Contralateral Thoracotomy With Extracorporeal Circulation for Reoperative Resection of a Kommerell Diverticulum.

Reoperative vascular ring surgery is uncommon. Standard redo ipsilateral thoracotomy may present technical challenges and risks. We describe a patient with right aortic arch, aberrant left subclavian artery, and a Kommerell diverticulum in whom previous vascular ring division via left thoracotomy did not relieve dysphagia. Three years after the unsuccessful operation, left subclavian-carotid transposition via supraclavicular incision followed by resection of the Kommerell diverticulum via right thoracotomy with extracorporeal circulation relieved symptoms. Contralateral thoracotomy with extracorporeal circulation provides a safe, alternative approach to redo ipsilateral thoracotomy for resection of a symptomatic Kommerell diverticulum. We review the literature on the incidence, surgical indications, and operative approaches to manage symptoms from a Kommerell diverticulum.

Development and validation of a machine-learning prediction model to improve abdominal aortic aneurysm screening.

OBJECTIVE: Despite recommendations by the United States Preventive Services Task Force and the Society for Vascular Surgery, adoption of screening for abdominal aortic aneurysms (AAAs) remains low. One challenge is the low prevalence of AAAs in the unscreened population, and therefore a low detection rate for AAA screenings. We sought to use machine learning to identify factors associated with the presence of AAAs and create a model to identify individuals at highest risk for AAAs, with the aim of increasing the detection rate of AAA screenings. METHODS: A machine-learning model was trained using longitudinal medical records containing lab results, medications, and other data from our institutional database. A retrospective cohort study was performed identifying current or past smoking in patients aged 65 to 75 years and stratifying the patients by sex and smoking status as well as determining which patients had a confirmed diagnosis of AAA. The model was then adjusted to maximize fairness between sexes without significantly reducing precision and validated using six-fold cross validation. RESULTS: Validation of the algorithm on the single-center institutional data utilized 18,660 selected patients over 2 years and identified 314 AAAs. There were 41 factors identified in the medical record included in the machine-learning algorithm, with several factors never having been previously identified to be associated with AAAs. With an estimated 100 screening ultrasounds completed monthly, detection of AAAs is increased with a lift of 200% using the algorithm as compared with screening based on guidelines. The increased detection of AAAs in the model-selected individuals is statistically significant across all cutoff points. CONCLUSIONS: By utilizing a machine-learning model, we created a novel algorithm to detect patients who are at high risk for AAAs. By selecting individuals at greatest risk for targeted screening, this algorithm resulted in a 200% lift in the detection of AAAs when compared with standard screening guidelines. Using machine learning, we also identified several new factors associated with the presence of AAAs. This automated process has been integrated into our current workflows to improve screening rates and yield of high-risk individuals for AAAs.

Internal iliac artery aneurysm in a patient with proximal occlusion at its origin.

We present the case of an 87-year-old man with a ruptured right internal iliac artery aneurysm with hemoperitoneum. The right internal iliac artery aneurysm appeared to fill from the retrograde profunda femoris artery in the setting of a previously repaired abdominal aortic aneurysm with aorta-bi-iliac bypass with ligation of the bilateral internal iliac arteries. Abdominal computed tomography revealed an aneurysm of the right internal iliac artery measuring 8.9 cm, with filling through the collateral vessels. Open repair was performed, leading to complete exclusion of the aneurysm with no perioperative complications.

Outcomes of Aortobifemoral Bypass Based on Configuration of the Proximal Anastomosis.

