A Scoping Review of Definitions of Success in Endovascular Aortic Arch Repair.

INTRODUCTION: The present standard of care to treat aortic arch pathologies is open surgical repair with cardiopulmonary bypass and deep hypothermic arrest. With approaches for total endovascular and extra-anatomic cervical debranching hybrid arch repair becoming more diverse, understanding what is considered a successful operation is prerequisite for a rigorous comparison of techniques. This review describes the specific outcomes reported, the rates of success, and the definitions of technical and clinical success in total endovascular and extra-anatomic cervical debranching hybrid aortic arch repair. METHODS: A comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed. Studies with patients undergoing total endovascular or hybrid extra-anatomic cervical debranching repair of the aortic arch were included. Any publications including only patients with Ishimaru zone 2 or distal repairs were excluded from this review. Studies with less than 5 patients were excluded. Data extraction was performed by one author. Data items included were study design, procedure type, procedural details, underlying pathology, type of cervical debranching, type of endograft repair, surgical outcomes, definition of cerebrovascular events, technical success, and the definition of technical success. RESULTS: Of 1754 studies screened for review, 85 studies with 5521 patients were included. By frequency, the included studies examined the following interventions: fenestrated devices, branched devices, parallel grafting. Most studies were retrospective single-institution studies. There were no randomized controlled trials. Short-term mortality and cerebrovascular events were nearly universally reported, present in 99% and 95% of studies reviewed, respectively. Only 27% of studies provided an explicit definition for cerebrovascular events. While 75% of studies reported a technical success rate, only 45% of those studies provided explicit criteria. Clinical success rates were infrequently reported, present in only 5.9% of studies reviewed. CONCLUSION: The definitions of technical success that were provided fell short of analogous defined reporting standards in nearly all studies, inflating technical success rates. Definitions of cerebrovascular events and technical success require stringent criteria to uniformly compare various methods of endovascular aortic arch repair. A societal consensus document for reporting standards of endovascular aortic arch repair would allow for higher-quality outcomes research. CLINICAL IMPACT: Total endovascular and extra-anatomic cervical debranching hybrid operations are being increasingly utilized for complex aortic arch repair. These techniques, however, can be associated with serious complications. Currently, there is no accepted metric to define technical or report clinical outcomes. Due to the paucity of high-quality data, use of these approaches may be limited in clinical practice. This study emphasizes the need for the development of standards for reporting outcomes in endovascular aortic arch repair. Future studies can then utilize these benchmarks, whcih will allow for improved efficacy and safety in these techniques.

Optimization of factors for the prevention of spinal cord ischemia in thoracic endovascular aortic repair.

OBJECTIVES: Spinal cord ischemia following thoracic endovascular aortic repair (TEVAR) is a devastating complication. This study seeks to demonstrate how a standardized protocol to prevent spinal cord ischemia affects incidence in patients undergoing TEVAR. METHODS: Using CPT codes 33880 and 33881, all TEVAR procedures performed at a single tertiary care center from January 2017 to December 2018 were examined. Patients who had concomitant ascending aortic repairs or a TEVAR for traumatic indications were excluded from analysis, leaving 130 TEVAR procedures. Comorbid conditions, procedural characteristics, extent of coverage, peri-procedural management strategies, and post-operative outcomes were collected and analyzed retrospectively. RESULTS: One hundred thirty patients undergoing TEVAR were examined for four perioperative variables: postoperative hemoglobin greater than 10 g/dL, subclavian revascularization, preoperative spinal drain placement, and somatosensory evoked potential monitoring (SSEP). All conditions were met in 46.2% (60/130) of procedures; 37.8% (28/74) in emergent/urgent cases and 61.5% (32/52) in elective cases. Of patients who required subclavian coverage, 87.1% (54/62) underwent subclavian revascularization; 70.8% (92/130) of patients received spinal drains preoperatively; 68.5% (89/130) of patients had SSEP monitoring; 73.8% (93/130) of patients obtained a postoperative hemoglobin of >10 g/dL. Out of all patients, two (1.5%) developed spinal cord ischemia. CONCLUSION: Incidence of spinal cord ischemia in our cohort was low at 1.5% (2/130). Individual and bundled interventions for the prevention of spinal cord ischemia were unable to demonstrate a statistically significant effect given the low rate. Nonetheless, we advocate for a proactive approach for the prevention of spinal cord ischemia given our experience in this complex population.

