Early survival benefit of a low-profile endograft in blunt traumatic aortic injury.

OBJECTIVE: The aim of this study was to demonstrate the safety and effectiveness of a low-profile thoracic endograft (19-23 French) in subjects with blunt traumatic aortic injury. METHODS: A prospective, multicenter study assessed the RelayPro thoracic endograft for the treatment of traumatic aortic injury. Fifty patients were enrolled at 16 centers in the United States between 2017 and 2021. The primary endpoint was 30-day all-cause mortality. RESULTS: The cohort was mostly male (74%), with a mean age of 42.4 ± 17.2 years, and treated for traumatic injuries (4% Grade 1, 8% Grade 2, 76% Grade 3, and 12% Grade 4) due to motor vehicle collision (80%). The proximal landing zone was proximal to the left subclavian artery in 42%, and access was primarily percutaneous (80%). Most (71%) were treated with a non-bare stent endograft. Technical success was 98% (one early type Ia endoleak). All-cause 30-day mortality was 2% (compared with an expected rate of 8%), with an exact two-sided 95% confidence interval [CI] of 0.1%, 10.6% below the performance goal upper limit of 25%. Kaplan-Meier analysis estimated freedom from all-cause mortality to be 98% at 30 days through 4 years (95% CI, 86.6%-99.7%). Kaplan-Meier estimated freedom from major adverse events, all-cause mortality, paralysis, and stroke, was 98.0% at 30 days and 95.8% from 6 months to 4 years (95% CI, 84.3%-98.9%). There were no strokes and one case of paraplegia (2%) during follow-up. CONCLUSIONS: RelayPro was safe and effective and may provide an early survival benefit in the treatment of blunt traumatic aortic injury.

Clinician perspectives regarding CYP2C19 genotype testing in patients with critical limb ischemia: A Delphi approach.

OBJECTIVES: Antiplatelet therapy is an essential element in the management of patients with arterial vascular disease. In peripheral arterial disease (PAD), dual antiplatelet therapy (DAPT), primarily clopidogrel and aspirin, is routinely prescribed following intervention. There is sparse data regarding the need for DAPT, the appropriate duration, or the heterogeneity of treatment effects for antiplatelet regimens across patients, leading to potential uncertainty and heterogeneity around treatment practices. An example of heterogeneity of treatment effects is a patients' metabolizer status for the use of clopidogrel. The aim of the study was to (1) assess clinicians' knowledge of and attitudes toward managing patients with CYP2C19 mutations, (2) identify barriers to implementation of CYP2C19 testing and management policies, and (3) reach consensus for CYP2C19 testing and management strategies for patients with PAD who undergo peripheral vascular interventions (PVI). METHODS: A modified Delphi method was used to establish consensus amongst PAD interventionalists around CYP2C19 testing. All practicing Yale New Haven Hospital PAD interventionalists with backgrounds in interventional cardiology, vascular surgery, or interventional radiology were approached by email for participation. Round 1 included the collection of baseline demographic questions, knowledge questions, and three statements for consensus. Knowledge questions were rated on a 0-10 Likert scale with the following anchors: 0 ("Not at all"), 5 ("Neutral), and 10 ("Very Much"). Participants were asked to rate the importance of the three consensus statements on a 9-point Likert scale from 1 ("Strongly Disagree") to 10 ("Strongly Agree"). In Round 2, participants were shown the same consensus statements, the median response of the group from the previous round, and their previous answers. Participants were instructed to revise their rating using the results from the previous round. This process was repeated for Round 3. RESULTS: Of the 28 experts invited to participate, 13 agreed (46%). Participants were predominantly male (92.3%) and white (61.5%) with representation from interventional cardiology (46.2%) and vascular surgery (53.8%). Most participants reported more than 10+ years in practice (61.5%). PAD interventionalists felt they would benefit from more education regarding CYP2C19 mutations (median score 8.0, interquartile range 5.0-8.5). They indicated some familiarity with CYP2C19 mutations (7.0, 6.0-9.5) but did not feel strongly that CYP2C19 was important to their practice (6.0, 5.5-7.5). In each round, the median responses for the three consensus statements were 5, 6, and 9, respectively. With each successive round the interquartile range narrowed indicative of evolving consensus but did not reach the prespecified interquartile range for consensus of 1 for any of the statements. CONCLUSIONS: PAD interventionalists practicing at an academic health system recognize the heterogenous response of their patients to clopidogrel therapy but are unsure when to leverage genetic testing to improve outcomes for their patients. Our study identified gaps regarding PAD interventionalists' knowledge, perceived barriers, and attitudes toward CYP2C19 testing in PAD. This information highlights the need for randomized data on genetic testing for clopidogrel responsiveness in peripheral vascular disease following intervention to help guide antiplatelet management.