BACKGROUND: Aortobifemoral bypass (ABF) remains an important treatment modality in the revascularization of aortoiliac occlusive disease. Despite ABF being performed for decades, questions remain regarding the preferred technique for the proximal anastomosis, specifically whether an end-to-end (EE) or an end-to-side (ES) configuration is superior. The goal of this study was to compare the outcomes of ABF based on proximal configuration. METHODS: We queried the Vascular Quality Initiative registry for ABF procedures performed between 2009 and 2020. Univariate and multivariate logistic regression analyses were used to compare perioperative and 1-year outcomes between EE and ES configurations. RESULTS: Of the 6,782 patients (median [interquartile range] age, 60.0 [54-66 years]) who underwent ABF, 3,524 (52%) had an EE proximal anastomosis and 3,258 (48%) had an ES proximal anastomosis. Postoperatively, the ES cohort had a higher frequency of extubation in the operating room (80.3% vs. 77.4%; P < 0.01), lower change in renal function (8.8% vs. 11.5%; P < 0.01), and lower use of vasopressors (15.6% vs. 19.1%; P < 0.01), but higher rates of unanticipated return to the operating room (10.2% vs. 8.7%; P = 0.037) compared with the EE configuration. At 1-year follow-up, the ES cohort had a significantly lower primary graft patency rate (87.5% vs. 90.2%; P < 0.01) and higher rates of graft revision (4.8% vs. 3.1%; P < 0.01) and claudication symptoms (11.6% vs. 9.9%; P < 0.01). The ES configuration was significantly associated with a higher rate of 1-year major limb amputations in univariate (1.6% vs. 0.9%; P < 0.01) and multivariate (odds ratio, 1.95, confidence interval, 1.18-3.23, P=<0.01) analyses. CONCLUSIONS: While the ES cohort seemed to have less physiologic insult immediately postoperatively, the EE configuration appeared to have improved 1-year outcomes. To our knowledge, this study is one of the largest population-based studies comparing the outcomes of the proximal anastomotic configurations. Longer-term follow-up is needed to determine which configuration is optimal.

Defining Duplex Ultrasound Criteria for In-Stent Restenosis of the Carotid Artery Using Computed Tomographic Angiography.

Introduction Duplex ultrasound (DUS) velocity measurement is the preferred method for evaluating carotid artery stenosis. However, velocity criteria based upon native carotid arteries may not apply to internal carotid artery stents. Previously, catheter-based angiography was used to determine DUS velocity criteria for in-stent restenosis (ISR), but conventional angiography is invasive and can be limited. This study sought to define duplex ultrasound velocity criteria for predicting internal carotid artery in-stent restenosis by correlating in-stent velocities with computed tomographic angiography (CTA) measurements of percent stenosis. Methods A retrospective chart review was conducted on all patients who underwent internal carotid artery (ICA) stenting within our health system between January 2013 and February 2020. Thirty-eight surveillance DUS studies from 32 patients were found to have CTA performed within 30 days. Centerline reconstructions of internal carotid artery stents were created using Aquarius iNtuition software (TeraRecon, Durham, NC, USA). Two independent observers measured percent stenosis by three built-in methods. Stenotic areas were matched to DUS-measured peak systolic velocities (PSV) and end-diastolic velocities (EDV). Internal carotid artery PSV (stent) to common carotid artery (CCA) PSV ratios (ICA/CCA) were calculated, and receiver operating characteristic (ROC) curves were generated. The optimal DUS velocity criteria in the stented ICA were determined by maximizing Youden's index. Results Mean vessel diameter measurement of percent stenosis resulted in the most accurate model for all DUS velocity parameters (PSV, EDV, and ICA/CCA ratio) and was used for threshold determinations (area under the receiver operating characteristics (AUROC): 0.99, 0.96, and 0.96, respectively). A PSV cutoff of 240 cm/s for ≥60% ISR resulted in the highest Youden's index (97%) with 100% sensitivity and 97% specificity. Secondary DUS parameters included an EDV ≥50 cm/s (Youden's index 84%) and an ICA/CCA ratio ≥ 2.2 (Youden's index 91%). Conclusions Velocity criteria to predict internal carotid artery ISR is needed to inform decisions for possible reintervention. Using CTA, we found that a PSV ≥240 cm/s on carotid DUS can predict ≥60% ISR with high sensitivity and specificity. This value can be used as an alternative to current velocity criteria based on native carotid arteries. However, the optimal thresholds for EDV and ICA/CCA ratio were similar to native carotid arteries.

The Use of Paclitaxel-Coated Devices in the Treatment of Peripheral Arterial Disease is Not Associated With Increased Mortality or Amputations.

