Patient-specific computational flow simulation reveals significant differences in paravisceral aortic hemodynamics between fenestrated and branched endovascular aneurysm repair.

Background: Endovascular aneurysm repair with four-vessel fenestrated endovascular aneurysm repair (fEVAR) or branched endovascular aneurysm repair (bEVAR) currently represent the forefront of minimally invasive complex aortic aneurysm repair. This study sought to use patient-specific computational flow simulation (CFS) to assess differences in postoperative hemodynamic effects associated with fEVAR vs bEVAR. Methods: Patients from two institutions who underwent four-vessel fEVAR with the Cook Zenith Fenestrated platform and bEVAR with the Jotec E-xtra Design platform were retrospectively selected. Patients in both cohorts were treated for paravisceral and extent II, II, and V thoracoabdominal aortic aneurysms. Three-dimensional finite element volume meshes were created from preoperative and postoperative computed tomography scans. Boundary conditions were adjusted for body surface area, heart rate, and blood pressure. Pulsatile flow simulations were performed with equivalent boundary conditions between preoperative and postoperative states. Postoperative changes in hemodynamic parameters were compared between the fEVAR and bEVAR groups. Results: Patient-specific CFS was performed on 20 patients (10 bEVAR, 10 fEVAR) with a total of 80 target vessels (40 renal, 20 celiac, 20 superior mesenteric artery stents). bEVAR was associated with a decrease in renal artery peak flow rate (-5.2% vs +2.0%; P < .0001) and peak pressure (-3.4 vs +0.1%; P < .0001) compared with fEVAR. Almost all renal arteries treated with bEVAR had a reduction in renal artery perfusion (n = 19 [95%]), compared with 35% (n = 7) treated with fEVAR. There were no significant differences in celiac or superior mesenteric artery perfusion metrics (P = .10-.27) between groups. Time-averaged wall shear stress in the paravisceral aorta and branches also varied significantly depending on endograft configuration, with bEVAR associated with large postoperative increases in renal artery (+47.5 vs +13.5%; P = .002) and aortic time-averaged wall shear stress (+200.1% vs -31.3%; P = .001) compared with fEVAR. Streamline analysis revealed areas of hemodynamic abnormalities associated with branched renal grafts which adopt a U-shaped geometry, which may explain the observed differences in postoperative changes in renal perfusion between bEVAR and fEVAR. Conclusions: bEVAR may be associated with subtle decreases in renal perfusion and a large increase in aortic wall shear stress compared with fEVAR. CFS is a novel tool for quantifying and visualizing the unique patient-specific hemodynamic effect of different complex EVAR strategies. Clinical Relevance: This study used patient-specific CFS to compare postoperative hemodynamic effects of four-vessel fenestrated endovascular aneurysm repair (fEVAR) and branched endovascular aneurysm repair (bEVAR) in patients with complex aortic aneurysms. The findings indicate that bEVAR may result in subtle reductions in renal artery perfusion and a significant increase in aortic wall shear stress compared with fEVAR. These differences are clinically relevant, providing insights for clinicians choosing between these approaches. Understanding the patient-specific hemodynamic effects of complex EVAR strategies, as revealed by CFS, can aid in future personalized treatment decisions, and potentially reduce postoperative complications in aortic aneurysm repair.

Cystathionine Gamma Lyase Is Regulated by Flow and Controls Smooth Muscle Migration in Human Saphenous Vein.

The saphenous vein is the conduit of choice for bypass grafting. Unfortunately, the hemodynamic stress associated with the arterial environment of the bypass vein graft leads to the development of intimal hyperplasia (IH), an excessive cellular growth and collagen deposition that results in restenosis and secondary graft occlusion. Hydrogen sulfide (H2S) is a ubiquitous redox-modifying gasotransmitter that inhibits IH. H2S is produced via the reverse trans-sulfuration pathway by three enzymes: cystathionine γ-lyase (CSE), cystathionine ß-synthase (CBS) and 3-mercaptopyruvate sulfurtransferase (3-MST). However, the expression and regulation of these enzymes in the human vasculature remains unclear. Here, we investigated the expression of CSE, CBS and 3-MST in segments of native human saphenous vein and large arteries. Furthermore, we evaluated the regulation of these enzymes in vein segments cultured under static, venous (7 mmHg pressure) or arterial (100 mmHg pressure) pressure. CSE was expressed in the media, neointima and intima of the vessels and was negatively regulated by arterial shear stress. Adenoviral-mediated CSE overexpression or RNA interference-mediated CSE knock-down revealed that CSE inhibited primary human VSMC migration but not proliferation. We propose that high shear stress in arteriovenous bypass grafts inhibits CSE expression in both the media and endothelium, which may contribute to increased VSMC migration in the context of IH.