The management of patients with popliteal artery aneurysms presenting with acute limb ischemia.

OBJECTIVE: Endovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared with open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well-studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI. METHODS: The Vascular Quality Initiative database for peripheral vascular interventions (PVIs) and infrainguinal bypass were reviewed for PAAs with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at 1 year. RESULTS: Urgent PAA repair for ALI constituted 10.5% (n = 571) of all PAAs. Most urgent repairs were open (80.6%; n = 460) with 19.4% (n = 111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8; P = .011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%; P = .006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%; P < .001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days; P < .001), and less likelihood of discharge to home (64.9% vs 70.3%; P = .051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to 1 year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%; P < .001), 30-day (6.3% vs 0.4%; P < .001), and 1-year (16.5% vs 8.4%; P = .02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality. CONCLUSIONS: Endovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias.

Characteristics and 1-year outcomes of patients with rupture of small abdominal aortic aneurysms.

OBJECTIVES: Ruptured abdominal aortic aneurysms (rAAA) are associated typically with a large sac diameter; however, some patients experience rupture before reaching operative thresholds for elective repair. We aim to investigate the characteristics and outcomes of patients who experience small rAAA. METHODS: The Vascular Quality Initiative database for open AAA repair and endovascular aneurysm repair from 2003 to 2020 were reviewed for all rAAA cases. Based on the 2018 Society for Vascular Surgery guidelines on operative size thresholds for elective repair, patients with infrarenal aneurysms of less than 5.0 cm in women or less than 5.5 cm in men were categorized as a small rAAA. Patients who met operative thresholds or had a concomitant iliac diameter 3.5 cm or greater were categorized as a large rAAA. Patient characteristics and perioperative as well as long-term outcomes were compared via univariate regression. Inverse probability of treatment weighting using propensity scores was used to examine the relationship between rAAA size and adverse outcomes. RESULTS: There were 3962 cases that met inclusion criteria, with 12.2% small rAAA. The mean aneurysm diameter was 42.3 mm and 78.5 mm in the small and large rAAA groups, respectively. Patients in the small rAAA group were significantly more likely to be younger, African American, have a lower body mass index, and had significantly higher rates of hypertension. Small rAAA were more likely to be repaired via endovascular aneurysm repair (P = .001). Hypotension was significantly less likely in patients with small rAAA (P<.001). Rates of perioperative myocardial infarction (P < .001), total morbidity (P < .004) and mortality (P < .001) were significantly higher for large rAAA cases. After propensity matching, there was no significant difference in mortality between the two groups, but smaller rAAA was associated with lower rates of myocardial infarction (odds ratio, 0.50; 95% confidence interval, 0.31-0.82). On long-term follow-up, no difference in mortality was noted between the two groups. CONCLUSIONS: Patients presenting with small rAAA represent 12.2% of all rAAA and are more likely to be African American. Small rAAA is associated with similar risk of perioperative and long-term mortality compared with rupture at larger size after risk adjustment.

Technical Feasibility and Safety of a Snare-Less, EVAR-First Technique for Iliac Branch Endoprosthesis.