BACKGROUND: Strategies for the most effective treatment for peripheral arterial disease (PAD) remain controversial among clinicians. Several trials have shown improved primary patency of femoropopliteal interventions with the utilization of paclitaxel-coated balloons or stents compared to conventional balloons or stents. However, a 2018 meta-analysis suggested an increased mortality risk for patients receiving drug-coated balloons or stents (DCBS), resulting in an international pause in the use of DCBS. A 2021 meta-analysis by the same group suggested an increased risk of major amputation following DCBS use in peripheral arterial revascularization procedures. Here we report our long-term institutional outcomes comparing uncoated devices to DCBS. METHODS: A retrospective review of all patients who underwent peripheral arterial angioplasty, stenting, atherectomy, or a combination between 2011 and 2020 within a regional healthcare system was performed. Univariate, multivariate, and survival analyses were performed using standard statistical methods to assess the primary end points of overall survival, 5-year survival, and amputation-free survival. RESULTS: A total of 2,717 patients were identified, of whom 1,965 were treated with conventional uncoated devices and 752 were treated with DCBS. A univariate analysis showed that patients treated with non-DCBS had higher rates of overall mortality, major amputations, and mortality at 1, 3, and 5 years. A multivariable analysis demonstrated that the use of conventional devices, age, diabetes, chronic kidney disease, myocardial infarction, transient ischemic attack, warfarin use, and atrial fibrillation all significantly increased the risk of 5-year mortality, overall mortality, and combined mortality and/or amputation. CONCLUSIONS: DCBS are not associated with increased mortality or worse amputation-free survival in this real-world cohort of patients treated for PAD. Our data suggest that mortality is more closely linked with pre-existing patient comorbidities rather than device selection at the time of revascularization.

Association of varicose veins with rare protein-truncating variants in PIEZO1 identified by exome sequencing of a large clinical population.

OBJECTIVE: The present study sought to determine whether protein-truncating variants (PTVs) in PIEZO1 and CASZ1 genes, previously shown to be associated with varicose veins, were associated with an altered risk of varicose veins. METHODS: An exome sequence database of 131,918 participants from the Geisinger MyCode Community Health Initiative was used to identify individuals with genetic variants in the PIEZO1 or CASZ1 gene. Clinical phenotypes, including varicose vein diagnoses, were determined by analysis of the electronic health record data. RESULTS: We identified 12,531 individuals (9.5%) with a diagnosis of varicose veins. Exome sequence data identified 92 PIEZO1 PTVs in 305 heterozygous carriers. PIEZO1 PTVs were significantly enriched in those with varicose vein (0.37% of cases vs 0.22% of controls; odds ratio [OR], 1.7; P = .0010). Nearly all varicose vein cases were associated with frameshift or stop-gain PTVs (OR, 3.0 for stop-gain [P = .0001]; OR, 2.9 for frameshift variants [P < .0001]). In the varicose vein cases, the PTV carriers were more likely to have an encounter with a vascular surgeon (62.5% for PTV carriers; 36.9% for noncarriers; P = .0003) and more likely to have received vein ablation therapy (OR, 6.9; P < .0001). No association was found between PIEZO1 PTVs and lymphedema, and no association was found for rare missense variants in PIEZO1 with varicose veins. PTVs in CASZ1 were extremely rare (16 total carriers), with none identified in those with varicose vein. CONCLUSIONS: Rare PTVs in PIEZO1 but not CASZ1 were associated with varicose veins and the need for vein ablation therapy. These results have demonstrated that PTVs in the PIEZO1 gene are rare but represent strong genetic risk factors for varicose veins and the need for vein ablation therapy. These results have also identified a potential biologic mechanism and target for the development of novel therapies.

Outcomes of transcaval endoleak embolization via laser fenestration of the inferior vena cava following endovascular abdominal aortic aneurysm repair.

This report describes a single center experience with laser fenestration of the inferior vena cava for the treatment of type 2 endoleak after endovascular abdominal aortic aneurysm repair. Our technique is reviewed, and clinical data after treatment are reported. Twelve patients underwent transcaval embolization via laser fenestration. Technical success was achieved in all cases (100%) with no postoperative complications. At a median follow-up of 12.9 months, no patient demonstrated a persistent endoleak and there were no cases of aortocaval fistula. Transcaval embolization, via laser fenestration, provides an additional strategy for the management of type 2 endoleak after endovascular abdominal aortic aneurysm repair.

