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

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

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

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

Do patients actually understand? An evaluation of the informed consent process for endoscopic procedures in rural Uganda.

INTRODUCTION: Improving surgical access in low- and middle-income countries is vital for the 5 billion people who lack safe surgical care. Tailoring a culturally sensitive approach to consent is essential for patient comprehension and comfort, thereby alleviating the effects of resource constraints and advancing equitable care. This study examines the consenting process for endoscopy at Kyabirwa Surgical Center in Kyabirwa, Jinja, Uganda, to assess patients' knowledge and attitudes as a potential barrier to participating in endoscopic procedures. METHODS: All adult upper endoscopy (EGD) and colonoscopy patients were recruited to participate in a survey of their demographics, knowledge, and attitudes toward their procedure. All patients received a standard consultation explaining the procedure and its risks and benefits. RESULTS: 75 patients were included; median age was 54 years and 56% (n = 42) were women. 92% (n = 69) of patients had never had an endoscopy before and 73% (n = 55) of patients were scheduled for an EGD while the remaining 27% (n = 20) were scheduled for a colonoscopy. Most patients 80% (n = 60) had a basic understanding of what an endoscopy is and 87% (n = 65) its diagnostic purpose. Few patients 15% (n = 11) knew of the most common side effects or if they would have a surgical scar 27% (n = 20). Overall, 46.7% (n = 35) of patients were moderately or severely fearful of getting an endoscopy. Additionally, 45.3% (n = 34) of patients were moderately or severely fearful of receiving anesthesia during their endoscopic procedure. Despite this fear, most patients 85.3% (n = 64) stated that they understood the benefits of the procedure either very well or extremely well. CONCLUSIONS: Most patients understood the role that an endoscopic procedure plays in their care and its potential benefits. Despite this, many patients continued to have high levels of fear associated with both the endoscopic procedure and with receiving anesthesia during their procedure. Future patient education should focus on addressing patients' fears and the risks of undergoing an endoscopy, which may improve the utilization of surgical services.

Collaborative international partnership: Enabling the development of a state-of-the-art minimally invasive surgical center in rural Uganda through telementoring.

BACKGROUND: Access to minimally invasive surgery (MIS) is limited in Sub-Saharan African countries. In 2019, the Mount Sinai Department of Surgery in New York collaborated with local Ugandans to construct the Kyabirwa Surgical Center (KSC), an independent, replicable, self-sustaining ambulatory surgical center in Uganda. We developed a focused MIS training program using a combination of in-person training and supervised telementoring. We present the results of our initial MIS telementoring experience. METHODS: We worked jointly with Ugandan staff to construct the KSC in the rural province of Jinja. A solar-powered backup battery system ensured continuous power availability. Underground fiber optic cables were installed to provide stable high-speed Internet. The local Ugandan general surgeon (JOD) underwent a mini-fellowship in MIS and then trained extensively using the Fundamentals of Laparoscopic Surgery program. After a weeklong in-person session to train the Ugandan OR team, JOD performed laparoscopic cases with telementoring, which was conducted remotely by surgeons in New York via audiovisual feeds from the KSC OR. RESULTS: From October 2021 to February 2024, JOD performed 61 telementored laparoscopic operations at KSC including 37 appendectomies and 24 cholecystectomies. Feedback was provided regarding patient positioning, port placement, surgical technique, instrument use, and critical steps of the operation. There were no intra-operative complications. Postoperatively, field medical workers visited patients at home to collect follow-up information. Two superficial wound infections (3.3%) were reported in the short-term follow-up. CONCLUSION: Telementoring can be safely implemented to assist surgeons in previously underserved areas to provide advanced laparoscopic surgical care to the local patient population.

Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair.

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

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

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

Technological Advances to Address the Challenging Abdominal Aortic Aneurysm Neck.

There have been significant technologic advances in endovascular aortic therapies since the introduction of conventional infrarenal endovascular aortic aneurysm repair (EVAR). These advances have sought to address the weaknesses of conventional EVAR- particularly the difficult or "hostile" infrarenal aortic aneurysm neck. We review anatomical features that create a hostile neck and the most recent advancements to overcome these limitations. EndoAnchors replicate open suture fixation to seal endograft to aortic tissue and have been shown to be useful as a prophylactic measure in short, angulated necks as well as therapeutic for type Ia endoleaks. Fenestrated EVAR (FEVAR) devices such as the Z-fen (Cook Medical, Bloomington, IN, USA) raises the seal zone to the suprarenal segment while maintaining renal perfusion. Finally, multibranch aortic grafts such as the Thoracoabdominal Branch Endoprosthesis (Tambe; W. L. Gore & Associates, Flagstaff, AZ, USA) raise the seal zone above the visceral segment and can be used off the shelf with promising results.