OBJECTIVE: The purpose of this study was to evaluate the technical feasibility, safety, and early outcomes of a snare-less, endovascular abdominal aortic aneurysm repair (EVAR)-first technique (SET) for iliac branch endoprosthesis (IBE) placement. METHODS: We retrospectively reviewed all patients who received IBEs between July 2018 and March 2022. Patients were divided into 2 categories based on method of IBE deployment: SET or Standard. Primary endpoints were technical success, major adverse events, mortality, reintervention, internal iliac artery (IIA) patency, and freedom from IIA branch instability. Technical success was defined by successful deployment of both the EVAR and the IBE with maintained patency of the IIA and no stent graft migration. RESULTS: There were 20 patients (90% male, median age 72 [65.4-74.5] years) who underwent IBE placement. Among these, 5 (33.3%) underwent SET to treat 5 common iliac artery (CIA)/IIA aneurysms, while the remaining 15 (66.7%) underwent standard IBE deployment with through-and-through femoral access (n=13) or trans-brachial access (n=2) to treat 19 CIA/IIA aneurysms. Overall median renal to iliac bifurcation length was 169 (152-177) mm, with 9 patients falling short of the minimum of 165 mm for on-label IBE placement. Median contrast used was 148 (120-201) mL, fluoroscopy time 42.8 (35.0-49.8) minutes, estimated blood loss 200 (100-275) mL, and procedure time 192 (167-246) minutes, with no significant differences between the 2 groups. Technical success was achieved in 100% of cases. At 30 days, there were no mortalities or major adverse events in either group; there were 100% IIA patency, no IIA instability, and no reinterventions in both groups. Median follow-up in the SET group was 5.7 (5.5-6.2) months, with 1 death at 6 months and 1 type 1B endoleak at 6 months requiring reintervention. Median follow-up for the Standard group was 1.6 (0.8-2.1) years with 2 non-aneurysm-related deaths and no reinterventions at 1 year. CONCLUSIONS: SET for IBE is a safe and effective approach that decreases technical complexity and mitigates anatomic barriers to IBE placement. CLINICAL IMPACT: SET for IBE is a safe and effective approach to IBE placement that decreases technical complexity. A critical component to this technique is a large bore sheath with a stiff steerable tip. Importantly, this approach also mitigates anatomic barriers to IBE placement, expanding applicability of IBE technology to patients who may be otherwise ineligible.

Elucidating the Role of the AFX2 Endograft in Endovascular Treatment of Aortic Pathology.

BACKGROUND: The purpose of this study is to elucidate the role of the AFX2 platform in the endovascular treatment of aortic pathology. METHODS: All procedures by a single surgeon resulting in implantation of a bifurcated unibody stent graft were reviewed retrospectively. Indications for selection of the AFX2 endograft in each case were evaluated. Aortic anatomy was determined via review of pre-operative computed tomography (CT) scans. Cumulative event probabilities for endoleak, reintervention, and mortality were estimated. Patient and procedural details were described using mean, standard deviation, medians, and interquartile range (IQR). Kaplan-Meier survival analysis estimated freedom from mortality and reintervention. Cumulative incidence probabilities were calculated as one minus the Kaplan-Meier estimator. RESULTS: Between March 2018 and December 2020, the author (NN) used 142 aortic endografts in 142 patients. Of these, 46 (32.4%) were AFX2 endografts and the remaining were modular bifurcated devices, predominantly Medtronic Endurant II and Terumo Treo. No AFX-Strata or AFX-Duraply devices were placed. Amongst the patients who received an AFX2, mean age was 71.3 +/- 9.8 years with 84.8% male. Median operative time was 116 (86-166) min, with contrast dose of 79 (41-120) milliliters and fluoroscopy time of 12 (8.6-18) min. Overall, 78.3% (n = 36) of AFX2 devices were placed in aortas with maximum true lumen diameter <5.0 cm. Median postoperative follow-up was 1.7 years (IQR 1.0-2.4 years), with a maximum follow-up of 3.6 years. There was 1 patient lost to follow-up at 5 months. The 2-year incidence of type II endoleak, reintervention, and all-cause mortality was 12.7% (95% confidence interval CI, 0-29.6%), 2.2% (95% CI, 0-6.3%), and 11.3% (95% CI, 0.1-2.1.2%), respectively. There were no type I or III endoleaks. CONCLUSIONS: The AFX2 endograft plays a safe and effective role in treatment of infrarenal aortic pathologies that may be otherwise more technically challenging for traditional modular, bifurcated devices.