The combined use of thoracic and abdominal aortic stent grafts for endovascular repair of wide neck abdominal aortic aneurysms in high risk patients.

INTRODUCTION: Treatment of abdominal aortic aneurysms (AAA) with large (28 mm to 34 mm) and wide diameter (> 35 mm) necks remains a challenge in patients who are high-risk candidates for open repair. While several case reports describe the use of a thoracic stent graft in conjunction with a traditional modular bifurcated stent graft, most patients do not have the aortic length to accommodate such a configuration. We present our experience utilizing a distal unibody bifurcated aortic stent graft (Endologix, Irvine, CA) in conjunction with a proximal thoracic aortic stent graft (Medtronic, Minneapolis, MN) to treat wide-necked non-ruptured AAAs in patients who were otherwise poor candidates for open or fenestrated repair. METHODS: A single center retrospective review of patients treated with a combination of a distal unibody bifurcated aortic stent graft and a proximal thoracic aortic stent graft extension from 2013 to 2019 was performed. Demographics, perioperative details and long-term outcomes were collected and summarized. Standard statistical methods were utilized. RESULTS: We identified 7 patients who underwent this procedure during the study interval. Of these, all 7 (100%) were male with an average age of 69.1 ± 5.1 years. Average Charlson Comorbidity Index was 5.0. Average pre-operative maximum aortic and neck diameters were 57.9 mm (± 5.8) and 37.4 mm (± 4.5) respectively. All patients underwent repair with a distal 28 mm diameter unibody bifurcated aortic stent graft and proximal extension with a thoracic aortic stent graft that ranged from 40 to 46 mm in diameter. Technical success was achieved in all 7 patients. There were no perioperative mortalities or aorta-related deaths. Follow up was a mean of 1.98 years with a mean survival of 4.75 years (± 0.86). One patient required an aneurysm-related intervention for a late type III endoleak. CONCLUSION: The combined use of thoracic and abdominal aortic stent grafts is a safe and effective endovascular method to treat high-risk surgical candidates with wide-necked AAAs.

Outcomes of Type II Endoleak Treatment Using Ethylene Vinyl Alcohol Copolymer (OnyxTM).

INTRODUCTION: This study reports our experience with the use of an ethylene vinyl alcohol copolymer (Onyx™) for the treatment of type II endoleak after endovascular repair of abdominal aortic aneurysms (EVAR) in comparison to coils and cyanoacrylate glue. METHODS: Clinical data of all patients treated for type II endoleak following EVAR between 2009 and 2017 were retrospectively analyzed. Abdominal aortic aneurysm (AAA) diameter and AAA sac volume during follow-up were measured using computed tomography angiography (CTA). Treatment failure variables were created for the change in sac diameter and volume. An increase in sac diameter ≥ 5 mm was considered a failure, as was an increase ≥ 10% in AAA sac volume. RESULTS: 35 patients underwent treatment for a persistent type II endoleak following EVAR. Of these patients, 18 (51.4%) were treated with Onyx and 17 (48.6%) were treated with coils ± cyanoacrylate glue embolization. There were no significant differences between the 2 groups with regard to demographics. The average volume of Onyx used per treatment was 13.4 ml (range 4.5 ml- 39 ml). There was no difference in efficacy between the Onyx and non-Onyx group. Complications were limited to 1 non-target embolization without significant clinical sequelae. CONCLUSIONS: Ethylene vinyl alcohol copolymer (Onyx™) embolization is similarly effective compared to traditional cyanoacrylate glue or coil embolization in the treatment of type II endoleak after EVAR.

Outcome of rectus femoris muscle flaps performed by vascular surgeons for the management of complex groin wounds after femoral artery reconstructions.