Predictors and Consequences of Sac Shrinkage after Endovascular Infrarenal Aortic Aneurysm Repair.

Background: Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). We evaluated the impact of sac shrinkage on secondary interventions, on survival and its association with endoleaks, and on compliance with instructions for use (IFU). Methods: This observational retrospective study was conducted on all consecutive patients receiving EVAR for an infrarenal abdominal aortic aneurysm (AAA) using exclusively Endurant II/IIs endograft from 2014 to 2018. Sixty patients were entered in the study. Aneurysm sac shrinkage was defined as decrease ≥5 mm of the maximum aortic diameter. Univariate methods and Kaplan-Meier plots assessed the potential impact of shrinkage. Results: Twenty-six patients (43.3%) experienced shrinkage at one year, and thirty-four (56.7%) had no shrinkage. Shrinkage was not significantly associated with any demographics or morbidity, except hypertension (p = 0.01). No aneurysm characteristics were associated with shrinkage. Non-compliance with instructions for use (IFU) in 13 patients (21.6%) was not associated with shrinkage. Three years after EVAR, freedom from secondary intervention was 85 ± 2% for the entire series, 92.3 ± 5.0% for the shrinkage group and 83.3 ± 9% for the no-shrinkage group (Logrank: p = 0.49). Survival at 3 years was not significantly different between the two groups (85.9 ± 7.0% vs. 79.0 ± 9.0%, Logrank; p = 0.59). Strict compliance with IFU was associated with less reinterventions at 3 years (92.1 ± 5.9% vs. 73.8 ± 15%, Logrank: p = 0.03). Similarly, survival at 3 years did not significantly differ between strict compliance with IFU and non-compliance (81.8 ± 7.0% vs. 78.6 ± 13.0%, Logrank; p = 0.32). Conclusion: This study suggests that shrinkage ≥5 mm at 1-year is not significantly associated with a better survival rate or a lower risk of secondary intervention than no-shrinkage. In this series, the risk of secondary intervention regardless of shrinkage seems to be linked more to non-compliance with IFU. Considering the small number of patients, these results must be confirmed by extensive prospective studies.

Fenestrated Aortic Aneurysm Repair in Patients Treated Inside Versus Outside of Instructions for Use.

OBJECTIVES: The aim of this study was to compare outcomes of patients treated with the Cook Zenith Fenestrated (ZFEN) device for juxtarenal aortic aneurysms inside versus outside the IFU. METHODS: We retrospectively reviewed our institutional ZFEN database for cases performed between 2012 and 2018, with analysis performed in 2020 in order to report midterm outcomes. The cohort was stratified based on treatment inside (IFU group) and outside (non-IFU group) the IFU for criteria involving the proximal neck: neck length 4 to 14 mm, neck diameter 19 to 31 mm, and neck angulation ≤45°. Patients with thoracoabdominal aneurysms or concurrent chimney grafting were excluded. The primary outcomes in question were mortality, type 1a endoleak, and reintervention. Univariate and multivariate analyses were performed to determine associations between adherence to IFU criteria and outcomes. RESULTS: We identified 100 consecutive patients (19% female, mean age 73.6 years) for inclusion in this analysis. Mean follow-up was 21.6 months. Fifty-four patients (54%) were treated outside the IFU because of inadequate neck length (n=48), enlarged neck diameter (n=10), and/or excessive angulation (n=16). Eighteen patients were outside IFU for two criteria, and one patient was outside IFU for all three. Non-IFU patients were exposed to higher radiation doses (3652 vs 5445 mGy, p=0.008) and contrast volume (76 vs 95 mL, p=0.004). No difference was noted between IFU and non-IFU groups for 30-day mortality (0% vs 3.7%, p=0.18), or type 1a endoleak (0% vs 1.9%, p=0.41). Reintervention was also similar between cohorts (13% vs 27.8%, p=0.13). Being outside IFU for neck diameter or length was each borderline significant for higher reintervention on univariate analysis (p=0.05), but this was not significant on multivariate Cox proportional hazard modeling (HR 1.82 [0.53-6.25]; 2.03 [0.68-7.89]), respectively. No individual IFU deviations were associated with the primary outcomes on multivariate analysis, nor being outside IFU for multiple criteria. CONCLUSIONS: Patients with juxtarenal aortic aneurysms may be treated with the ZFEN device with moderate deviations from the IFU. While no differences were seen in mortality or proximal endoleak, larger studies are needed to examine the potential association between IFU nonadherence and reinterventions and close follow-up is warranted for all patients undergoing such repair.