Trends and outcomes of thoracic endovascular aortic repair with open concomitant cervical debranching.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has become the most common surgical procedure for treatment of descending thoracic aortic pathology. Cervical debranching in the form of carotid-subclavian bypass or transposition (CSBT) and carotid-carotid bypass (CCB) has enabled the use of TEVAR for the treatment of more complex anatomy involving the arch. The present study examined the effects of concomitant cervical bypass on the perioperative outcomes of TEVAR. METHODS: The American College of Surgeons National Surgical Quality Improvement Program files (2005-2017) were reviewed. Using the Current Procedural Terminology codes, all patients who had undergone TEVAR were identified and were divided into three groups: TEVAR, TEVAR with one bypass (CSBT or CCB), and TEVAR with two bypasses (CSBT and CCB). The patient characteristics and perioperative outcomes of the three groups were compared. Multivariable analysis was performed to determine the factors associated with mortality. RESULTS: A total of 3281 patients had undergone TEVAR and 10% had also undergone one or more debranching procedure (one bypass, 9%; two bypasses, 1%). The frequency of debranching had increased from 3.4% to 10.9% (P = .01) during the study period. Significant differences were found among the three groups in age, sex, smoking history, urgency of surgery, and anesthesia technique. The patients who had undergone TEVAR with cervical debranching had had significantly greater morbidity, longer operating times, and longer hospital stays compared with those who had undergone TEVAR alone. The mortality of TEVAR with two bypasses (22.6%) was significantly greater than that of TEVAR alone (7.5%) and TEVAR with one bypass (6.8%; P < .01). The total morbidity (30.9% vs 35.1% vs 67.7%; P < .001) and stroke rate (3% vs 7.5% vs 12.9%; P < .0001) increased with the increasing number of bypasses. A subgroup analysis of patients who had undergone TEVAR with one bypass showed no significant differences in mortality between TEVAR plus CSBT (6.6%) vs TEVAR plus CCB (8.8%; P = .63). Multivariable analysis showed that TEVAR with two bypasses was associated with significantly increased mortality compared with TEVAR alone (odds ratio [OR], 4.33; 95% confidence interval [CI], 1.75-10.73) and TEVAR with one bypass (OR, 3.44; 95% CI, 1.24-9.51). Older age (OR, 1.74; 95% CI, 1.42-2.13), dependent functional status (OR, 1.48; 1.00-2.19), dialysis (OR, 2.61; 95% CI, 1.57-4.33), and emergent status (OR, 3.66; 95% CI, 2.73-4.90) were also associated with mortality. CONCLUSIONS: TEVAR with concomitant cervical debranching has been increasingly used to treat complex aortic pathology but is associated with significantly worse outcomes than TEVAR alone. As advanced endovascular technology to treat the aortic arch emerges, the outcomes of open surgical debranching in the present study constitute an important benchmark for comparison.

Characteristics and outcomes of small abdominal aortic aneurysm rupture in the American College of Surgeons National Surgical Quality Improvement Program database.

