure ECOG functional performance status on risk of in-hospital adverse cardiovascular events, vascular events, and mortality. RESULTS: The number of operations complicated by adverse cardiovascular and vascular events was 480 (2.6%) and 190 (1.0%) for EVAR and 733 (11.1%) and 219 (3.3%) for TEVAR, respectively. There were 118 (0.6%) and 240 (3.6%) in-hospital deaths following EVAR and TEVAR, respectively. Patients with ECOG grades 3 or 4 undergoing EVAR were at increased risk of cardiovascular events (OR = 1.62; 95% CI = 1.09, 2.41) and one-year mortality (HR = 2.62; 95% CI = 1.92, 3.57) compared to those with ECOG grade 0. Patients undergoing TEVAR with ECOG grade 3 or 4 were at increased risk for both inpatient death (OR = 2.77; 95% CI = 1.56, 4.9) and one-year mortality (HR = 3.27, 95% CI = 2.06, 5.21). ECOG status was not associated with an increased risk of adverse vascular events following either EVAR or TEVAR. CONCLUSIONS: Poor preoperative functional status as assessed by ECOG score is associated with an increased risk of adverse postoperative cardiovascular events following EVAR and a higher mortality risk following both EVAR and TEVAR. Functional status assessment may be useful for risk stratification and determining procedural candidacy prior to EVAR and TEVAR.

Management strategy for lower extremity malperfusion due to acute aortic dissection.

OBJECTIVE: Aortic dissection can result in devastating cerebral, visceral, renal, spinal, and extremity ischemia. We describe the management and outcomes of patients presenting with aortic dissection and lower extremity malperfusion (LEM). METHODS: A single-center institutional aortic database was queried for patients with aortic dissection and LEM from 2011 to 2019. The primary end point was resolution of LEM after aortic repair. Secondary end points were amputation, in-hospital mortality, time to intervention, and postoperative complications. RESULTS: Of 769 patients with aortic dissection, 42 (5.5%) presented acutely with LEM: 16 with Stanford type A and 26 Stanford type B aortic dissection (age 55 ± 13 years; 90% men). Most presented as Rutherford IIB symptoms, but patients with type A had Rutherford III more often, compared with those with type B. Aortic repair was performed before limb interventions in 36 patients (86%; 19 TEVAR, 16 open arch and ascending repair, and 1 open descending aortic repair with fenestration). Seven (19%) had immediate failure with persistent malperfusion recognized in the operating room and underwent additional limb intervention, including extra-anatomic revascularization (n = 4), iliac stenting (n = 2), and femoral patch with septal fenestration or tacking (n = 2). Three patients (8%) had early delayed failure requiring extra-anatomic bypass in two and amputation in one. In contrast, six patients had limb-first intervention with extra-anatomic revascularization. None had immediate failure, but one-half had early delayed failure requiring proximal aortic intervention: two TEVAR and one open aortic fenestration. Limb-first patients were more likely to have early delayed failure compared with aortic dissection treated first patients (50% vs 8%; P = .029). The amputation rate was 2%, occurring in one type A patient. The overall in-hospital mortality was 7% (n = 3), with no difference between type A and type B aortic dissection. There was no difference in surgical site infection, postoperative dialysis need, stroke, and myocardial infarction. CONCLUSIONS: In patients presenting with acute aortic dissection with limb ischemia, resolution of the malperfusion occurs in the majority of cases after primary aortic dissection intervention, emphasizing the usefulness of urgent TEVAR for complicated type B and open repair of type A before lower extremity intervention. Limb-first interventions have a higher early delayed failure rate and thus require more frequent reoperation. However, the overall amputation rate in LEM owing to aortic dissection remains low.

Risk of renal failure and death when renal arteries are involved in endovascular aortic aneurysm repair.