Increasing access to pathology services in low- and middle-income countries through innovative use of telepathology.

INTRODUCTION: In low- and middle-income countries (LMICs), surgical care can be limited by access to pathology services. In Uganda, the pathologist-to-population ratio is less than 1 to 1 million people. The Kyabirwa Surgical Center in Jinja, Uganda, created a telepathology service in collaboration with an academic institution in New York City. This study demonstrated the feasibility and considerations of implementing a telepathology model to supplement the critical pathology needs of a low-income country. METHODS: This was a retrospective, single-center study of an ambulatory surgery center with pathology capability using virtual microscopy. The remote pathologist (also known as a telepathologist) controlled the microscope and reviewed histology images transmitted across the network in real time. In addition, this study collected demographics, clinical histories, the surgeon's preliminary diagnoses, and the pathology reports from the center's electronic medical record. RESULTS: Nikon's NIS Element Software was used as a dynamic, robotic microscopy model with a video conferencing platform for communication. An underground fiber optic cable established Internet connectivity. After a two-hour tutorial session, the lab technician and pathologist were able to proficiently use the software. The remote pathologist read (1) pathology slides with inconclusive reports from external pathology labs, and (2) tissues labeled by the surgeon as suspicious for malignancy, which belonged to patients who lacked financial means for pathology services. Between April 2021 and July 2022, tissue samples of 110 patients were examined by a telepathologist. The most common malignancies on histology were squamous cell carcinoma of the esophagus, ductal carcinoma of the breast, and colorectal adenocarcinoma. CONCLUSION: With the increasing availability of video conference platforms and network connections, telepathology is an emerging field that can be used by surgeons in LMICs to improve access to pathology services, confirming histological diagnosis of malignancies to ensure appropriate treatment.

Remote training and teleproctoring in gastrointestinal endoscopy for practicing surgeon in rural Uganda.

BACKGROUND: There is a significant, unmet need for endoscopy services in rural Uganda. With limited diagnostic and therapeutic interventions, patients in these communities often present with advanced disease. Practicing surgeons must continually adapt to new techniques to meet the needs of their patient populations. Here, we present a remotely proctored endoscopy training program for a surgeon practicing in an area devoid of endoscopic capabilities. METHODS: This was a retrospective case series conducted between February 2020 and December 2022 at Kyabirwa Surgical Center (KSC). After a 1-week in-person training camp, one surgeon performed endoscopy under guidance of a remote proctor. Patient data and outcomes were collected retrospectively. RESULTS: The previously endoscopic naïve practicing Ugandan surgeon was remotely proctored for 139 endoscopic cases and he subsequently independently performed 167 diagnostic colonoscopies and 425 upper endoscopies. Therapeutic endoscopy was conducted under remote guidance after proficiency in diagnostic endoscopy. A total of 43 therapeutic procedures were performed, including 29 esophageal stent placements, 5 variceal bandings, and 9 foreign body retrievals. All procedures were completed without complication. CONCLUSION: Our center developed a remotely proctored endoscopy program that allowed for training of practicing surgeons in an area lacking endoscopic services. Despite its limitations, remotely proctored endoscopy serves as a unique but highly valuable method of expanding access to endoscopy, particularly in areas that lack adequate training opportunities.

The Venous Thrombectomy Armamentarium: An Expanding World.

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

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

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

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

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

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

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

Endovascular techniques in the treatment of extracranial carotid artery aneurysms.