OBJECTIVE: The current guidelines recommend elective abdominal aortic aneurysm (AAA) repair at 5.5 cm for men and 5.0 cm for women. However, rupture can occur in patients with an aneurysm smaller than these size thresholds. In the present study, we investigated the proportion of AAAs that rupture at sizes less than elective operative thresholds and compared the outcomes of repair with those of aneurysms that had ruptured at a larger size. Our hypothesis was that the rupture of small AAAs carries mortality similar to that of rupture at larger sizes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program targeted vascular files for open AAA repair and endovascular aneurysm repair (EVAR) were reviewed for all cases of ruptured AAAs (rAAAs) from 2011 to 2018. The patients were divided into two groups: those with small AAAs that had ruptured at a size less than the current size guidelines for elective repair and those with large AAAs that had ruptured at a size that had met the criteria for elective repair. Univariate analyses were conducted to compare the comorbidities and perioperative outcomes of infrarenal rAAA repair between the groups. Multivariable logistic regression was performed to examine the differences in mortality between small and large rAAAs after controlling for confounding variables. RESULTS: Of the 1612 rAAA repairs, 167 (10.4%) were small rAAAs. The proportion of small rAAAs did not significantly change during the study period (P = .15). The large rAAA group was more likely to have juxtarenal or suprarenal aneurysms compared with the small rAAA group (27% vs 16%; P = .001). A comparison of infrarenal rAAAs only demonstrated that the mean small rAAA (n = 141) diameter was 4.1 cm in the women and 4.5 cm in the men compared with the large rAAAs (n = 1051), with a mean diameter of 7.1 cm in women and 8.3 cm in men (P < .01 for the women; P < .01 for the men). The patients in the small rAAA group had had a significantly lower body mass index but were more likely to be African American and to have hypertension. The small rAAA group was more likely to present without hypotension and to have undergone EVAR. The repair of small rAAAs was associated with lower bleeding and mortality and a shorter mean operative time but with more readmissions. Multivariable regression analysis demonstrated that size was not associated with outcome after adjusting for other variables. CONCLUSIONS: Of all AAA repairs classified as treating rupture, 10% were for patients with small AAAs. Patients with small rAAA were less likely to present with hypotension and were more likely to have undergone EVAR. Further research into sac morphology and more sensitive imaging modalities might help identify small rAAAs at high risk of rupture that would benefit from elective repair.

Discrepancy in Outcomes after Revascularization for Chronic Limb-Threatening Ischemia Warrants Separate Reporting of Rest Pain and Tissue Loss.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) manifests as rest pain (RP) and tissue loss (TL). Outcomes of lower extremity revascularization (LER) for CLTI have traditionally been evaluated as a single entity and compared with claudication. We hypothesize that patients presenting with TL have worse short-term outcomes after LER, compared to patients with RP. METHODS: The National Inpatient Sample was reviewed between 2009 and 2013. All patients undergoing LER for TL and RP were identified. Patient characteristics, Charlson Comorbidity Index (CCI), length of stay, rates of inpatient major amputation, and mortality after LER were noted. Multivariable regression analysis was performed to identify predictors of inpatient mortality and major amputation between the 2 groups. RESULTS: A total of 218,628 patients underwent LER (RP = 76,108, TL = 142,519). Patients with TL were more likely to undergo endovascular LER (RP = 31.3% vs. TL = 48.7%; P < 0.001). Patients with TL had higher comorbidities as suggested by increased likelihood of having CCI ≥3 (RP = 22.9% vs. TL = 40.3%; P < 0.001). The mean costs were significantly higher in the TL group (RP = $23,795 vs. TL = $31,470; P < 0.001). There was a significantly higher rate of major amputation (RP = 1.3% vs. TL = 6.6%; P < 0.001) and inpatient mortality (RP = 0.9% vs. TL = 1.9%; P < 0.001) after LER for TL. On multivariable analysis, TL was independently associated with increased major amputation (odds ratio [OR] 4.93, 95% confidence interval [CI] 4.18-5.81) and increased mortality (OR 1.42, 95% CI 1.16-1.74) compared to RP. CONCLUSIONS: There is significant discrepancy in outcomes of LER for TL and RP. TL is independently associated with major amputation and inpatient mortality. Outcomes of LER for TL and RP should be reported separately for better benchmarking.

Alternative Endograft Aortoiliac Reconstruction for Iliac Branch Endoprostheses.

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

Endovascular Revascularization Incorporating Infrapopliteal Coronary Drug-Eluting Stents Improves Clinical Outcomes in Patients with Critical Limb Ischemia and Tissue Loss.