OBJECTIVE: Endovascular abdominal aortic repair can involve the incorporation of renal arteries. Revascularization after intentional or unintentional renal artery (RA) coverage is not always technically successful, and the loss of a single RA may result in the need for postoperative dialysis. Thus, we compared the outcomes after endovascular aneurysm repair (EVAR) stratified by RA involvement (RAI). METHODS: Patient data from the Vascular Quality Initiative from 2009 to 2018 registry were analyzed. The exclusion criteria were preoperative dialysis, missing RAI data, and repair above the superior mesenteric artery. The repair type cohorts were defined as (1) no RAI (NRAI), (2) RAI with revascularization (RAI-R), and (3) RAI with no revascularization (RAI-NR). A sensitivity analysis was performed by excluding ruptured presentations. The primary outcome was the need for postoperative dialysis. The secondary outcomes were 30-day mortality, dialysis at follow-up, postoperative renal function, and 2-year survival. Multivariate analysis was used to determine the independent predictors for postoperative dialysis. The 2-year survival analysis was performed using Kaplan-Meier log-rank test. RESULTS: Of 54,020 patients in the EVAR and TEVAR (thoracic EVAR)/complex EVAR modules in the Vascular Quality Initiative, 25,724 met the criteria for inclusion (NRAI, n = 24,879; RAI-R, n = 733; RAI-NR, n = 112). The demographics and comorbidities were similar among the three groups. The RAI-NR group had more frequently had ruptured or symptomatic aneurysms. The postoperative dialysis requirement was higher in the RAI-NR group (NRAI, 0.7%; RAI-R, 2.2%; RAI-NR, 17%; P < .0001), as were the 30-day mortality and dialysis requirement at follow-up. On multivariate analysis, RAI-R (odds ratio [OR], 2.2; P = .03) and RAI-NR (OR, 5.9; P < .0001) were independent predictors of postoperative dialysis and remained so after excluding ruptured presentations (RAI-R: OR, 3; P = .003; RAI-NR: OR, 22.3; P < .0001). Other independent predictors of the need for postoperative dialysis were worse preoperative renal function, a symptomatic presentation, any preoperative or intraoperative blood transfusion, and larger blood loss (≥200 mL). Excluding those with rupture, the overall survival at 2 years on Kaplan-Meier analysis was lower for the RAI-NR group (NRAI, 92%; RAI-R, 89%; RAI-NR, 80%; P = .004). CONCLUSIONS: RAI is highly predictive of the need for postoperative and permanent dialysis after EVAR. RAI-NR was associated with lower overall survival. These risks should be considered when planning and performing EVAR and should be weighed against the risks of open repair when considering the treatment options.

Complications associated with lumbar drain placement for endovascular aortic repair.

OBJECTIVE: We reviewed the complications associated with perioperative lumbar drain (LD) placement for endovascular aortic repair. METHODS: Patients who had undergone perioperative LD placement for endovascular repair of thoracic and thoracoabdominal aortic pathologies from 2010 to 2019 were reviewed. The primary endpoints were major and minor LD-associated complications. Complications that had resulted in neurological sequelae or had required an intervention or a delay in operation were defined as major. These included intracranial hemorrhage, symptomatic spinal hematoma, cerebrospinal fluid (CSF) leak requiring intervention, meningitis, retained catheter tip, arachnoiditis, and traumatic (or bloody) tap resulting in delayed operation. Minor complications were defined as a bloody tap without a delay in surgery, asymptomatic epidural hematoma, and CSF leak with no intervention required. Isolated headaches were recorded separately owing to the minimal clinical impact. RESULTS: A total of 309 LDs had been placed in 268 consecutive patients for 222 thoracic endovascular aortic repairs, 85 complex endovascular aortic repairs (EVARs; fenestrated branched EVAR/parallel grafting), and 2 EVARs (age, 65 ± 13 years; 71% male) for aortic pathology, including aneurysm (47%), dissection (49%), penetrating aortic ulcer (3%), and traumatic injury (0.6%). A dedicated neurosurgical team performed all LD procedures; most were performed by the same individual, with a technical success rate of 98%. Radiologic guidance was required in 3%. The reasons for unsuccessful placement were body habitus (n = 2) and severe spinal disease (n = 3). Most were placed prophylactically (96%). The overall complication rate was 8.1% (4.2% major and 3.9% minor). Major complications included spinal hematoma with paraplegia in 1 patient, intracranial hemorrhage in 2, meningitis in 2, arachnoiditis in 3, CSF leak requiring a blood patch in 3, bloody tap delaying the operation in 1, and a retained catheter tip in 1 patient. Patients who had undergone previous LD placement had experienced significantly more major LD-related complications (12.2% vs 3%; P = .019). The rate of total LD-associated complications did not differ between prophylactic and emergent therapeutic placements (8.1% vs 7.7%; P = 1.00) nor between major or minor complications. On multivariate analysis, previous LD placement and an overweight body mass index were the only independent predictors of major LD-related complications. CONCLUSIONS: The complications associated with LD placement can be severe even when performed by a dedicated team. Previous LD placement and overweight body mass index were associated with a significantly greater risk of complications; however, emergent therapeutic placement was not. Although these risks are justified for therapeutic LD placement, the benefit of prophylactic LD placement to prevent paraplegia should be weighed against these serious complications.