OBJECTIVE: Carotid artery aneurysms and pseudoaneurysms (extracranial carotid artery aneurysm [ECCAs]) are relatively rare. The gold standard treatment has historically been open repair; however, there is increasing evidence of successful treatment of ECCAs with endovascular techniques. Our study examines the evolving experience with endovascular management of ECCAs at a tertiary care center. METHODS: We performed a retrospective analysis of patients with ECCAs who underwent endovascular interventions at a single institution from 2010 to 2020. With increasing experience, the techniques evolved from covered stents to stent-assisted coil embolization and finally to braided stents and overlapping closed cell stents. RESULTS: There were 18 ECCAs in 17 patients treated with endovascular modalities. The average age was 65.9 years. There were 11 males (64.7%). Seven aneurysms (38.9%) were symptomatic: three patients had painless pulsatile masses, three patients had painful pulsatile masses, and one had transient ischemia attacks. Two (11.1%) were treated with covered stents, 2 (11.1%) were treated with stent-assisted embolization, 2 (11.1%) were treated with flow-diverting braided stents, 10 (55.6%) were treated with overlapping bare metal stents, and 2 (11.1%) were treated with embolization or ligation alone. Technical success was achieved in all patients. The mean duration of follow up was 338 days (range, 8-3039 days). No perioperative or postoperative complications were encountered, including no neurologic deficits and no embolic events. All patients were discharged on postoperative day 1 or 2. All 16 stents (100%) retained vessel patency on follow-up imaging and exclusion of ECCAs was confirmed on postprocedure surveillance imaging. CONCLUSIONS: Endovascular modalities for the management of ECCAs have evolved with experience. Our study suggests that endovascular management is technically feasible as well as clinically effective and suggests an algorithm for navigating the various treatment modalities.

Acute thrombotic manifestations of coronavirus disease 2019 infection: Experience at a large New York City health care system.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel coronavirus that has typically resulted in upper respiratory symptoms. However, we have encountered acute arterial and venous thrombotic events after COVID-19 infection. Managing acute thrombotic events from the novel virus has presented unprecedented challenges during the COVID-19 pandemic. In our study, we have highlighted the unique treatment required for these patients and discussed the role of anticoagulation for patients diagnosed with COVID-19. METHODS: The data from 21 patients with laboratory-confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. The demographics, comorbidities, home medications, laboratory markers, and outcomes were analyzed. The primary postoperative outcome of interest was mortality, and the secondary outcomes were primary patency and morbidity. To assess for significance, a univariate analysis was performed using the Pearson χ2 and Fisher exact tests for categorical variables and the Student t test for continuous variables. RESULTS: A total of 21 patients with acute thrombotic events met our inclusion and exclusion criteria. Most cases were acute arterial events (76.2%), with the remainder venous cases (23.8%). The average age for all patients was 64.6 years, and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil/lymphocyte ratio (8.8) and D-dimer level (4.9 µg/mL). Operative intervention included percutaneous angiography in 25.00% of patients and open surgical embolectomy in 23.8%. Most of the patients who had undergone arterial intervention had developed a postoperative complication (53.9%) compared with a 0% complication rate after venous interventions. Acute kidney injury on admission was a factor in 75.0% of those who died vs 18.2% in the survivors (P = .04). CONCLUSIONS: We have described our experience in the epicenter of the pandemic of 21 patients who had experienced major thrombotic events from infection with COVID-19. The findings from our cohort have highlighted the need for increased awareness of the vascular manifestations of COVID-19 and the important role of anticoagulation for these patients. More data are urgently needed to optimize treatment and prevent further vascular complications of COVID-19 infections.

Neutrophil-to-Lymphocyte Ratio Associated With Adverse Events After Endovascular Aneurysm Repair (EVAR).

BACKGROUND: The blood neutrophil-to-lymphocyte ratio (NLR) is a surrogate biomarker of systemic inflammation with important prognostic significance in multiple disease processes, including cardiovascular diseases. It is inexpensive, widely available, and may be related to the outcomes of patients after surgery. We aimed to investigate the possible association of NLR with the outcomes of patients following endovascular aneurysm repair (EVAR). METHODS: This single-center, retrospective study of a prospectively maintained database evaluated 777 patients with a diagnosed abdominal aortic aneurysm (AAA) who underwent EVAR and were longitudinally followed between 2001 and 2017. NLR was defined as the ratio of absolute neutrophil count to absolute lymphocyte count. The mortality and reinterventions were used to evaluate outcomes using the appropriate univariate models, and the effect of clinical variables on NLR was further investigated using multivariate modelling. RESULTS: The median NLR for all patients was 3 IQR [2.2 - 4.6]. A cut-off point of 3.6 was uncovered in a training set of 388 patients using the maximally ranked statistic method. Patients with NLR < 3.6 had significantly improved mortality rates (P< 0.0001) in the training set, and results were internally validated in a testing set of 389 patients (P = 0.042). Multivariate analysis revealed that high NLR (HR 1.4 95% CI [1.0 - 2.0]; P< 0.05) remained an independent predictor of mortality in a multivariate analysis controlling for characteristics such as comorbidities, age, and maximal aortic diameter. 5-year mortality and 30-day, 1-year and 5-year reinterventions were all higher in the high NLR group. CONCLUSION: High NLR was significantly associated with higher rates of death at 5 years as well as higher rates of reinterventions at 30 days, 1 year and 5 years. We also suggest that an internally validated cut-off point of NLR >3.6 may be clinically important to help segregate patients into high and low NLR categories. It remains unclear whether NLR is directly linked to adverse events post-EVAR or whether it is a surrogate for an inflammatory state that predisposes patients to higher risk of death or reinterventions.