Predictive Factors of Surgical Complications in the First Year Following Kidney Transplantation.

BACKGROUND: In the recent years, an increased use of marginal donors and grafts and a growing prevalence of peripheral arterial disease in the recipients have been observed. Meanwhile, the open surgical technique for kidney transplantation has not changed. The aim of this study is to analyze all surgical complications occurring in the first year after kidney transplant and to determine potential predictive risk factors. METHODS: Data of the 399 patients who underwent kidney transplant in our University Hospital between January 2006 and December 2015 were retrospectively reviewed. The primary endpoint was the overall rate of vascular, parietal and urological complications at 1 year following kidney transplantation. The secondary outcomes were graft and patient' survival rates, and the identification of predictive factors of the surgical complications. RESULTS: 24% of patients developed 134 complications. Vascular complication represented 39% of all complications and resulted in 9 graft losses. Parietal and urological complications represented 46-15% of all complications, respectively, No parietal or urological complications were associated with graft loss. 5 patients died during the 1st year, none of these cases was associated with graft loss. The graft survival rate reached 96% at 1 year, including patients still alive. The occurrence of surgical complication was associated with reduced graft survival at 1 year. Using a multivariate analysis, 4 predictive factors were identified: age, deceased donor, operative time and dyslipidemia. CONCLUSION: Surgical complications after kidney transplantation remained frequent and age, deceased kidney donors, and operative time were identified as risk factors. As vascular complications were a major cause of early graft loss, efforts should aim to reduce their occurrence to increase graft survival.

Fenestrated Endovascular Repair With Large Device Diameters (34-36 mm) is Associated With Type 1 and 3 Endoleak and Reintervention.

BACKGROUND: Patients with abdominal aortic aneurysms undergoing EVAR with larger device diameters (34-36 mm) have worse outcomes due to proximal fixation failure and need for reintervention. We examine outcomes relating to standard fenestrated repair (FEVAR) with larger device diameters, and investigate whether a similar relationship exists. METHODS: Retrospective review of a prospectively maintained, single institution database of patients treated with the Cook ZFEN device between 2012-2017. Outcomes were stratified by device diameter into normal-diameter (ND,≤ 32 mm) and large-diameter (LD,34-36 mm). Primary endpoints were need for reintervention and composite type I/III endoleak. RESULTS: One-hundred consecutive patients treated were identified for inclusion. Overall mean age was 73.6 years and mean aortic diameter was 59.1 mm. Mean follow-up was 22 months. A total of 26 (26%) patients were treated with LD devices. Number of target vessels per patient was 2.8 in both groups. Infrarenal neck length and diameter were significantly different in the LD and ND patients, respectively (2.6 mm vs. 4.7 mm (P < 0.01) and 30.1 mm vs. 23.4 mm (P < 0.01)). Percent graft oversizing was lower in the LD cohort (19% vs. 24%; P = 0.006). No difference was seen in overall mortality at 30-days (0% vs. 2%; P = 0.4) or at latest follow up (6% vs. 14%; P = 0.6). Reinterventions were not significantly different at 30 days, but were significantly higher over the follow-up period in the LD cohort (46.2 vs. 17.6%; P = 0.002). LD diameter was associated with reintervention on univariate (HR 1.19, 95% CI 1.04-1.37), but not multivariate analysis. The composite endpoint of type I/III endoleak was higher in the LD cohort (15.4% vs. 2.7%; P = 0.004). CONCLUSIONS: FEVAR requiring 34- or 36-mm device diameters is associated with an increased risk of composite type I/III endoleak and reintervention. Patients undergoing fenestrated repair requiring LD devices should be closely monitored, with consideration for proximal or open repair.

