In situ bypass and extra-anatomic bypass procedures result in similar survival in patients with secondary aortoenteric fistulas.

OBJECTIVE: The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF. METHODS: A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed. RESULTS: During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality. CONCLUSIONS: These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, <50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.

Contemporary Outcomes After Partial Resection of Infected Aortic Grafts.

INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.

Nine-Month Outcomes of the DURABILITY Iliac Study on Self-Expanding Stents for Symptomatic Peripheral Artery Disease.

BACKGROUND: The DURABILITY Iliac clinical study evaluated the safety and effectiveness of 2 nitinol self-expanding stents for the treatment of atherosclerotic common and external iliac artery lesions up to 10 cm in length and >50% stenosis in subjects with Rutherford classification peripheral arterial disease stages 2-4. METHODS: DURABILITY Iliac was a prospective, multicenter, core lab adjudicated, nonrandomized clinical study enrolling 75 subjects from 15 sites in the United States and Europe. Clinical follow-up visits were at 30 days, 9 months, and 1, 2, and 3 years after procedure. The primary outcome measured was the major adverse event (MAE) rate at 9 months, defined as a composite of periprocedural death, in-hospital myocardial infarction (MI), clinically driven target lesion revascularization (CD-TLR), and amputation of the treated limb through 9 months after procedure. Secondary outcomes included primary patency rate at 9 months, clinically driven target vessel revascularization (CD-TVR), change in ankle-brachial index, and change in Walking Impairment Questionnaire score at 30 days and 9 months. Device success was defined as the ability to deploy the stent as intended at the treatment site. RESULTS: The MAE rate at 9 months was 1.3% (1/75), with 1 subject experiencing a CD-TLR. No periprocedural deaths, MIs, or amputations were reported. Primacy patency at 9 months was 95.8%. Freedom from CD-TVR was 98.6% at 9 months. Subjects improved in Walking Impairment Questionnaire scores for all categories (walking impairment, walking speed, walking distance, and stair climbing) at the 30-day and 9-month visit. Device success was 100%. CONCLUSIONS: The 9-month results of the DURABILITY Iliac study demonstrate the safety and effectiveness of 2 nitinol self-expanding stents for the treatment of atherosclerotic lesions of the common and external iliac arteries.

A survey of 0 + 5 vascular surgery residency candidates: Perceptions of an applicant pool.

BACKGROUND: Applications to integrated (0 + 5) vascular surgery residencies have increased, while total applications have stayed relatively constant. This survey sought to document the perceptions of 0 + 5 vascular surgery applicants. METHODS: Academic faculty conducted interviews for 0 + 5 residency match at an academic medical center in preparation for the National Resident Matching Program (NRMP) Main Residency Match. Applicant pool (n = 20) perceptions were determined with surveys. Participation was anonymous and voluntary. RESULTS: Nineteen interviewees (26.3% female: 73.7% male), age (26.8 ± 2.6 years) responded (95% response rate). Of 19 respondents, 68% became interested in vascular surgery in their third year with 53% becoming aware of 0 + 5 programs in their third year. All respondents identified a vascular surgery attending at their institution as significant mentors. Forty-seven percent identified their mentor during their third year of medical school. All respondents felt that 0 + 5 training would prepare them adequately for the workforce and board certification exams. Almost all (89%) had plans to seek jobs immediately upon completion of residency. CONCLUSION: Applicants remained positive about their planned training and career paths. Attending vascular surgeons were identified as the strongest mentors, yet most students decided only in their third and fourth years to pursue 0 + 5 residencies. Educational debt remains a concern, and there may be consideration for a concerted effort to recruit potential candidates sooner.

Carotid artery stenting may be performed safely in patients with radiation therapy-associated carotid stenosis without increased restenosis or target lesion revascularization.