BACKGROUND: Critical limb ischemia (CLI) involving infrapopliteal arterial atherosclerosis and tissue loss remains a formidable clinical scenario with significant morbidity and mortality. Despite level IA evidence, tibial revascularization with coronary drug-eluting stents (DES) remains a seldom-used technique in the United States due, in part, to lack of a Food and Drug Administration-approved indication and dedicated stent technology for infrapopliteal application. Furthermore, follow-up data beyond 1 year remain scarce, and further evidence for improvement in clinical outcomes using this technique is needed. Herein, we present our multi-institutional experience with endovascular revascularization of patients with CLI and tissue loss using coronary DES for infrapopliteal lesions of appropriate dimensions and the Wound, Ischemia, and foot Infection (WIfI) score as supportive evidence for improvement in clinical outcomes. METHODS: In this retrospective study, 40 sequential tibial revascularization procedures performed in 32 patients with CLI were reviewed. Outcomes including changes in WIfI scores, patency rates, freedom from major amputation, target lesion recurrence, and all-cause mortality were analyzed. Average follow-up duration was 19.3 months (interquartile range: 7-27.1 months). RESULTS: Freedom from major amputation was 88.6%. One-year primary patency was 90.3%. Mean ankle-brachial indices increased after revascularization (0.57 ± 0.26 to 0.97 ± 0.26; P = 0.03). All components of the WIfI score significantly improved after revascularization (W: 1.9 to 1.1, P = 0.03; I: 2.0 to 0.6, P = 0.001; and fI: 1.5 to 0.8, P = 0.01). WIfI risk of major amputation score before revascularization was 3.58 ± 0.75 (high risk), which was reduced to 2.04 ± 1.31 (low risk; P < 0.001). One-year survival rate was 90.6%. CONCLUSIONS: Coronary DES continue to demonstrate promising primary patency and limb salvage rates in appropriately selected patients undergoing multilevel endovascular revascularization for CLI and tissue loss. In addition to its value as a predictor for major amputation and revascularization benefit, the WIfI score can also serve as a multicomponent tool for objective assessment of outcomes after revascularization.

Intraoperative retrograde TEVAR to control endoleak after emergent total arch replacement and frozen elephant trunk repair for ruptured Kommerell's diverticulum.

We report an emergent complex hybrid repair of a type A intramural hematoma with a tear of the aortic arch at the site of Kommerell's diverticulum and an aberrant right subclavian artery. We identified a type IA endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.

Molecular changes associated with vascular malformations.

Vascular anomalies are typically classified into two major categories, vascular tumors and vascular malformations. Most vascular malformations are caused sporadically by somatic mosaic gene mutations, and genetic analyses have advanced our understanding of the biomolecular mechanisms involved in their pathogenesis. Culprit gene mutations typically involve two major signaling pathways; the RAS/MAPK/ERK pathway is typically involved in fast-flow arteriovenous malformations, whereas the PI3K/AKT/mTOR pathway is typically mutated in slow-flow venous and lymphatic malformations. These findings suggest new therapeutic approaches to vascular malformations, focusing on targeting the etiologic mutated pathways. This review summarizes the currently available literature reflecting the updated International Society for Study of Vascular Anomalies classification system with emphasis on potential therapeutic targets that will provide vascular surgeons with an updated perspective on the etiologic basis of vascular malformations, allowing improved multidisciplinary collaboration.

Covered Stent Treatment of a Chronically Thrombosed Popliteal Artery Aneurysm in the Setting of Critical Limb Ischemia following Multiple Failed Bypass Operations.

Endovascular salvage of failed surgical bypasses has been scantly reported for treatment of infrainguinal occlusive disease. Although catheter-directed thrombolysis and/or mechanical thromboembolectomy have been the mainstay of endovascular salvage of previous bypass grafts, native vessel recanalization remains seldom attempted. Herein, we present a unique approach to native vessel recanalization of a chronically thrombosed popliteal artery aneurysm for nonhealing distal ulceration.

An Academic Tertiary Referral Center's Experience with a Vascular Surgery-Based Uterine Artery Embolization Program.