Predictors of sac regression after fenestrated endovascular aneurysm repair.

OBJECTIVE: Aneurysm sac regression after standard endovascular aortic repair is associated with improved outcomes, but similar data are limited after fenestrated endovascular aortic repair (FEVAR). We sought to evaluate sac regression after FEVAR, and identify any predictors of this favorable outcome. METHODS: Patients undergoing elective FEVAR using the commercially available Zenith Fenestrated device (ZFEN; Cook Medical, Bloomington, IN) from 2012 to 2018 at a single institution were reviewed retrospectively. The maximal aortic diameter was compared between the preoperative scan and those obtained in follow-up. Patients with of 5 mm or more sac regression were included in the regression (REG) group, with all others in the nonregression (NONREG) group. Outcomes were compared between groups using univariate analysis, and logistic regression analysis was performed to identify any predictive factors for sac regression. RESULTS: We included 132 patients undergoing FEVAR in the analysis. At a mean follow-up of 33.1 months, 65 patients (49.2%) had sac regression of 5 mm or more and comprised the REG group (n = 65 [49.2%]). The REG group had smaller diameter devices, and were less likely to have had concomitant chimney grafts placed (P < .05). The NONREG group had a higher incidence of type II endoleak (35.8% vs 12.3%; P = .002). Sac regression was associated with a significant mortality benefit on Kaplan-Meier analysis (log rank P = .02). Multivariate analysis identified adjunctive parallel grafting (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.03-0.36; P < .01), persistent type II endoleak (OR, 0.13; 95% CI, 0.02-0.74; P < .01), and a greater number of target vessels (OR, 0.25; 95% CI, 0.10-0.62; P = .002) as independent predictors of failure to regress. CONCLUSIONS: Sac regression after FEVAR occurred in nearly one-half of patients, but seems to be less common in patients with persistent type II endoleaks and those undergoing concomitant parallel grafting. Sac regression was associated with a significant survival advantage, and can be used as a clinical marker for success after FEVAR.

Hydrogen Sulphide Release via the Angiotensin Converting Enzyme Inhibitor Zofenopril Prevents Intimal Hyperplasia in Human Vein Segments and in a Mouse Model of Carotid Artery Stenosis.

OBJECTIVE: Hypertension is a major risk factor for intimal hyperplasia (IH) and re-stenosis following vascular and endovascular interventions. Preclinical studies suggest that hydrogen sulphide (H2S), an endogenous gasotransmitter, limits re-stenosis. While there is no clinically available pure H2S releasing compound, the sulfhydryl containing angiotensin converting enzyme inhibitor zofenopril is a source of H2S. Here, it was hypothesised that zofenopril, due to H2S release, would be superior to other non-sulfhydryl containing angiotensin converting enzyme inhibitors (ACEi) in reducing intimal hyperplasia. METHODS: Spontaneously hypertensive male Cx40 deleted mice (Cx40-/-) or wild type (WT) littermates were randomly treated with enalapril 20 mg or zofenopril 30 mg. Discarded human vein segments and primary human smooth muscle cells (SMCs) were treated with the active compound enalaprilat or zofenoprilat. IH was evaluated in mice 28 days after focal carotid artery stenosis surgery and in human vein segments cultured for seven days ex vivo. Human primary smooth muscle cell (SMC) proliferation and migration were studied in vitro. RESULTS: Compared with control animals (intima/media thickness 2.3 ± 0.33 µm), enalapril reduced IH in Cx40-/- hypertensive mice by 30% (1.7 ± 0.35 µm; p = .037), while zofenopril abrogated IH (0.4 ± 0.16 µm; p < .002 vs. control and p > .99 vs. sham operated Cx40-/- mice). In WT normotensive mice, enalapril had no effect (0.9665 ± 0.2 µm in control vs. 1.140 ± 0.27 µm; p > .99), while zofenopril also abrogated IH (0.1623 ± 0.07 µm; p < .008 vs. control and p > .99 vs. sham operated WT mice). Zofenoprilat, but not enalaprilat, also prevented IH in human vein segments ex vivo. The effect of zofenopril on carotid and SMCs correlated with reduced SMC proliferation and migration. Zofenoprilat inhibited the mitogen activated protein kinase and mammalian target of rapamycin pathways in SMCs and human vein segments. CONCLUSION: Zofenopril provides extra beneficial effects compared with non-sulfhydryl ACEi in reducing SMC proliferation and re-stenosis, even in normotensive animals. These findings may hold broad clinical implications for patients suffering from vascular occlusive diseases and hypertension.