Site of service influence on stent use for hemodialysis access interventions.

OBJECTIVE: With rising health care spending in the United States, the Centers for Medicare and Medicaid Services (CMS) in recent years attempted to use reimbursement rates to influence use of less expensive care sites for covered patients, such as ambulatory surgery centers (ASCs) and office-based laboratories (OBLs), in lieu of hospital service sites. It has been suggested that cost savings have not been realized because of more procedures being performed by physicians with ownership interests in nonhospital facilities. CMS adopted massive reimbursement changes for 2019 OBL and ASC-based procedures, which reduced dialysis access angioplasty reimbursement in the ASC setting by 50%, whereas facility reimbursement for stenting increased by 33% above prior levels. The clinical utility of adjunctive stenting in treating dialysis access stenosis remains controversial and highly discretionary. As a vascular group performing such procedures in both a hospital and nonhospital facility in which we have equity interest, we reviewed our use of stents in dialysis access procedures both in the hospital and in the ASC/OBL to determine whether site of service affected stent use. METHODS: A retrospective review of a prospectively maintained database was performed from 2014 to 2018. All patients undergoing dialysis access angiography with angioplasty and adjunctive stent placement at our OBL (later ASC) and our primary hospital were included in the study. RESULTS: There were 961 angioplasty or stent procedures performed for dialysis accesses between the two sites, 564 (58.7%) in the hospital setting and 397 (41.3%) at the OBL/ASC. There was a significant difference in race and age between the two sites, with younger, minority patients more frequently being treated in the hospital and older, white patients more likely to be treated in the ambulatory setting; 153 (27.1%) underwent adjunctive stent placement in the hospital and 127 (32.0%) in the ambulatory setting (P = .09). CONCLUSIONS: Whereas financial incentives have not yet had an appreciable influence on stent use for dialysis access within previous reimbursement paradigms, the dramatic changes recently adopted by CMS may well alter this dynamic and could lead to substantially higher overall costs without proven clinical advantage. Interventionalists may be incentivized to add stents when performing balloon angioplasty in ASCs. With high failure and reintervention rates and increasingly expensive adjuncts (drug-coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific type of procedure or site of care are substantial, and unintended negative consequences are likely to occur.

Co-Operative Vascular Intervention Disease (COVID) Team of Greater Philadelphia.

We established the Co-Operative Vascular Intervention Disease (COVID) Team of Greater Philadelphia because national guidelines may not apply to different geographic areas of the United States owing to varying penetrance of the virus. On April 10, 2020, a 10-question survey regarding issues and strategies dealing with COVID-19 was e-mailed to 58 vascular surgeons (VSs) in the Greater Philadelphia area. Fifty-four VSs in 18 surgical groups covering 28 hospitals responded. All groups accepted transfers because of continued availability of intensive care unit beds. Thirteen groups were asked to "redeploy" if the need arose to function outside of the usual duties of a VS. None imposed age restrictions regarding older VSs continuing clinical hospital work. The majority restricted noninvasive vascular laboratory studies to those studies for which findings might mandate intervention within 2 or 3 weeks, restricted dialysis access operations to urgent revisions of arteriovenous fistulas or grafts that were failing or had ulcerations, converted from in-person to telemedicine clinic interactions, and experienced moderate-severe anxiety or fear about personal COVID-19 exposure in the hospital. The majority of VSs in the Philadelphia area dramatically adjusted their clinical practices before the COVID-19 crisis reached peak levels experienced in other metropolitan areas.

Attitudes Regarding Pregnancy Among Vascular Surgery Trainees and Program Directors Based on a Survey of Vascular Residents, Vascular Fellows, and the Association of Program Directors in Vascular Surgery.