Branch Vessel Patency after Thoracic Endovascular Aortic Repair for Type B Aortic Dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) for type B aortic dissections is used to promote false lumen (FL) thrombosis and favorable aortic remodeling, but its impact on occlusion of FL origin branch vessels has not been widely described. We compare FL versus true lumen (TL) branch vessel patency after TEVAR. METHODS: Patients treated by TEVAR for type B aortic dissection in zones 2-5 in the Vascular Quality Initiative from 2009 to 2018 were evaluated. The primary outcome was postoperative branch patency. Secondary outcomes were need for branch vessel intervention, preoperative origin, and postoperative patency of individual branch vessels (celiac, superior mesenteric artery, renal arteries, and iliac arteries). A subset analysis was performed comparing acute and chronic dissections. RESULTS: Of 11,774 patients, 1,484 met criteria for analysis. The left renal was the most common to have FL origin (21.6%), whereas right and left common iliac arteries were the most likely to originate off both lumens (BLs; 22% and 24%). Branch vessels that originated from the TL, FL, BLs, or were obstructed had postoperative patency rates of 99%, 99%, 99%, and 87% (P < 0.0001). Branch vessel treatment was performed in 5% of patients. The right (2.5%) and left (2.8%) renal arteries were the most frequently obstructed branches postoperatively. On multivariate analysis, preoperatively obstructed branches (odds ratio 0.03, P < 0.0001) were negatively associated with postoperative branch patency and branch vessel treatment (odds ratio 3.8, P = 0.004) was positively associated with postoperative patency. FL or BL origin, number of zones covered by TEVAR, urgency, dissection chronicity (acute versus chronic), and demographics were not independently associated with patency. These findings remained unchanged in the subset analysis of only acute dissections. CONCLUSIONS: Branch vessel patency rates after TEVAR for a type B aortic dissection are high and are not significantly different for FL or BL origin vessels compared with TL vessels. Branches that are patent before TEVAR almost always remain patent after TEVAR, but branch vessel stenting may be required in less than 5%.

Functional ambulatory status as a potential adjunctive decision-making tool following wound, level of ischemia, and severity of foot infection assessment.

The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System has been developed to stratify amputation risk on the basis of extent of the wound, level of ischemia, and severity of foot infection (WIfI). However, there are no currently validated metrics to assess, grade, and consider functional status, especially ambulatory status, as a major consideration during limb salvage efforts. Therefore, we propose an adjunct to the current WIfI system to include the patient's ambulatory functional status after initial assessment of limb threat. We propose a functional ambulatory score divided into grade 0, ambulation outside the home with or without an assistive device; grade 1, ambulation within the home with or without an assistive device; grade 2, minimal ambulation, limbs used for transfers; and grade 3, a person who is bed-bound. Adding ambulatory function as a supplementary assessment tool can guide clinical decision making to achieve optimal future functional ambulatory outcome, a patient-centered goal as critical as limb preservation. This adjunct may aid limb preservation teams in rapid, effective communication and clinical decision making after initial WIfI assessment. It may also improve efforts toward patient-centered care and functional ambulatory outcome as a primary objective. We suggest a score of functional ambulatory status should be included in future trials of patients with chronic limb-threatening ischemia.

Association of upper extremity and neck access with stroke in endovascular aortic repair.