BACKGROUND: Despite growing endovascular experience within the vascular surgery community, some catheter-based interventions-such as uterine artery embolization (UAE)-remain outside the clinical scope of most vascular surgeons, owing in part to established referral patterns and limited awareness among referring colleagues. We present our experience with a vascular surgery-based, multidisciplinary UAE program at an academic tertiary referral center. METHODS: In a collaborative effort between vascular surgeons and gynecologists, a pelvic vascular disease program has been established to provide palliative, prophylactic, and therapeutic embolizations including, but not limited to, UAE. For UAE, inclusion criteria are women over the age of 18 years with symptomatic uterine fibroids demonstrated on magnetic resonance imaging and a negative endometrial biopsy. Exclusion criteria are desire for future pregnancy and previous embolization(s). Technique and perioperative protocol is presented. Data including symptom resolution, reintervention rates, and complications were prospectively gathered and retrospectively reviewed. RESULTS: Over an 18-month period, 30 patients with symptomatic fibroids were referred for potential UAE. Five patients were excluded because of uncertainty about future pregnancy wishes (4) and prior embolization (1). Twenty-four bilateral and 2 unilateral UAEs were performed (mean age, 46.3 years [range 28-53 years]). Presenting symptoms were pelvic and abdominal pain (25), cramps (25), menorrhagia (25), dysmenorrhea (25), urinary frequency (12), and dyspareunia (5). Technical success, defined as successful microcatheterization of uterine arteries and delivery of a particulate liquid embolic agent (embospheres, 500-700 microns), was 100%. There were no perioperative or delayed complications. Twenty-one patients (87.5%) reported complete symptomatic relief without further intervention at the time of last follow-up. Three patients (12.5%) reported pain relief but had persistent vaginal bleeding requiring hysterectomy 12 months after UAE. All patients underwent a 23-hr observation postoperatively for pain control. Mean follow-up was 7.4 months (1-23 months) and included pelvic ultrasound assessment of fibroid size at 1, 3, and 6 months after UAE and annually thereafter. One patient was lost to follow-up. Fibroid shrinkage was noted in all patients. Given the willingness and capability to work-up, admit, treat, and follow-up patients, vascular surgery was deemed the preferred service for UAE by the referring gynecologists. CONCLUSION: Within the framework of a collaborative, multidisciplinary program, vascular surgery can play a prominent role in providing safe and effective UAE.

Direct stick embolization of extremity arteriovenous malformations with ethylene vinyl alcohol copolymer.

Direct stick embolization (DSE) of high-flow peripheral arteriovenous malformations (AVMs) has previously been reported using n-butyl cyanoacrylate and ethanol. The use of ethylene vinyl alcohol copolymer (Onyx; Covidien, Plymouth, Minn) through this delivery route has been extremely limited, particularly in the peripheral interventional realm, owing to concerns about technique and conduit for delivery, skin discoloration, and ulceration. We describe three patients with relatively focal, symptomatic, congenital high-flow AVMs of the upper and lower extremity treated successfully by multifaceted approaches including transvenous coil embolization of the nidus venous outflow, transarterial embolization, and DSE of the AVM nidus with Onyx. Successful delivery of Onyx into the AVM nidus was achieved without nontarget embolization. Sustained symptomatic relief without recurrence or associated complications was achieved at 1 month, 3 months, and 6 months of follow-up. Nidus embolization is a key technical maneuver for optimal treatment of high-flow AVMs, although it is not always easily achievable by the transarterial route in more extensive, convoluted angioarchitectural varieties. With appropriate technical considerations and precautionary measures, Onyx can be safely and effectively delivered through DSE into the AVM nidus with satisfactory short-term and midterm clinical outcomes. This maneuver expands the armamentarium of the treating vascular surgeon facing complicated peripheral AVMs.

Stent-Assisted Coil Embolization of a Symptomatic Renal Artery Aneurysm at a Bifurcation Point.