OBJECTIVE: Neck radiation therapy (XRT) can induce carotid artery stenosis and may increase the technical difficulty of endarterectomy. It is considered a relative indication for carotid angioplasty and carotid artery stenting (CAS). This study sought to evaluate differences in CAS embolic potential and restenosis performed on XRT and non-XRT patients. METHODS: At three institutions, 366 CAS procedures were performed on 321 patients (XRT, n = 43; non-XRT, n = 323). Mean follow-up was 410 days (median, 282 days; range, 7-1920 days). Patients were observed with duplex ultrasound to assess for restenosis. Additional end points included target lesion revascularization (TLR), myocardial and cerebrovascular events, and perioperative complications. Captured particulate from embolic protection filters was analyzed with photomicroscopy and image analysis software for 27 XRT and 214 non-XRT filters. RESULTS: XRT patients were more likely to be male and had lower rates of hypertension, coronary artery disease, and diabetes mellitus, although the mean age at procedure did not differ. There was no increase in severe internal carotid tortuosity among XRT patients (XRT: 50% vs non-XRT: 34.7%; P = .06). Indication for CAS did not differ between the two groups, including the number of CAS procedures performed for symptomatic carotid stenosis (XRT: 39.7% vs non-XRT: 39.0%; P = NS). Perioperative outcomes, including the composite 30-day stroke, myocardial infarction, and mortality, were not significantly different (XRT: 2.6% vs non-XRT: 3.9%; P = NS.) There were no significant differences in restenosis rate at the 50% (XRT: 9.4% vs non-XRT: 8.6%; P = NS) or 70% (XRT: 3.5% vs non-XRT: 8.6%; P = NS) threshold. Filter particle analysis revealed that filters from XRT patients had more numerous large particles per filter (1.4 vs 0.7; P < .05) and larger mean particle size (464.1 µm vs 320.0 µm; P < .05). TLR did not differ significantly between the groups. CONCLUSIONS: In contrast to earlier studies, this analysis reveals that there are significant differences in XRT and non-XRT patients undergoing CAS in terms of medical comorbidities and embolic material captured in embolic protection filters. The decreased incidence of atherosclerotic risk factors was observed in XRT patients probably because XRT was the primary factor responsible for carotid stenosis. Despite increased embolic particle size, CAS can be performed safely with no increased morbidity, TLR, or restenosis in XRT patients.

Two-stage hybrid repair of a complex symptomatic celiac aneurysm.

We report the case of a novel 2-stage hybrid repair of a complex celiac artery aneurysm. The patient was a 42-year-old man with a proximal celiac artery aneurysm giving rise to distinct right and left hepatic arterial branches. Repair was performed using a staged approach. First, a bifurcated aortohepatic bypass was constructed to the common and left hepatic arteries. After recovering from surgery, he underwent percutaneous embolization of the aneurysm. Completion angiograms demonstrated flow into all celiac branches with successful thrombosis of the aneurysm. At 12-month follow-up, the patient had remained symptom-free with patent bypass grafts and complete aneurysm exclusion. We describe the treatment option we used, which involves repair of a complex celiac aneurysm using a 2-stage, open, endovascular approach.

Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion.

PURPOSE: To examine the outcomes following interventions for type II endoleaks in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). METHODS: A retrospective review was conducted of all patients who underwent treatment for type II endoleak from July 2001 to September 2010 in a single center. In this time period, 29 (4.7%) patients (22 men; mean age 78.6 years, range 54-87) were identified as having a type II endoleak and enlargement of the aneurysm sac, meeting the criterion for treatment. All patients had at least one attempted percutaneous intervention. Patients were followed both clinically and radiographically, with computed tomographic angiography every 3 to 12 months, over a follow-up period that ranged from 1 to 10 years (mean 3.5). RESULTS: Forty-eight interventions were performed on the 29 patients. Of these, 15 (56%) patients underwent multiple (2-4) procedures. Of the 11 endoleaks with an isolated inferior mesenteric artery identified as the source, initial success for transarterial embolization at 2 years was 72%, with 2 of the failures having successful secondary interventions. For the 18 endoleaks with a lumbar source, the success of the initial intervention was 17% at 2 years; repeated embolization attempts produced a 40% secondary success rate. Seven (24%) patients had continued endoleak despite multiple treatment attempts; 3 ultimately required elective aortic graft explantation. There were no ruptures or deaths during the study period. In a comparison of type II endoleak patients who had stable aneurysm sacs and those who had persistent sac expansion, the only significant differences in preoperative anatomical characteristics were a lower prevalence of mural thrombus (p = 0.036) and longer right iliac arteries (p = 0.012) in the group with sac expansion. Independent predictors of type II endoleak were mural thrombus (p<0.001), patent lumbar arteries (p = 0.004), aneurysm length (p = 0.011), and iliac artery length (p = 0.004). CONCLUSION: This study demonstrates that most patients require multiple reinterventions to treat type II endoleaks; specifically, lumbar artery embolization carries a low midterm success rate.