OBJECTIVE: Upper extremity and neck access is commonly used for complex endovascular aortic repairs. We sought to compare perioperative stroke and other complications of (1) arm/neck (AN) and femoral or iliac access versus femoral/iliac (FI) access alone, (2) right- versus left-sided AN, and (3) specific arm versus neck access sites. METHODS: Patients entered in the thoracic endovascular aortic repair/complex endovascular aortic repair registry in the Vascular Quality Initiative from 2009 to 2018 were analyzed. Patients with a missing access variable and aortic arch proximal landing zone were excluded. The primary outcome was perioperative in-hospital stroke. Secondary outcomes were other postoperative complications and 1-year survival. Kaplan-Meier curves and log-rank test were used for survival analysis. RESULTS: Of 11,621 patients with 11,774 recorded operations, 6691 operations in 6602 patients met criteria for analysis (1418 AN, 5273 FI). AN patients had a higher rate of smoking history (83.6% vs 76.1%; P < .0001), and prior stroke (12.6% vs 10.1%; P = .01). Operative time (280 ± 124 minutes vs 157 ± 102 minutes; P < .0001), contrast load (141 ± 82 mL vs 103 ± 67 mL; P < .0001), and estimated blood loss (300 mL vs 100 mL; P < .0001) were larger in the AN group, indicative of greater complexity cases. Overall, AN had a higher rate of stroke (3.1% vs 1.8%; P = .003) compared with FI and on multivariable analysis AN access was found to be an independent risk factor for stroke (odds ratio, 1.97; P = .0003). There was no difference in stroke when comparing right- and left-sided AN access (2.8% vs 3.2%; P = .71). Stroke rates were similar between arm, axillary, and multiple access sites, but were significantly higher in patients with carotid access (2.6% vs 3.5% vs 13% vs 3.7%; P = .04). AN also had higher rates of puncture site hematoma, access site occlusion, arm ischemia, and in-hospital mortality (7.1% vs 4.2%; P < .0001). At 1 year, AN had a lower survival rate (85.1% vs 88.1%; P = .03). CONCLUSIONS: Upper extremity and neck access for complex aortic repairs has a higher risk of stroke compared with femoral and iliac access alone. Right-sided access does not have a higher stroke rate than left-sided access. Carotid access has a higher stroke rate than axillary, arm, and multiple arm/neck access sites.

Association of aberrant subclavian arteries with aortic pathology and proposed classification system.

OBJECTIVE: Aberrant subclavian artery (aSCA) is a rare anatomic variant whose association with other aortic branch variations and aortic pathology has yet to be established. Knowledge of such an association could be relevant to recommendations for screening and awareness as associated variations are important for operative planning. We describe the incidence of aSCA variations, its association with aortic pathology, and a proposed classification system. METHODS: The thoracic cross-sectional imaging database at Keck Hospital of the University of Southern California from 2006 to 2018 was queried for presence of aSCA. Studies were evaluated for aSCA laterality, variant anatomy, and aortic and branch vessel disease. Medical records were reviewed for associated symptoms and diagnoses. The primary outcome was association of aSCA with aortic pathology (aneurysm or dissection). Secondary outcomes were comparison of right and left aSCA, comparison between the sexes, and creation of a proposed classification system. RESULTS: Of 98,580 axial imaging studies, 810 studies (0.82%) were identified with aSCA in 312 unique patients. Right aSCA made up the majority of cases (90.1%). All aSCAs had a retroesophageal course. Kommerell's diverticulum (KD) was present in 184 (59%) with an average diameter of 1.67 cm (range, 1.2-3.3 cm). KD was more frequent (84% vs 56%; P = .0003) and larger (2.05 cm vs 1.61 cm; P < .0001) in left aSCA patients. When present, KD was more often symptomatic in left aSCA compared with right aSCA (77.4% vs 49.1%; P = .005). Dysphagia, chest pain, reflux, and asthma were all more common in left aSCA patients. KD was also more common in men (73.3% vs 50%; P < .0001) and larger in men (1.81 cm vs 1.54 cm; P < .0001) but with no difference in symptoms between sexes. Our proposed classification system based on aortic arch branching is as follows: type 1, left arch with right aSCA (59.9%); type 2, left arch with common carotid trunk and right aSCA (30.1%); type 3, right arch with left aSCA (9.6%); and type 4, right arch with common carotid trunk and left aSCA (0.3%). Subtypes describe the right vertebral artery (RVA) and left vertebral artery (LVA) origin: subclavian (s, RVA 90.1%, LVA 96.8%), carotid (c, RVA 9.6%, LVA 0.3%), or arch (a, RVA 0.3%, LVA 2.9%). Overall, 9.9% (31/312) had associated aortic pathology, although the study was underpowered to detect a difference between right aSCA and left aSCA (9.3% vs 16.1%; P = .213). Type 3 and type 4 arches more often have associated aortic pathology, KD, and symptoms. CONCLUSIONS: aSCAs are frequently symptomatic and commonly associated with aortic dissection and aneurysm. Our proposed classification scheme depicts all four aSCA arch variants and accounts for vertebral artery origin variation. These variants are common, and vertebral anatomy can differ greatly. Knowledge of these anatomic variations is critical to planning for endovascular and open repair of aortic arch pathology.