OBJECTIVE: Groin wound complications after femoral artery reconstructions are highly morbid and notoriously difficult to treat. Successful techniques include long-term antibiotic therapy, operative débridement, and muscle flap coverage. Historically, more complex muscle flap coverage, such as a rectus femoris muscle flap (RFF), has been performed by plastic and reconstructive surgeons. In this study, the experience of vascular surgeons performing RFF in the management of wound complications after femoral artery reconstructions is reported. METHODS: Clinical data between 2012 and 2018 were retrospectively analyzed. Data were summarized, and standard statistical analysis was performed. RESULTS: There were 23 patients who underwent 24 RFFs for coverage of complex groin wounds after femoral artery reconstructions. One of the 23 patients underwent bilateral RFFs. In this study cohort, patients had a median age of 67.5 years, and 79% (n = 19) were male. Median body mass index was 28.0 kg/m2, and 38% of patients were classified as obese on the basis of body mass index criteria. A history of tobacco use was present in 88%; however, only 29% were current smokers. Diabetes was present in 38% of patients and chronic kidney disease in 29%. Of the 24 RFFs, 14 (58%) were constructed in patients with reoperative groin surgery resulting in the need for muscle flap coverage. Femoral endarterectomy was the most common index procedure (46%), followed by infrainguinal leg bypass surgery (17%) and aortobifemoral bypass (17%). Grafts used during the original reconstruction included 12 bovine pericardial patches (50%), 6 Dacron grafts (25%), 4 PTFE grafts (17%), and 2 autogenous reconstructions (8%). Microbiology data identified 33% of patients (n = 8) to have gram-positive bacterial infections alone, 21% (n = 5) to have gram-negative infections alone, and 29% (n = 7) to have polymicrobial infections; 4 patients (13%) had negative intraoperative culture data. Median hospital stay after RFF was 8 days, and median follow-up time was 29.3 months. Major amputation was avoided in 20 of 24 limbs (83%) undergoing RFF. Eight patients underwent intentional graft or patch explantation (33%) before RFF, whereas 14 of the remaining 15 patients (93%) had successful salvage of the graft or patch after RFF. Two of the patients (13%) who underwent RFF with the intention of salvaging a prosthetic graft or patch required later graft excision. After RFF, 30-day and 1-year survival was 96% and 87%, respectively. CONCLUSIONS: RFF coverage of complex groin wounds after femoral artery reconstructions may safely be performed by vascular surgeons with excellent outcomes.

A systematic review and meta-analysis of bivalirudin application in peripheral endovascular procedures.

OBJECTIVE: The direct thrombin inhibitor bivalirudin (BIV) was shown to be superior to unfractionated heparin (UFH) in percutaneous coronary interventions for reducing procedural blood loss. The aim of this study was to compare outcome profiles of BIV and UFH in peripheral endovascular procedures (PEPs) by synthesizing the currently available data. METHODS: Following the PRISMA statement, we conducted a comprehensive literature search using Medline, Cochrane CENTRAL, PubMed, EMBASE, CINAHL Google scholar, and clinicaltrials.gov. We recruited randomized, controlled trials and well-conducted observational studies that compared UFH and BIV in PEPs requiring anticoagulation, excluding endovascular cardiac procedures and coronary interventions. Random-effects meta-analyses were conducted to compare the outcome profiles of these two agents. RESULTS: Thirteen articles containing 14 studies involving a total of 21,057 patients were enrolled. Of these, 2 were randomized controlled trials, 2 were prospective cohort studies, and 10 were retrospective studies. There were no significant differences between BIV and UFH in terms of procedural success rates, major and minor perioperative bleeding, transfusion, perioperative transient ischemic attack, or hemorrhagic strokes. However, compared with UFH, BIV had significantly lower odds ratios (OR) of perioperative mortality (OR, 0.58; 95% confidence interval [CI], 0.40-0.86), major adverse cardiovascular events (OR, 0.65; 95% CI, 0.51-0.83), net adverse clinical events (OR, 0.75; 95% CI, 0.63-0.88), perioperative myocardial infarction (OR, 0.73; 95% CI, 0.55-0.98), major vascular complications (OR, 0.59; 95% CI, 0.39-0.91), and minor vascular complications (OR, 0.58; 95% CI, 0.40-0.84). CONCLUSIONS: Compared with UFH, PEPs using BIV had comparable procedural success rates and odds of perioperative transient ischemic attack and hemorrhagic stroke. However, procedures with BIV had a lower but nonsignificant odds of perioperative bleeding and transfusion. Depending on the procedures conducted, the patients who received BIV will have reduced or comparable odds of perioperative mortality, myocardial infarction, major adverse cardiovascular events, net adverse clinical events, and major and minor vascular complications. Therefore, BIV may be chosen solely as an alternative procedural anticoagulant to UFH for PEPs.