Endovascular management as first therapy for chronic total occlusion of the lower extremity arteries: comparison of balloon angioplasty, stenting, and directional atherectomy.

PURPOSE: To evaluate the role of endovascular therapy in the management of infrainguinal arterial chronic total occlusions (CTOs). METHODS: Data on all patients with CTOs treated at a single center from 2004 to 2010 were extracted from a prospectively maintained database for retrospective analysis. Patient demographics, angiographic studies, noninvasive vascular test results, and clinical outcomes were evaluated. In this time frame, 481 patients (283 men; mean age 71.7±11.5 years, range 52-85) with claudication (n = 177) or critical limb ischemia (CLI, n = 304) were treated for 688 CTOs. Lesions were segregated according to location [SFA (n = 193), popliteal (n = 67), tibial (n = 217), and multilevel (n = 211)] and analyzed based on treatment mode (angioplasty, angioplasty with stenting, or atherectomy) and clinical indication. Primary patency, assisted primary patency, and secondary patency, as well as limb salvage rates for CLI patients, were calculated. RESULTS: At 2 years in claudicants with CTOs confined to the SFA, primary patency ranged from 44% to 58% and secondary patency to 92% depending on treatment type; there were no significant differences among the treatments. However, in CLI patients with SFA CTOs, atherectomy produced better outcomes at 2 years (p = 0.002 for primary and p = 0.012 for secondary patency) than angioplasty alone. The limb salvage rates ranged from 73% to 91% (no differences among treatment types). In diabetics, CTOs treated with angioplasty and stent had improved secondary patency rates over angioplasty alone. CONCLUSION: The endovascular management of CTO results in reasonable primary patency; moreover, secondary patency at 2 years is excellent. Endovascular therapy should be the first-line option for many patients with peripheral artery disease, including those with CLI, claudicants with poor bypass conduit, or patients at high medical risk for surgery. The presence of CTOs does not appear to change these recommendations. Although multiple reinterventions may be required, endovascular therapies can be considered a primary therapy for many patients with CTO.

Outcomes and timing of aortic surgery in renal transplant patients.