Introduction: We conducted a survey of vascular surgery (VS) trainees and program directors (PDs) to examine differing attitudes regarding pregnancy, starting a family, and work-life balance. Methods: A 20 question survey was e-mailed to VS residents (0+5), fellows (5+2) and PDs using Survey Monkey Inc. (San Mateo, California). Results: The survey was sent to 781 participants (608 VS trainees, 173 PDs) with a similar response rate among residents [39% (133/343)), fellows [37% (98/265)], and PDs [38% (65/173)]. Of the 296 total respondents, most were male [61% (181)] and ≤40 years old [81% (240)]. VS trainees and PDs believed their work load or scheduling-coverage issues significantly increased when a trainee or peer was pregnant [PDs = 73% (38/52); fellows = 66% (59/89); residents = 54% (38/71), 13 PDs, 7 fellows and 59 residents had never worked with a pregnant peer or trainee]. Male respondents overall were significantly more likely than females to opine that a pregnant vascular trainee or attending was less capable of performing her job while pregnant [28% (50/179) vs.16% (18/110); P = .024). Women overall reported each of the following factors more commonly than men as reasons for delaying childbearing: impairing professional advancement [42% (42/99) vs 14% (23/165); P < .001], limited time to devote to children [60% (59/99) vs 39% (64/165); P = .001], not wanting to burden peers or associates [36% (36/99) vs 13% (22/165); P < .001), extra stress [67% (66/99) vs 30% (50/165); P < .001], perceived negative view of peers and program directors towards pregnancy [29% (29/99) vs 1% (2/165); P < .001], and encouragement not to have children from peers or attending [15% (15/99) vs 2% (3/165); P < .001). More females than males overall regret their career choice in VS as it relates to starting a family [22% (24/107) vs. 12%; 21/170); P = .028]. When asked about the major barriers for female vascular surgeons who wanted to become pregnant, PDs cited an unsupportive home environment more than trainees [37% (24/65) vs 22% (51/231); P = .015], whereas trainees cited safety concerns affecting the pregnancy, such as radiation, more than PDs [71% (164/231) vs 43% (28/65); P < .001] Conclusions: There are significant differences in views toward pregnancy among males and females and among trainees and PDs overall. Contrasting gender-based perceptions of the impact of pregnancy on vascular training need to be addressed before adequate solutions to the challenge of work-life balance can be achieved. Significant opportunities exist for trainees and PDs to address these knowledge gaps.

Completion Arteriogram Following Carotid Endarterectomy Yields Lower Perioperative Stroke Rate.

Introduction: Completion imaging following carotid endarterectomy (CEA) remains controversial. We present our experience performing routine completion arteriography (CA). Methods: A retrospective review of our prospectively maintained institutional database was performed for patients undergoing isolated CEA. Results: 1439 isolated CEAs with CA were performed on 1297 patients. CEA was for asymptomatic lesions in 70% (1003) of cases. There were no complications related to arteriography. An abnormal arteriogram documented significant abnormalities in the internal carotid artery (ICA) and prompted revision in 1.7% (24/1439) of cases: 20 unsatisfactory distal endpoints of the endarterectomy (12 residual stenoses, 7 intimal flaps, and 1 dissection), 3 kinks or stenoses within the body of the patch, and 1 thrombus. Of the 20 distal endpoint lesions, stent deployment was used in 17 cases and patch revision in 3 cases. The other 4 cases were treated by patch angioplasty (3) or thrombectomy (1). None suffered a perioperative stroke. The overall 30-day stroke, death, and combined stroke/death rate for the 1439 patients in our series was 1.5% (22), .5% (7), and 1.9% (27), respectively. The combined stroke/death rate for asymptomatic lesions was 1.1% (11/1003) and for symptomatic lesions was 2.5% (11/436). Of the 22 strokes in the entire series (all with normal CA), 15 were non-hemorrhagic strokes ipsilateral to the CEA; 14 were confirmed to have widely patent endarterectomy sites by CT-A (13) or re-exploration and repeat arteriography (1). The occluded site was re-explored and underwent thrombectomy, but no technical problems were identified. The remaining strokes were hemorrhagic (4 reperfusion syndrome and 1 surgical site bleeding) or contralateral to the CEA (2). Conclusion: Although not all patients in this series who underwent intraoperative revision due to abnormal CA might have suffered a stroke, performing this simple and safe study may have halved our overall perioperative stroke rate from 3.2% to 1.5%.