Decreased Abdominal Aortic Aneurysm Size Following EVAR in Patients With CT Evidence of Subclinical Thoracic Aortic Dissection.

BACKGROUND: Aneurysm sac regression following endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) is an established indicator of surgical success. However, even with a completely excluded aneurysm, the degree of aortic sac regression may vary. This study evaluates the relationship between aneurysm sac regression after EVAR and the presence of morphological features in the thoracic aorta that can be associated with a subclinical aortic dissection, termed dissection morphology in this study. METHODS: Patients who underwent EVAR to repair an infrarenal aortic aneurysm at Mount Sinai Hospital between 1996 and 2017 with a postoperative CT scan and a 3-year follow-up scan available for analysis were included in the study. Patients with a type I or type III endoleak were not included. The thoracic aorta was evaluated for dissection morphology on CT scan, which included the presence of aortic dissection, penetrating aortic ulcers, and intramural hematomas. AAA sac regression after EVAR was compared between patients with dissection morphology (n = 157) and patients without those characteristics (n = 141). An independent investigator performed the CT analysis and was blinded to the degree of sac regression. RESULTS: Demographics and comorbid clinical conditions were compared between patients with and without dissection morphology. There were no significant differences in age, gender, smoking habits, or cardiovascular conditions. The median AAA diameter after EVAR, over the course of the study, in patients with dissection morphology decreased by 11.30 mm (-17.20, -3.60) compared to a median change of 0.30 mm (-8.60, 8.60) in patients without dissection morphology features (p < 0.001). Patients with dissection morphology also had fewer type II endoleaks in postoperative follow-up scans (22.9% vs. 53.9%, p < 0.001). Additionally, patients with dissection morphology had longer EVAR operative times (192.00 min [167.25, 230.00] vs.174.00 min [150.00, 215.00], p = 0.004). AAA-related mortality after 3 years was not significantly different between the 2 groups (p = 1.0). CONCLUSIONS: The presence of imaging features consistent with dissection morphology in the thoracic aorta correlated with greater AAA sac regression and fewer type II endoleaks after EVAR. Assessing these imaging features in patients undergoing EVAR may be useful in understanding aneurysm behavior in terms of aneurysm growth, risk of rupture, and outcomes following endovascular surgery. Identifying differential rates of aneurysm sac regression may have implications regarding the role of subclinical dissections in the etiology of AAA development.

The Impact of Body Mass Index on Perioperative and Postoperative Outcomes for Endovascular Abdominal Aneurysm Repair.

BACKGROUND: There is varying evidence regarding the effects of body mass index (BMI) on outcomes of endovascular aneurysm repair (EVAR). This study investigates the effects of BMI on an index of perioperative and postoperative outcomes after EVAR. METHODS: Four hundred ninety-two patients who underwent elective EVAR at Mount Sinai Hospital were included in this study. Patients were classified as either normal weight (BMI = 18.5-25), overweight (BMI = 25-30), or obese (BMI>30). Chi-squared tests were used to determine significant differences between weight classes across an index of outcomes. The following outcomes were collected: intraoperative complications (e.g., conversion to open), perioperative complications (e.g., hematoma, bowel ischemia, and so forth), and postoperative outcomes (endoleak, sac enlargement, sac shrinkage, access site infection, prolonged postoperative length of stay, reintervention, stroke, claudication/lower extremity ischemia, deep vein thrombosis, limb occlusion, renal complications, abdominal aortic aneurysm (AAA) rupture, AAA-related mortality, and all-cause mortality). Kaplan-Meier survival analysis and a log-rank test were used to determine meaningful differences in all-cause mortality following EVAR between the respective weight classes. Subsequently, multivariate Cox proportional hazards were performed for selection of outcomes, with weight classes as predictors. Finally, a multivariate logistic regression was performed for postoperative hospital stay. Subgroup multivariate analysis was also performed examining only class I obese patients, rather than all obese patients. RESULTS: Overweight patients were significantly less likely to experience all-cause mortality up to 9 years after EVAR than normal-weight patients in both Kaplan-Meier and multivariable Cox proportional hazards models. Obese patients similarly had a lower risk of mortality in Kaplan-Meier analysis, but this did not persist in the multivariate analysis. Overweight patients were also significantly less likely to require a postoperative hospital stay longer than 1 day when compared with normal-weight patients. Finally, obese patients were less likely to have a sac shrinkage greater than 5 mm after EVAR, but were also less likely to have an endoleak. CONCLUSIONS: This study adds to the debate on the effects of BMI on outcomes of EVAR. Obesity was not a risk factor for negative perioperative or postoperative outcomes after EVAR with the exception of decreased sac shrinkage. Obese patients were less likely to have an endoleak, and overweight patients were protected against all-cause mortality and longer postoperative hospital stays.