BACKGROUND: Solid organ transplantation in elderly patients has become more common in recent years. An increasing number of patients present with renal failure requiring transplantation and comorbid occlusive or aneurysmal aortic pathology. The optimal strategy for the timing and management of the aortic disease and renal transplantation in these patients is unknown. Before the availability of endovascular therapies, our policy was to provide open repair of aortic disease before cadaveric transplantation, or by simultaneous aortic reconstruction with renal allotransplantation if a living donor was available. Since the wide acceptance of endovascular modalities, our strategy has changed to take advantage of endovascular treatment pre-transplant. This study examines the outcome of both approaches. METHODS: We performed a retrospective review of 12 patients between 1996 and 2009 who underwent both renal transplantation and a major abdominal aortic procedure either simultaneously (n = 6), metachronous, with the procedures occurring within the same month (n = 2), or distant, with the aortic procedures occurring between 5 and 24 months before or after transplantation (n = 4). All patients with occlusive disease underwent an aortobifemoral bypass, one before transplant, one subsequent to transplantation, and four simultaneous with a renal allograft. To assess renal transplant status, patients' serum creatinine levels were followed up every 3 months. Of the 12 patients, eight underwent open aortic procedures, whereas four underwent endovascular aortic aneurysm repair. Patients who underwent endovascular aortic aneurysm repair were followed up with ultrasound examinations at 6-month intervals, and with contrast computed tomography scans every other year. RESULTS: Aortic reconstruction was performed successfully in all the 12 patients irrespective of timing strategy. All the patients who underwent endovascular repair had functional renal allografts for the duration of follow-up. Two patients had simultaneous aortobifemoral bypass and pancreas-kidney transplantation without complication. Among the patients with open aortic repairs, there was one 5-year mortality and one patient had failure of two renal allografts. None of the patients had limb loss, and aortic grafts (one limb required a secondary procedure) remained patent. The 5-year patient survival of 90% and kidney survival of 75% appeared similar to results in the general transplant population without aortic disease. Two significant complications related to the open procedures were observed: two renal transplants developed postoperative hematomas requiring evacuation and one aortobifemoral bypass (ABF) developed a femoral wound infection requiring evacuation and sartorius flap closure. The 30-day mortality rate in all patients was zero. The length of stay for patients receiving simultaneous procedures ranged from 5 to 14 days (median, 10.5) and was significantly lower than the 10-52-day (median, 18) combined length of stay in the metachronous and/or distant groups (p = 0.016). CONCLUSION: The coexistence of aortic disease and renal transplantation is an increasingly common clinical scenario. Exclusion from transplantation of patients with major aortoiliac disease is commonplace in many transplant centers as early registry data suggested a poor outcome. Appropriate planning with a vascular surgical team can lead to outcomes, which are comparable with the general transplant population without significant aortic disease.

Acute thrombotic events as initial presentation of patients with COVID-19 infection.

We describe three patients with COVID-19 who presented with an acute vascular event rather than with typical respiratory symptoms. These patients were all subsequently found to have laboratory-confirmed COVID-19 infections as the likely cause of their thrombotic event. The primary presentation of COVID-19 infection as a thrombotic event rather than with respiratory symptoms has not been described elsewhere. Our cases and discussion highlight the thrombotic complications caused by COVID-19; we discuss management of these patients and explore the role of anticoagulation in patients diagnosed with COVID-19.

Rapid progression of carotid artery atherosclerosis and stenosis in a patient with a ventricular assist device.

This case describes the management of cerebrovascular disease in a patient with a left ventricular assist device (LVAD) who was awaiting cardiac transplantation. It demonstrates several unique features in managing vascular disease in patients with cardiac assist devices. First, we detail the difficulties in using duplex ultrasound to assess patients with altered hemodynamic physiology. Second, we report an instance of rapid progression of known carotid stenosis in a patient with a recently placed LVAD. This case suggests that patients with any degree of carotid stenosis before LVAD placement should be monitored closely for progression after the LVAD is placed.

Gender differences in outcomes of endovascular treatment of infrainguinal peripheral artery disease.

OBJECTIVE: Our goal was to assess the outcomes of females compared to males treated with endovascular lower extremity interventions in order to determine optimal therapy based on gender. METHODS: We performed a retrospective review evaluating the outcomes of primary transluminal angioplasty (PTA) and PTA + stenting (PTA + S) for peripheral arterial disease (PAD). Patency rates and limb salvage were the primary end points. RESULTS: A total of 1017 lesions were analyzed in 537 patients (229 male and 308 female) between 2004 and 2009. There were no differences between genders in lesion characteristics. Women were more likely to have interventions for critical limb ischemia (CLI). In CLI patients with superficial femoral artery (SFA) and tibial lesions, women had better patency rates (P < .005). CONCLUSIONS: Women have better patency rates compared with men following treatment of some CLI lesions. Interestingly, women are treated more frequently for CLI when compared to men. For some lesion types in women, PTA alone was equivalent to PTA + S. Our results suggest that outcomes may be optimized by tailoring interventions to gender.