Management of Pancreaticoduodenal Artery Aneurysms Based on a Single-Institution Experience.

OBJECTIVES: Pancreaticoduodenal artery aneurysms (PDAAs) are rare and have a high propensity for rupture. Historically, management of PDAAs included surgical reconstruction but has evolved with advances in endovascular therapy. We report our experience with management of PDAAs during the last 30 years. METHODS: We retrospectively reviewed our prospectively maintained registry between January 1, 1992 - March 30, 2020. RESULTS: We identified 8 patients with PDAAs: 4 with associated celiac artery occlusive disease and 4 without identifiable etiologies. Four patients were treated with surgical resection of the PDAAs: 2 intact aneurysms underwent concomitant revascularization (superior mesenteric artery-to-hepatic artery Dacron bypass; supra celiac aorta-to-hepatic artery Dacron bypass) and 2 (1 intact, 1 rupture) underwent ligation alone. Four patients were treated with coil embolization of the PDAA: 2 with concomitant stent-graft exclusion of the aneurysm (1 non-rupture, 1 rupture) and 2 without adjunctive measures (intact). There were no deaths nor any significant procedure-related morbidity. CONCLUSION: Our large single-center experience shows that PDAAs can be successfully treated by open or endovascular intervention with selective revascularization.

The Utility of Duplex Ultrasonography Surveillance in Identifying Failing Aortobifemoral Grafts.

OBJECTIVE: The Society for Vascular Surgery stated there are a lack of studies describing long-term surveillance for aortobifemoral (AoBF) bypasses. Our goal was to investigate the value of DU studies as a surveillance tool for AoBF bypasses. METHODS: We retrospectively identified patients in our prospectively maintained database who underwent AoBF bypasses between 1995-2018. Surveillance was performed routinely with DU post-operatively, every 6 months for 1 year, and then annually. We considered "abnormal" DU findings to include peri-graft fluid, pseudoaneurysm or, peak systolic velocities (PSVs) > 350 cm/sec or PSV ratio > 3.5 anywhere from the proximal aortic to distal femoral anastomosis. If abnormalities were identified patients underwent intervention or shorter surveillance intervals. RESULTS: Of 153 AoBF bypasses, 60 patients with 120 graft limbs fulfilled our post-operative surveillance protocol with a mean follow-up of 4.0 years (0.5-24 years). "Normal" DU surveillance studies were documented throughout follow-up in 112 (93%) limbs. Of these, 2 (1.7%) developed acute limb occlusion. Eight (6.7%) limbs had "abnormal" DU findings: 5 failing grafts with focal elevated PSVs, 2 with peri-graft fluid leading to a diagnosis of an infected graft, and 1 with a pseudoaneurysm (PSA). Contrast arteriography or CT-angiography confirmed > 75% diameter stenosis, fluid or PSA in all 8 limbs. Graft revision (5 endovascular, 2 surgical) was performed in 7 of the 8 limbs initially or after 2 successive "abnormal" DU studies within 6 weeks of each other; 1 patient refused intervention. Without surveillance, urgent or emergent treatment might have proved necessary in 7.5% (7 + 2 = 9/120) of cases instead of only 1.7% (2/120) of cases. CONCLUSION: Vascular surgeons should adopt DU as a useful surveillance tool to identify AoBF bypasses that are failing or have other problems not identified clinically. Persistence of "abnormal" DU findings should prompt operative or endovascular intervention.

Nutcracker Syndrome as an Unusual Cause of Postprandial Pain.