Iliac Vein Stenting for Chronic Proximal Venous Outflow Obstruction in a Predominantly Asian-American Cohort.

BACKGROUND: We investigated the outcome of vein stenting placement for chronic proximal venous outflow obstruction (PVOO) in a predominantly Asian-American cohort to improve patient selection, enhance technical approach, and better define quality measurements of this emerging vascular intervention. METHODS: A total of 462 consecutive patients, 73% Asian American (n = 336), who underwent iliac vein stenting for chronic PVOO from October 2013 to July 2016 were reviewed. Postoperative outcomes at five follow-up visits were assessed. Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were run for demographic and operative variables. Ordered logistic regressions were run for the outcome at each time point, and Chi-squared tests as well as Fisher's exact tests were used for categorical variables. RESULTS: Follow-up was maintained in 90% of patients, with a mean follow-up time of 695 days. Asian-American patients were more likely to present with varicose veins (77.4% vs. 54.8%, P < 0.001), and non-Asian patients were more likely to present with active ulceration (26.2% vs. 5.1%, P < 0.001). Asian-American patients were more likely to have bilateral stents placed (61.6% vs. 50%, P = 0.026) and were less likely to have reinterventions (11.3% vs. 27.8%, P < 0.001), a history of deep vein thrombosis (8.3% vs. 29.4%, P < 0.001), or intraoperative findings of chronic postphlebitic changes (17.6% vs. 33.3%, P < 0.001). Kruskal-Wallis tests were significant for improvement in patients of all the Clinical, Etiology, Anatomy, Pathophysiology classes at 30 days (P = 0.041), 90 days (P = 0.045), 6 months (P = 0.041), and 1 year (P < 0.01). The Asian-American population had improved but comparatively lower follow-up scores at the 30-day mark (48% significantly improved or better vs. 63%, P = 0.008) but higher follow-up scores at the >1 year mark (80% significantly improved or better vs. 59%, P < 0.001). CONCLUSIONS: Asian-American patients undergoing vein stent placement for chronic PVOO had comparatively worse outcomes than non-Asian patients at 30 days and better outcomes after one year. These patient groups had different outcomes postoperatively and outcomes which evolve differently over time.

A Review of the Evolution of Abdominal Aortic Endografts and Future Directions.

INTRODUCTION: Over the years, endovascular aortic aneurysm repair (EVAR) has become the gold-standard of therapy for abdominal aortic aneurysm (AAA) repairs. This study aims to analyze the evolution of stent graft devices and discuss the future direction of technological development. MATERIALS AND METHODS: In this paper, we will review prior eras of graft development (1992 to 2019) that included physician-made devices (era one), industry-made devices (era two), branch devices (era three), and fenestrated devices (era four). Additionally, future advancements that aim to overcome issues with short aneurysm necks, involvement of proximal visceral branches, and formation of endoleaks will be discussed. RESULTS: Future devices of note include a more conformable version of the EXCLUDER® device (W. L. Gore & Associates, Inc., Newark, Delaware) to better steer the top of the graft and modify for angulated necks, a version of the Endurant® device to include EndoAnchors (Medtronic plc, Minneapolis, Minnesota) to prevent formation of endoleaks, a novel Nellix® EVAS II device (Endologix Inc., Irvine, California) with aneurysm sac filling to prevent endoleaks and exclude the aneurysm sac, and an expanded Zenith® fenestrated device (Cook Medical Inc., Bloomington, Indiana) to include more visceral branches. This is in the setting of more recent advancements like pivoting fenestrated branch devices for "off-shelf" use and aneurysm repair that now extends to the thoracic aorta. CONCLUSION: With each iteration of devices, EVAR has evolved to overcome technical challenges and offer expanded applicability to different types of AAAs.