BACKGROUND: Symptomatic renal artery aneurysms at bifurcation points present challenging clinical scenarios rarely amenable to endovascular repair due to concerns regarding parenchymal loss following intervention. Herein, we add to the scant body of literature describing successful endovascular repair of a saccular, symptomatic renal artery aneurysm situated at a bifurcation point. METHODS: A 52-year-old woman with a 2.5-cm extraparenchymal, saccular, symptomatic left renal artery aneurysm underwent self-expanding stent-assisted detachable platinum microcoil embolization. RESULTS: Complete aneurysm exclusion was achieved with minimal parenchymal loss. There were no perioperative complications, and no evidence of acute kidney injury perioperatively or at 3-month follow-up. Sustained symptomatic relief was achieved. CONCLUSIONS: Endovascular therapy can provide safe and effective aneurysm treatment within challenging bifurcated renal artery anatomy.

Endovascular Reconstruction for Chronic Infrarenal Aortoiliac Occlusive Disease.

According to the 2007 TransAtlantic Inter-Society Consensus (TASC II) guidelines, surgery is the preferred treatment for extensive (TASC II type C and D) aortoiliac occlusive disease (AIOD). Recent studies, however, have shown that endovascular management can be an effective first-line treatment option for TASC II type C and D categories. While endovascular therapy is now commonly performed in patients with TASC II type D lesions, very few studies have investigated the feasibility and effectiveness of extending endovascular therapy to the most severe subcategory of TASC II D lesions, chronic infrarenal aortoiliac occlusion (CIAO). Herein, we present our technique for endovascular treatment of CIAO which relies on bidirectional subintimal aortoiliac dissection, wire snare for true lumen reentry, and combined balloon-expandable and self-expanding covered stent reconstruction of the aortic bifurcation and bilateral iliac arteries. This technique safely extends the reach of endovascular therapy to the most severe subcategory of TASC II D AIOD, CIAO. It is a viable minimally invasive alternative to aortobifemoral bypass surgery. Long-term follow-up of larger cohorts is needed to verify clinical efficacy and durability of therapy.

Evaluation and management of congenital peripheral arteriovenous malformations.

The International Society for Study of Vascular Anomalies (ISSVA) broadly categorizes vascular anomalies into vascular tumors and vascular malformations. Vascular malformations are further divided based on their flow properties into slow-flow venous and lymphatic malformations, high-flow arteriovenous malformations (AVMs), and congenital mixed syndromes, which can include combinations thereof. Whether occurring in isolation or as part of a broader syndrome, congenital high-flow AVMs are arguably the most complicated, challenging, and gratifying of all vascular malformations to diagnose and manage. Various configurations exist depending on location and coexisting clinical features. Transcatheter embolization has evolved into the mainstay of treatment for most congenital peripheral AVMs with surgical excision playing a growingly limited role as an adjunctive modality. Successful treatment requires technical precision, creativity, patience, and persistence given the ever-evolving angioarchitecture and hemodynamic profile of these lesions. Despite these challenges, certain fundamental principles have been established as our understanding of the pathogenesis, natural history, hemodynamics, and treatment outcomes has expanded and evolved over the last few decades. These principles are crucial to adhere to in the overall management of these lesions and are highlighted and expanded upon herein.

Multimodal endovascular palliation for femoral arterial blowout in the setting of metastatic vulvar carcinoma.

BACKGROUND: Vascular blowout syndrome is a well-known, life-threatening condition complicating advanced-stage head and neck malignancies but has rarely been reported in the gynecologic oncology realm in association with the femoral circulation. A 50-year-old woman with metastatic vulvar squamous cell carcinoma presented with left threatened femoral arterial blowout, secondary to an exophytic neoplastic mass originating from the left inguinal lymph nodes. METHODS: Bland embolization of the tumor as well as 3 vessel covered stent revascularization was successfully performed with excellent tumor devascularization and reinstitution of arterial integrity. RESULTS: Successful devascularization of the tumor, with no non-target embolization was achieved, with excellent apposition and deployment of 3 covered stents in the femoral artery bifurcation. CONCLUSION: We present a unique case of threatened femoral artery blowout syndrome in the setting of metastatic vulvar carcinoma requiring various endovascular techniques for palliation. These endovascular techniques can be invaluable in minimally invasive palliation of advanced stage neoplasms abutting the iliofemoral circulation.