Outcomes of endovascular treatments for in-stent restenosis in patients with mesenteric atherosclerotic disease.

OBJECTIVE: Mesenteric angioplasty and stenting (MAS) has surpassed open revascularization as the treatment of choice for mesenteric ischemia. Despite the lower perioperative mortality associated with MAS, the need for reintervention is not infrequent. The purpose of this study was to review the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR). METHODS: Clinical data from a single center between 2004 and 2017 were retrospectively analyzed. Standard statistical analysis including Kaplan-Meier estimate for time-dependent outcomes, χ2 test for categorical variables, and two-sample t-test for continuous variables was performed. Primary end points included stent patency and reintervention rate. Secondary end points included mortality and morbidity. RESULTS: During the study period, 91 patients underwent primary MAS. In total, 113 mesenteric vessels were treated with 20 covered stents and 93 bare-metal stents. Overall primary patency was 69% at 2 years. At 2 years, primary patency was 83% for covered stents compared with 65% for bare-metal stents (P = .17). Of these 91 primary MAS patients, 27 (30%) were treated for MAISR (32 vessels). Two covered stent patients developed significant restenosis (11%) compared with 25 (34%) bare-metal stent patients (P = .02). The mean age of patients requiring reintervention was 69 years (36% male), with the majority having a history of tobacco use (85%), hypertension (75%), and hyperlipidemia (78%). Fourteen reintervention patients (52%) presented with recurrent symptoms, 10 (37%) had asymptomatic restenosis, and 3 (11%) developed intestinal ischemia. Twelve patients (44%) underwent reintervention with balloon angioplasty alone and 15 (56%) underwent repeated stent placement. Of the 15 patients who had repeated stent placement, 7 patients had covered stents placed. The 30-day mortality rate after reintervention for mesenteric stent restenosis was 0%. Postoperative complications occurred in 15% of patients (myocardial infarction, 4%; reversible kidney injury, 4%; and bowel ischemia requiring surgical exploration, 7%). There was no difference in the perioperative morbidity in comparing symptomatic and asymptomatic patients undergoing reintervention. Mean follow-up after mesenteric reintervention was 31 months, with one-third of patients (n = 9) requiring another reintervention because of either recurrence of symptoms or asymptomatic high-grade restenosis. Assisted primary patency at 2 years was 92% after reintervention with balloon angioplasty and 87% for repeated stent placement, with no statistically significant difference between the groups (P = .66). CONCLUSIONS: Treatment of MAISR is associated with low mortality and acceptable morbidity. The initial use of covered stents may reduce the need for reintervention.

Outcomes of familial abdominal aortic aneurysm repair in the Vascular Quality Initiative.