The effects of COVID-19 pandemic on patients with lower extremity peripheral arterial disease: A near miss disaster.

BACKGROUND: The COVID-19 pandemic has led to widespread postponement and cancelation of elective vascular surgeries in Switzerland. The consequences of these decisions are poorly understood. PATIENTS AND METHODS: In this observational, retrospective, single-center cohort study, we describe the impact of COVID-19 pandemic containment strategies on patients with lower extremity peripheral arterial disease (PAD) referred during the period March 11, to May 11, 2020, compared to the same time frames in 2018 to 2019. Patients admitted for acute limb ischemia (ALI) or chronic PAD and undergoing urgent or elective vascular surgery or primary amputation were included. Patients' characteristics, indications for admission, and surgical features were analyzed. The occurrence of 30 day outcomes was assessed, including length of stay, rates of major adverse cardiovascular events (MACE) and major adverse limb events (MALE), and procedural and hemodynamic success. RESULTS: Overall, 166 patients were included. Fewer subjects per 10 day period were operated in 2020 compared to, 2018 to 2019 (6.7 vs. 10.5, respectively; P < 0.001). The former had higher rates of chronic obstructive pulmonary disease (COPD) (25% vs. 11.1%; P = 0.029), and ASA score (3.13 vs. 2.90; P = 0.015). The percentage of patients with ALI in 2020 was about double that of the same period in 2018 to 2019 (47.5% vs. 24.6%; P = 0.006). Overall, the types of surgery were similar between 2020 and 2018 to 2019, while palliative care and primary amputations occurred only in 2020 (5 out 40 cases). The rate of post-operative MACE was significantly higher in 2020 (10% vs. 2.4%; P = 0.037). CONCLUSIONS: During the first state of emergency for COVID-19 pandemic in 2020, less regular medical follow-up and hindered hospital access could have resulted in more acute and advanced clinical presentations of patients with PAD undergoing surgery. Guidelines are needed to provide appropriate care to this vulnerable population and avoid a large-scale disaster.

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.

Successful repair of an arch aneurysm with acute aortic dissection in a patient with Marfan syndrome using a hybrid surgical approach and the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair technique.

Endovascular management of aortic complications in patients with Marfan syndrome (MFS) is uncommon. We treated a patient with MFS with a diagnosis of a 75-mm aortic arch aneurysm and uncomplicated aortic type B dissection using single-stage hybrid surgery combining total arch replacement with elephant trunk and the STABILISE (stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair) technique for complete aortic remodeling. The repair was successful, and the aortic true lumen was completely expanded. At 6 months after surgery, clinical evaluation confirmed the early success of the intervention. This type of surgery must be studied further before it can become routine treatment for patients with MFS but it proved safe and feasible.

Quantification of suprarenal aortic neck dilation after fenestrated endovascular aneurysm repair.