A standardized trauma-specific endovascular inventory.

We believe that the rapid and widespread adoption of resuscitative endovascular balloon occlusion of the aorta as well as enthusiasm for catheter-based strategies has led to increased interest in basic endovascular techniques among trauma surgeons. The aim of this article was to describe the most commonly performed endovascular procedures for trauma patients, the basic capital equipment and room set up, and a parsimonious inventory of disposable supplies needed to perform each procedure. Together, these make a standardized trauma-specific endovascular inventory. LEVEL OF EVIDENCE: Economic/decision, level V.

Methicillin-resistant Staphylococcus aureus portends a poor prognosis after endovascular repair of mycotic aortic aneurysms and aortic graft infections.

OBJECTIVE: Mycotic aortic aneurysms and aortic graft infections (aortic infections [AIs]) are rare but highly morbid conditions. Open surgical repair is the "gold standard" treatment, but endovascular repair (EVR) is increasingly being used in the management of AI because of the lower operative morbidity. Multiple organisms are associated with AI, and bacteriology may be an important indication of mortality. We describe the bacteriology and associated outcomes of a group of patients treated with an EVR-first approach for AI. METHODS: All patients who underwent EVR for native aortic or aortic graft infections between 2005 and 2016 were retrospectively reviewed. Primary end points were 30-day mortality and overall mortality. The primary exposure variable was bacteria species. Logistic regression analysis was used to determine association with mortality. Kaplan-Meier survival analysis was used to estimate survival. RESULTS: A total of 2038 EVRs were performed in 1989 unique and consecutive patients. Of those, 27 patients had undergone EVR for AI. Thirteen presented ruptured (48%). Eighteen (67%) were hemodynamically unstable. Ten had a gastrointestinal bleed (37%), whereas others presented with abdominal pain (33%), fever (22%), chest or back pain (18.5%), and hemothorax (3.7%). Twenty patients had a positive blood culture (74%), with the most common organism being methicillin-resistant Staphylococcus aureus (MRSA) isolated in 37% (10). Other organisms were Escherichia coli (3), Staphylococcus epidermidis (2), Streptococcus (2), Enterococcus faecalis (1), vancomycin-resistant Enterococcus (1), and Klebsiella (1). Thirteen patients had 4 to 6 weeks of postoperative antibiotic therapy, six of whom died after therapy. Fourteen were prescribed lifelong therapy; 10 died while receiving antibiotics. On univariate analysis for mortality, smoking history (P = .061) and aerodigestive bleeding on presentation (P = .109) approached significance, whereas MRSA infection (P = .001) was strongly associated with increased mortality. On multivariate analysis, MRSA remained a strong, independent predictor of mortality (adjusted odds ratio, 93.2; 95% confidence interval, 1.9-4643; P = .023). Overall 30-day mortality was 11%, all MRSA positive. At mean follow-up of 17.4 ± 28 months, overall mortality was 59%. Overall survival at 1 year, 3 years, and 5 years was 49%, 31%, and 23%. Kaplan-Meier survival analysis demonstrated that MRSA-positive patients had a significantly lower survival compared with other pathogens (1-year, 20% vs 71%; 5-year, 0% vs 44%; P = .0009). CONCLUSIONS: In our series of AI, the most commonly isolated organism was MRSA. MRSA is highly virulent and is associated with increased mortality compared with all other organisms, regardless of treatment. Given our results, EVR for MRSA-positive AI was not a durable treatment option.

Impact of ligation versus repair of isolated popliteal vein injuries on in-hospital outcomes in trauma patients.