OBJECTIVE: Recent investigations have reported increased rates of aneurysm-related complications after endovascular aneurysm repair (EVAR) in familial abdominal aortic aneurysm (fAAA) patients. The purpose of this study was to evaluate the outcomes of open aortic repair (OAR) and EVAR in sporadic AAA (spAAA) and fAAA patients in the Society for Vascular Surgery Vascular Quality Initiative. METHODS: This was a retrospective review of all AAA repairs in the Vascular Quality Initiative from 2003 to 2017. Patients' data were summarized, and standard statistical analysis was performed. Patients with known genetic syndromes and centers with long-term follow-up of <50% of patients were excluded. RESULTS: From 2003 to 2017, there were 1997 fAAA patients compared with 18,185 spAAA patients undergoing OAR and EVAR during the same study period. Compared with their spAAA counterparts, fAAA patients were younger (P < .001), were more likely to be living at home before surgery (P = .008), and demonstrated a lower incidence of coronary artery disease (P = .001) and hypertension (P = .039). Rates of smoking and end-stage renal disease did not differ between groups. However, fAAA patients were more likely to have aneurysmal degeneration of their iliac arteries (P < .001) and to undergo OAR (P < .001). When analyzing patients undergoing OAR, we found that fAAA patients were more likely to require concomitant renal bypass surgery (P = .012) but were extubated sooner (P = .005), received fewer blood transfusions (P < .001), and had a shorter length of stay (P = .018). Although individual complication rates did not differ between fAAA and spAAA groups after OAR, a composite end point of all early postoperative complications was decreased in fAAA patients (P = .020). When comparing fAAA and spAAA patients who underwent EVAR, we found a greater incidence of early lumbar branch endoleaks (type II) in fAAA patients; however, the rate of proximal type IA endoleaks (P = .279) and the rate of late reintervention for sac growth (P = .786), any endoleak (P = .439), or rupture (P = .649) did not differ between the groups. Whereas spAAA patients undergoing EVAR required longer postoperative intensive care unit stays (P < .001) and had a greater incidence of blood transfusions (P < .001), fAAA and spAAA patients had similar rates of postoperative complications (P = .510), 30-day mortality (P = .177), and long-term mortality (P = .259). CONCLUSIONS: This study shows that patients with a familial form of AAA do not have increased morbidity or mortality after AAA repair. Our findings suggest that EVAR and OAR are both safe and effective for fAAA patients. Further studies with longer follow-up are needed to best care for this unique cohort of patients.

Long-term comparative effectiveness of carotid stenting versus carotid endarterectomy in a large tertiary care vascular surgery practice.

OBJECTIVE: Carotid interventional trials have strict inclusion and exclusion criteria that make translation of their results to the real-world population challenging. Furthermore, the specialty of the operating surgeon and the role of clinical decision-making are not well studied. This study compares the effectiveness of carotid endarterectomy (CEA) vs carotid artery stenting (CAS) in a real-world setting when the procedure is performed by fellowship-trained vascular surgeons. METHODS: A retrospective study was conducted of all consecutive patients undergoing CEA and CAS performed by vascular surgeons in a large rural tertiary health care system from 2004 to 2014. Postoperative outcomes of stroke, acute myocardial infarction (AMI), and death were analyzed at 30 days and during the long term (median follow-up of 5.5 years for CEA and 4.8 years for CAS). Standard statistical analysis was performed. Differences in long-term outcomes were expressed as cumulative incidence functions for nondeath outcomes (stroke and AMI), which account for the high death rate in this population of vascular patients, and as Kaplan-Meier curves for death itself. RESULTS: From January 1, 2004, through December 31, 2014, there were 2331 carotid interventions performed (CEA, 1853; CAS, 478), all by fellowship-trained vascular surgeons. The average age of the patients was 71 years, and 63% were male, with more men in the CAS group (61.5% vs 67.8%; P = .011). Preoperatively, 30% of patients were symptomatic, and 77% of patients had high-grade stenosis in the 70% to 99% range. CEA patients were more likely to have preoperative hypertension (89.7% vs 86.2%; P = .029) and were less likely to have a history of cardiovascular disease (53.4% vs 59.4%; P = .018). There were no significant differences in 30-day outcomes between CEA and CAS (stroke, 1.1% vs 1.3% [P = .743]; AMI, 2.2% vs 1.7% [P = .474]; death, 0.7% vs 0.6% [P = .859]) or long-term outcomes (stroke, 6.8% vs 7.7% [P = .321]; AMI, 22.7% vs 21.0% [P = .886]; death, 28.4% vs 28.2% [P = .122]). CONCLUSIONS: The short- and long-term outcomes after CEA vs CAS are similar when the procedure is performed in a real-world setting by fellowship-trained vascular surgeons.

Genetic Association of Lipids and Lipid Drug Targets With Abdominal Aortic Aneurysm: A Meta-analysis.