OBJECTIVE: Suprarenal aortic neck dilation (AND) after fenestrated endovascular aneurysm repair (FEVAR) with commercially available devices has not yet been well characterized. The aim of this study was to measure diameter changes in the supravisceral aorta after FEVAR. METHODS: This is a single-center retrospective review involving patients with juxtarenal aneurysms treated with Cook ZFEN devices (Cook Medical, Bloomington, Ind). Patients with at least 1 year of cross-sectional radiologic follow-up were included. AND was defined as ≥3 mm at any measured location. Aortic diameter, defined as the average outer to outer diameter on three-dimensional centerline imaging, was measured at seven locations along the length of the ZFEN device from the proximal fixation struts to the bottom of the second seal stent. The first postoperative CT scan (≤1 month) served as a baseline from which subsequent measurements at annual intervals were compared. RESULTS: A total of 43 patients who underwent FEVAR from 2012 to 2018 met inclusion criteria, with a total of 119 target vessels (83 renal stents, 41 superior mesenteric artery scallops or large fenestrations). Mean follow-up time was 30.3 months. Any AND was found to occur in 32 (74.4%) patients. Aortic diameter dilation at latest follow-up was found to occur at all measured locations from the top of the fixation struts (1.9 ± 2.4 mm; P < .0001) to the middle of the second seal stent (1.3 ± 3.8 mm; P < .01). Diameter growth was most pronounced in the middle of the first seal stent, with mean AND of 3.6 ± 3.2 mm. At this location, the aorta experienced nearly linear annual growth of 0.99 mm (95% confidence interval, 0.7-1.28 mm) per year. Increasing device oversizing relative to the native visceral aorta was the strongest predictor of postoperative neck diameter growth (1.34 mm per 10% increase in oversizing; P = .02), whereas increasing proximal seal length was protective of growth (-1.82 mm per 10-mm increase in seal length; P = .016). Proximal seal lengths ≥3 cm were associated with less neck dilation compared with <3 cm (2.6 mm vs 4.9 mm; P = .022). Type IA endoleak in this cohort was rare (n = 1) and not associated with AND (P = .256). CONCLUSIONS: Dilation of the suprarenal aorta is a common finding in midterm follow-up after FEVAR and not associated with proximal endoleak. Aggressive device oversizing is predictive of dilation, whereas longer seal lengths are associated with less dilation along the suprarenal seal zone. These results support the continued use of FEVAR for juxtarenal aneurysms, particularly in patients in whom ≥3 cm of healthy seal length can be obtained.

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.

Renal Stent Complications and Impact on Renal Function after Standard Fenestrated Endovascular Aneurysm Repair.

BACKGROUND: To report renal outcomes including long-term patency, secondary interventions, and related renal function after fenestrated endovascular aortic repair (fEVAR). METHODS: Single-center retrospective review of patients undergoing fEVAR between 2012 and 2018 using the Cook ZFEN device. Renal stent complications, defined as any stenosis, occlusion, kink, renal stent-related endoleak, and reinterventions were tabulated. Estimated glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease formula. RESULTS: During the study period, 114 patients underwent elective fEVAR. Of 329 total target vessels, 193 renal arteries were stented (133 Atrium iCAST, 60 Gore VBX). Technical success was achieved in 97.4%, and the mean follow-up was 23.3 months. Seventeen renal complications occurred in 14 patients (12.3%), including 4 occlusions, 9 stenosis, 3 dislocations, and 1 type III endoleak. All stent complications underwent endovascular reintervention with a median hospital stay of 1 day (0-10) and a technical success of 94.2%. One patient suffered renal hemorrhage that warranted embolization. Patients with occlusion were treated the day of diagnosis, and mean time from diagnosis to intervention for stenosis was 21.5 days. Estimated primary patency was 92.1 % and 81.5% at 24 and 48 months, respectively. On multivariate analysis, larger native renal artery diameter was the only independent protective factor against patency loss (HR 0.23 (0.09-0.59)). Secondary patency at latest follow-up was 99.4%. Mean eGFR was not significantly different at latest follow-up between patients with renal complications versus those without (43.75 vs. 55.58 mL/min/1.73 m2, P = 0.09). Comparing patients with and without renal stent complications, 81.4% and 72.7% of patients had stable or improved renal disease by chronic kidney disease staging compared with baseline (P = 0.51). CONCLUSIONS: fEVAR is a durable option for the treatment of juxtarenal aortic aneurysms and is associated with excellent secondary patency. Renal stent complications have no significant impact on renal function, but smaller native renal arteries are at higher risk of stent-graft complications.

Innovative Technique for Below the Knee Arterial Revascularisation Using Porcine Self Made Stapled Pericardial Tube Grafts.