BACKGROUND: Popliteal vascular injuries are common and frequently associated with limb loss. Although many studies have evaluated the treatment and outcomes of popliteal artery injuries (PAI), there is little available evidence regarding popliteal venous injuries (PVI). As such, substantial debate remains regarding the benefit of repair over ligation of PVI. The objectives of this study were to compare in-hospital outcomes of repair versus ligation of isolated PVI, as well as to determine nonvascular factors associated with worse outcomes. METHODS: Patients in the National Trauma Databank from 2007 to 2014 with at least one PVI were evaluated. First, patients with concomitant PVI and PAI were compared with patients with isolated PVI. Second, outcomes were compared between ligation and repair of isolated PVI. To limit the impact of concomitant injuries and focus on the impact of venous injury management, we defined isolated PVI as cases without concomitant PAI and with Abbreviated Injury Scale severity score of less than 3 for all body regions other than lower extremity. Patients dead on arrival and those with less than 18 years of age were excluded. The primary outcomes were in-hospital mortality, amputation, and in-hospital amputation-free survival (AFS). Secondary outcomes included lower extremity compartment syndrome, fasciotomy, acute kidney injury, pulmonary embolism, deep venous thrombosis, and inferior vena cava filter placement. RESULTS: Overall, 1819 patients (0.03%) had a PVI and after exclusion 1213 met the criteria for initial analysis. Of those, 308 had isolated PVI, and 905 had combined PVI and PAI. Patients with combined PVI and PAI had higher rates of amputation (15.2% vs 6.8%; P < .001), fasciotomy (64.5% vs 30.8%; P < .001), compartment syndrome (14.8% vs 8.8%; P = .006), and a lower AFS (82.9% vs 91.8%; P < .001) than patients with isolated PVI. There was no difference in in-hospital mortality, amputation, or in-hospital AFS between ligation and repair of isolated PVI. On multivariable logistic regression of isolated PVI, ligation was not independently associated with in-hospital AFS, amputation, or mortality. CONCLUSIONS: Ligation of isolated PVI was not an independent predictor of in-hospital mortality, lower extremity amputation, or in-hospital AFS. Ligation also did not result in higher rates of fasciotomy, acute kidney injury, or pulmonary embolism.

Endovascular septal fenestration using a radiofrequency wire to salvage inadvertent false lumen deployment of a frozen elephant trunk stent graft.

We report a case of a frozen elephant trunk arch repair, where the stent graft was unintentionally placed into the false lumen. Postoperative imaging demonstrated an enlarged false lumen with no thoracic aorta fenestrations that could be traversed to place another thoracic endovascular aortic repair endograft into the true lumen. An atraumatic radiofrequency wire (PowerWire, Baylis Medical, Montreal, Quebec, Canada) was used to create a new septal fenestration, enabling thoracic endovascular aortic repair endograft extension into the thoracic true lumen. This novel use of a radiofrequency wire can enable safe and controlled endovascular septal fenestration even in chronic dissections to redirect flow into the true lumen.

Impact of inferior vena cava ligation on mortality in trauma patients.

OBJECTIVE: Inferior vena cava (IVC) injuries are potentially lethal and require prompt intervention. Repair of complex IVC injuries may require the use of a prosthetic graft or a complicated panel or spiral vein graft reconstruction to avoid the need for ligation. Collateral venous drainage may be sufficient to allow acceptable results from IVC ligation; however, previous studies have suffered from low numbers and have differing results. The aims of this study were to assess the outcomes of isolated IVC injuries overall and to compare IVC ligation with repair. METHODS: Patients in the National Trauma Data Bank from 2007 to 2014 with an IVC injury were evaluated. Isolated IVC injury was defined as patients with nonvascular Abbreviated Injury Scale scores <4 and no other named vascular injury. The primary outcome was mortality; secondary outcomes were in-hospital amputation-free survival, major lower extremity amputation, lower extremity compartment syndrome, acute kidney injury (AKI), deep venous thrombosis (DVT), and pulmonary embolism (PE). RESULTS: Overall, 1075 (0.018%) patients had IVC injuries and 443 met inclusion criteria. On univariate analysis, in comparing IVC ligation and primary repair, ligation was not associated with mortality (23% vs 16%; P = .102) but was associated with blunt mechanism (22% vs 11%; P = .009), higher fasciotomy rate (11% vs 0%; P < .001), trend toward lower in-hospital amputation-free survival (76% vs 84.4%, P = .056), and higher rates of AKI (9% vs 4%; P = .060) and PE (3% vs 1%, P = .087). Similarly, major lower extremity amputation, compartment syndrome, and DVT were not different between groups. IVC ligation was not independently associated with mortality (adjusted odds ratio [AOR], 1.54; P = .197), in-hospital amputation-free survival (AOR, 0.61; P = .141), major amputation (AOR, Inf; P = .99), lower extremity compartment syndrome (AOR, 0.82; P = .827), or PE (AOR, 6.72; P = .052), but it was independently associated with fasciotomy (AOR, 31.4; P = .002), AKI (AOR, 2.7; P = .048), and DVT (AOR, 2.3; P = .021). CONCLUSIONS: IVC ligation was not independently associated with mortality or lower extremity amputation, but it was associated with AKI and need for fasciotomy.