Nutcracker syndrome is a rare entity in which compression of the left renal vein (LRV), usually by the overlying superior mesenteric artery (SMA), results in renal venous congestion and reflux in the left ovarian vein (LOV). Patients may present with hematuria, left flank pain, dyspareunia, and vaginal or abdominal wall varicose veins. We report a patient with nutcracker syndrome who presented atypically with left flank pain that was exacerbated in the postprandial state. We hypothesize that the physiologic dilation of the SMA after oral intake caused increased LRV compression at that site and augmented lateral LRV distention. The patient had no evidence of SMA syndrome or chronic mesenteric insufficiency. Her symptoms resolved after we performed an LOV to inferior vena cava transposition.

Persistent Hypoglossal Artery: Challenges Associated With Carotid Revascularization.

Anomalous connections between the anterior and posterior cranial circulation are rare embryologic entities. A persistent hypoglossal artery has a reported incidence of 0.03% to 0.09% and has been linked to intracranial aneurysms, atherosclerosis, and posterior circulation ischemia. Identification of this anomaly is essential prior to carotid artery revascularization given the technical challenges and added risks with intervention. We report a case of an 80-year-old female with progression of carotid stenosis in the setting of a persistent hypoglossal artery. We provide a review of the literature and discuss the technical challenges of carotid revascularization in this patient.

Giant renal vein aneurysm.

A 37-year-old asymptomatic man presented with incidentally identified intra-abdominal venous aneurysms. Workup, which included venography, demonstrated an absent segment of the inferior vena cava between the inferior right and superior left renal vein, resulting in a 4.4-cm right renal vein aneurysm, dilated common iliac veins, and left external iliac vein aneurysm. Collateralization was robust. Given the limited natural history data and complexities of open reconstruction, we opted to observe this asymptomatic patient with serial imaging, which demonstrated no interval change. We present our case and a review of the literature pertaining to intra-abdominal venous aneurysms.

Evolving strategies for the management of venous thoracic outlet syndrome.

OBJECTIVE: Traditional management of venous thoracic outlet syndrome (VTOS) has involved catheter-directed thrombolysis (CDT) followed by transaxillary or paraclavicular (PC) first rib resection. More recently, we have adopted an infraclavicular (IC) approach for first rib resection and five other strategies to treat these patients. We report our evolving experience with the treatment of acute VTOS. METHODS: We reviewed our prospectively maintained database to identify patients treated for VTOS. Our strategy includes CDT with pharmacomechanical thrombectomy, IC first rib resection during the same hospitalization, and subclavian vein angioplasty immediately after rib resection. Postoperatively, a sequential compression device was applied to the affected arm and low-dose heparin given through the ipsilateral venous sheath. Antiplatelet therapy was given for 6 weeks and anticoagulation for 6 months. Our strategy evolved from a PC to an IC approach, given that the added morbidity of the supraclavicular approach to allow excision of the posterior portion of the rib may add no benefit with VTOS compared with arterial or neurogenic thoracic outlet syndrome. RESULTS: There were 51 patients who underwent first rib resection for VTOS, 11 (22%) through a PC approach and 40 (78%) through an IC approach. The average age was 36 years (range, 16-63 years), and the majority were female (36 [71%]) and involved the right subclavian vein (36 [71%]). All patients underwent preoperative CDT, 40 (78%) at our hospital and 11 (22%) elsewhere. Fifty patients (98%) underwent subclavian vein angioplasty after rib resection. A bare-metal stent was placed in two (4%) patients for persistent stenosis. Average length of stay was 3.7 (±2.1) days. Average operative time was 2.2 hours (range, 1.5-3.0 hours) when the IC approach was used vs 3.5 hours (range, 2.5-4.5 hours) for the PC approach (P < .0001). Of the entire group, one (2.6%) patient required reoperation for wound hematoma and six (12%) patients underwent repeated endovascular intervention for recurrent vein stenosis during follow-up (average, 38 months; range, 1-240 months). Primary and assisted primary patency rates at 3 years were 78% and 100%, respectively. There were no significant differences in patency rates or complications between the IC and PC approaches. CONCLUSIONS: Our transition to an IC approach demonstrated low perioperative morbidity and excellent subclavian vein patency rates with shorter operative times compared with a PC approach. Our practice has evolved to include IC first rib resection followed by concomitant postoperative venous balloon angioplasty.