INTRODUCTION: When no autologous vein is available for distal bypass in the setting of chronic limb threatening ischaemia (CLTI), new alternatives are required to solve the problems of availability, patency, and resistance to infection. An innovative technique of below the knee bypass for CLTI using a porcine self made stapled pericardial tube graft is reported. REPORT: An 84 year old man, admitted with right CLTI with foot infection due to long occlusion of the femoropopliteal segment, required urgent revascularisation. In the absence of autologous vein and cryopreserved vessels, a 4 mm self made stapled porcine pericardial tube graft 56 cm long was created from two 14 × 8 cm patches, to perform a femorotibioperoneal trunk bypass. On day 10, bypass thrombectomy and balloon angioplasty of the distal anastomosis were needed to treat early occlusion. Oral anticoagulation was then started. Right toe pressure increased from 0 to 70 mmHg, and no infection was reported. Complete wound healing was achieved. At six months, the bypass was still patent. DISCUSSION: The use of porcine self made stapled pericardial tube grafts could offer new options for revascularisation in CLTI. Larger cohort studies with longer follow up are needed to confirm this successful preliminary experience.

Long-term Functional Outcomes Follow-up after 188 Rib Resections in Patients with TOS.

BACKGROUND: Short-term outcomes in patients with all forms of TOS have been widely reported in the literature and have established that rib resection can be beneficial in decompressing the thoracic outlet and relieving pressure on traversing structures. We sought to determine long-term functional outcomes using the Disability of the Arm, Shoulder, and Hand (QuickDASH) survey in patients with TOS who underwent rib resection. METHODS: Clinical records for patients who underwent rib resection for TOS at a single institution were retrospectively reviewed. All patients were contacted via telephone and long-term functional outcome was assessed at latest follow-up via the 11-item version of the QuickDASH questionnaire. Demographics, TOS type, preoperative QuickDASH score, and athletic status were recorded. Patients were asked if they returned to baseline activity since their surgery, would have the procedure again, and if they were subjectively better postoperatively. RESULTS: From 2000 to 2018, 261 patients underwent rib resection surgery. One hundred seventy patients (65.1%) were able to be contacted via telephone for long-term follow-up. A total of 188 surgeries (102 neurogenic thoracic outlet syndrome, 82 venous thoracic outlet syndrome, 4 arterial thoracic outlet syndrome) were performed in these 170 patients. The mean follow-up time for the cohort was 5.3 years (range 1-18). Overall, 167 (88.9%) patients returned to baseline activity postoperatively. Postop QuickDASH decreased to 12 from 44 preoperatively for the cohort. CONCLUSIONS: First rib resection and thoracic outlet decompression for all forms of TOS is a durable surgical treatment which results in excellent long-term functional outcomes as determined by both the QuickDASH score and subjective patient reporting.

Incidence and Risk Factors for Deep Vein Thrombosis after Radiofrequency and Laser Ablation of the Lower Extremity Veins.

BACKGROUND: The rates of thromboembolic complications such as deep vein thrombosis (DVT) after venous ablation procedures for symptomatic superficial venous insufficiency are controversial. We sought to describe the risk factors for and incidence of DVT after radiofrequency ablation (RFA) and laser ablation (LA). METHODS: We queried the Truven Health Marketscan Database from 2007-16 for patients who underwent RFA or LA and had a follow-up duplex ultrasound within 30 days of the ablation procedure. The primary outcome was DVT at 7 and 30 days identified by International Classification of Diseases-9 and International Classification of Diseases-10 codes. Multivariable regression was used to evaluate the patient and procedural variables associated with a DVT at 30 days, expressed as odds ratios (ORs) with a 95% confidence interval (95% CI). Patients and procedures with a previous DVT diagnosis were excluded. RESULTS: A total of 256,999 patients underwent 433,286 ablation procedures: 192,195 (44.4%) RFA and 241,091 LA. Of these, 8,203 (1.9%) had a newly diagnosed DVT within 7 days and 13,347 (3.1%) within 30 days of the procedure. The incidence of DVT decreased over the study period. LA (2.8%) demonstrated a lower incidence of DVT at 30 days compared with RFA (3.4%), P < 0.001. On multivariable regression, LA (OR, 0.82; 95% CI 0.80-0.85) was again associated with a decreased risk for 30-day DVT, as was female gender (OR, 0.74; 95% CI, 0.71-0.77), and sclerotherapy performed on the same day (OR, 0.91; 95% CI, 0.85-0.98). A diagnosis of peripheral artery disease (OR, 1.23; 95% CI, 1.16-1.31) and concomitant stab phlebectomy (OR, 1.43; 95% CI, 1.37-1.49) was associated with an increased risk of DVT within 30 days. CONCLUSIONS: The incidence of newly diagnosed DVT within 30 days of an ablation procedure was 3.2%. The risk for DVT decreased in recent years, and LA was associated with an 18% decreased risk compared with RFA.