Fourth Time Redo Common Femoral Vein Reconstruction with a Novel Hybrid Technique.

BACKGROUND: Iliofemoral vein thrombosis can lead to debilitating edema and venous claudication that significantly worsens quality of life, especially in young active individuals. Venous reconstruction becomes increasingly complex and has worsening patency with subsequent revisions so preoperative planning is critical to success. METHODS: We report a case of a 54-year-old man in active military service with profoundly symptomatic leg swelling after failure of 3 previous common femoral vein (CFV) reconstructions. The CFV and distal external iliac vein were thrombosed up to a few centimeters above the inguinal ligament. Direct proximal control would have required a retroperitoneal or transabdominal incision. However, a hybrid approach utilizing through-wire access, remote balloon control of the external iliac vein, cryopreserved vein graft, stent graft, and arteriovenous fistula was able to address the factors (graft size, external compression, adequate flow) contributing to his previous graft failures with a novel, less invasive approach. RESULTS: At 1-year follow-up, he was asymptomatic and the graft remained patent with normal vascular duplex studies. His leg swelling subsided and he was able to return to his previous physical activity level. CONCLUSIONS: A hybrid approach to complex venous reconstruction can provide a minimally invasive and durable alternative to more invasive procedures and alleviate mechanical causes of early graft failure.

Carotid Artery Entrapment by the Hyoid Bone-A Rare Cause of Recurrent Strokes in a Young Patient.

The search for etiology of stroke in a young patient may present a diagnostic challenge. In rare cases, chronic trauma to the carotid artery may be the cause of cerebral thromboembolic events. The hyoid bone lies in close proximity to the carotid artery bifurcation, and anatomic variants have been implicated in carotid compression, stenosis, dissection, and pseudoaneurysm. We report a case of recurrent strokes in a 32-year-old woman due to an elongated hyoid bone causing thrombus formation in her right internal carotid artery (ICA), resulting in recurrent embolic strokes confirmed on diffusion-weighted magnetic resonance imaging. Computed tomography angiography of the neck and head demonstrated the right hyoid bone was located between the ICA and external carotid artery (ECA), just above the carotid bifurcation, with residual nonocclusive thrombus in the right ICA. Carotid duplex ultrasonography confirmed that with the neck in neutral position, the hyoid was located between the ICA and ECA; however, with neck rotation, the hyoid slipped across the ICA and out of the bifurcation. There was no evidence of carotid stenosis. After an initial course of anticoagulation and antiplatelet therapy, resection of the greater cornu of the hyoid bone with release of the right ICA was performed. One year postoperatively, the patient had complete return of neurologic function and had no further neurologic events. Hyoid bone entrapment of the carotid artery is a rare etiology of thromboembolic stroke caused by repetitive local trauma. The diagnosis can be confirmed by carotid duplex with provocative maneuvers. Partial hyoid resection is a safe and effective treatment to relieve recurrent symptoms. Hyoid bone entrapment may be an important and under-recognized cause of stroke in young adults.

Inferior Vena Cava Filter Resulting in Perforation and Massive Retroperitoneal Hematoma Presenting as Acute Onset of Lower Extremity Weakness.

Perforation of inferior vena cava (IVC) filter struts is a common incidental finding on postoperative computed tomography (CT) scans that is not associated with bleeding or major complications. However, in rare circumstances, it can be associated with hemorrhage requiring immediate removal. We present a case of a 62-year-old man who developed abdominal pain and right lower extremity weakness 2 weeks after treatment of a pulmonary embolism with IVC filter placement and anticoagulation. A CT scan revealed a large right-sided retroperitoneal hematoma with active extravasation from the IVC filter struts that had perforated the IVC wall. He underwent a hybrid operation with endovascular retrieval of the IVC filter and concomitant IVC primary repair combined with evacuation of the hematoma, causing nerve compression. Postoperatively, he regained normal sensory and motor function. Perforation of IVC filter struts is usually asymptomatic, but in rare circumstances, it can cause hemorrhage requiring immediate removal and IVC repair. Surgical intervention is indicated in the setting of a large hematoma with nerve or vessel compression and may require a combined endovascular and open approach.