Multivessel tibial revascularization does not improve outcomes in patients with critical limb ischemia.

OBJECTIVE: Multivessel tibial revascularization for critical limb ischemia (CLI) remains controversial. The purpose of this study was to evaluate single vs multiple tibial vessel interventions in patients with multivessel tibial disease. We hypothesized that there would be no difference in amputation-free survival between the groups. METHODS: Using the Vascular Quality Initiative registry, we reviewed patients undergoing lower extremity endovascular interventions involving the tibial arteries. Patients with CLI were included only if at least two tibial vessels were diseased and adequate perioperative data and clinical follow-up were available for review. The primary outcome was amputation-free survival. RESULTS: There were 10,849 CLI patients with multivessel tibial disease evaluated from 2002 to 2017; 761 limbs had adequate data and follow-up available for review. Mean follow-up was 337 ± 62 days. Of these, 473 (62.1%) underwent successful single-vessel tibial intervention (group SV), whereas 288 (37.9%) underwent successful multivessel (two or more) intervention (group MV). Patients in group MV were younger (69.1 vs 73.2 years; P < .001), with higher tobacco use (29.5% vs 18.2%; P < .001). Group SV more commonly had concurrent femoral or popliteal inflow interventions (83.7% vs 78.1%; P = .05). Multivessel runoff on completion was significantly greater for group MV (99.9% vs 39.9%; P < .001). No differences were observed between group SV and group MV for major amputation (9.0% and 7.6%; P = .6), with similar amputation-free survival at 1 year (90.6% vs 92.9%; P = .372). In a multivariate Cox model, loss of patency was the only significant predictor of major amputation (hazard ratio, 5.36 [2.7-10.6]; P = .01). A subgroup analysis of 355 (46.6%) patients with tissue loss data showed that tissue loss before intervention was not predictive of future major amputation. CONCLUSIONS: In the Vascular Quality Initiative registry, patients with CLI and occlusive disease involving multiple tibial vessels did not appear to have a limb salvage benefit from multiple tibial revascularization compared with single tibial revascularization.

Long-Term Quality of Life Comparison between Supraclavicular and Infraclavicular Rib Resection in Patients with vTOS.

BACKGROUND: Rib resection in venous thoracic outlet syndrome (vTOS) may be approached via a transaxillary, supraclavicular, or infraclavicular approach based on surgeon preference. The purpose of this study was to evaluate long-term postoperative quality of life function after surgery for vTOS and to determine if there were long-term patency differences associated with the surgical approach or whether prophylactic postoperative venography was performed. METHODS: All patients with vTOS undergoing rib resection at a single institution were retrospectively reviewed. In 2012, we switched our approach to infraclavicular with postoperative venogram performed within 2 weeks of rib resection. Clinical records and imaging results were tabulated, and postoperative outcomes, complications, and long-term symptom follow up via the disabilities of the arm, shoulder, and hand score surveys. The disabilities of the arm, shoulder, and hand score ranges from 0 to 100 with lower numbers indicating better functional status (100 = worst). RESULTS: During the 19-year study period, we performed 109 rib resections in patients with vTOS (mean age, 29.8 years). From 2000 to 2012, 54 patients were approached via a supraclavicular approach, and from 2012 to 2018, 55 patients were approached via an infraclavicular approach. There was a significant decrease in the number of complications in the infraclavicular cohort compared with the supraclavicular group. There was no difference in patency between the 2 groups even with a higher rate of postoperative venogram in the infraclavicular cohort. There was no difference in long-term the disabilities of the arm, shoulder, and hand scores. There was an increased rate of complications in the supraclavicular cohort as compared with the infraclavicular group (P < 0.05). CONCLUSIONS: The infraclavicular approach in patients with vTOS is associated with a lower rate of complications, but long-term quality of life outcomes and patency are not different between groups.