Importance: Risk factors for abdominal aortic aneurysm (AAA) are largely unknown, which has hampered the development of nonsurgical treatments to alter the natural history of disease. Objective: To investigate the association between lipid-associated single-nucleotide polymorphisms (SNPs) and AAA risk. Design, Setting, and Participants: Genetic risk scores, composed of lipid trait-associated SNPs, were constructed and tested for their association with AAA using conventional (inverse-variance weighted) mendelian randomization (MR) and data from international AAA genome-wide association studies. Sensitivity analyses to account for potential genetic pleiotropy included MR-Egger and weighted median MR, and multivariable MR method was used to test the independent association of lipids with AAA risk. The association between AAA and SNPs in loci that can act as proxies for drug targets was also assessed. Data collection took place between January 9, 2015, and January 4, 2016. Data analysis was conducted between January 4, 2015, and December 31, 2016. Exposures: Genetic elevation of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG). Main Outcomes and Measures: The association between genetic risk scores of lipid-associated SNPs and AAA risk, as well as the association between SNPs in lipid drug targets (HMGCR, CETP, and PCSK9) and AAA risk. Results: Up to 4914 cases and 48 002 controls were included in our analysis. A 1-SD genetic elevation of LDL-C was associated with increased AAA risk (odds ratio [OR], 1.66; 95% CI, 1.41-1.96; P = 1.1 × 10-9). For HDL-C, a 1-SD increase was associated with reduced AAA risk (OR, 0.67; 95% CI, 0.55-0.82; P = 8.3 × 10-5), whereas a 1-SD increase in triglycerides was associated with increased AAA risk (OR, 1.69; 95% CI, 1.38-2.07; P = 5.2 × 10-7). In multivariable MR analysis and both MR-Egger and weighted median MR methods, the association of each lipid fraction with AAA risk remained largely unchanged. The LDL-C-reducing allele of rs12916 in HMGCR was associated with AAA risk (OR, 0.93; 95% CI, 0.89-0.98; P = .009). The HDL-C-raising allele of rs3764261 in CETP was associated with lower AAA risk (OR, 0.89; 95% CI, 0.85-0.94; P = 3.7 × 10-7). Finally, the LDL-C-lowering allele of rs11206510 in PCSK9 was weakly associated with a lower AAA risk (OR, 0.94; 95% CI, 0.88-1.00; P = .04), but a second independent LDL-C-lowering variant in PCSK9 (rs2479409) was not associated with AAA risk (OR, 0.97; 95% CI, 0.92-1.02; P = .28). Conclusions and Relevance: The MR analyses in this study lend support to the hypothesis that lipids play an important role in the etiology of AAA. Analyses of individual genetic variants used as proxies for drug targets support LDL-C lowering as a potential effective treatment strategy for preventing and managing AAA.

Adductor canal compression syndrome in an 18-year-old female patient leading to acute critical limb ischemia: A case report.

BACKGROUND: Adductor canal compression syndrome is a rare non-atherosclerotic cause of arterial occlusion and limb ischemia. PRESENTATION OF CASE: The patient is an 18-year-old healthy female who presented to the emergency department with acute left lower extremity ischemia. Her symptoms began as sudden onset mild foot pain approximately two months ago. Over the 72h prior to presentation, she developed severe pain, pallor, paralysis, loss of pedal pulses, paresthesia, and poikilothermia. Due to her advanced ischemia, she was taken immediately to the operating room for angiography and intervention. Initial angiography demonstrated distal superficial femoral and popliteal artery occlusions along with lack of tibial or pedal artery blood flow. She underwent percutaneous mechanical thrombectomy and initiation of catheter directed thrombolysis. After 48h of catheter directed thrombolysis and repeat mechanical thrombectomy, computed tomography (CT) was performed and demonstrated external compression of the superficial femoral artery in the adductor canal and residual chronic thrombus. Echocardiography and CT of the thoracic aorta was also performed, and were negative, therefore excluding other potential sources of arterial embolism. She next underwent surgical exploration, division of an anomalous musculotendinous band compressing the left superficial femoral artery and thromboendarterectomy of the distal left superficial femoral artery. The patient recovered well without any post-operative complications and could return to her daily activities 3 weeks following surgery. CONCLUSION: Knowledge of rare non-atherosclerotic vascular disorders, such as adductor canal compression syndrome, is paramount when treating patients who present with limb ischemia and lack traditional risk factors.

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report.

BACKGROUND: Emergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. We report the successful treatment of a ruptured thoracic aortic aneurysm (TAA) in the setting of a Stanford type B aortic dissection (TBAD) and right-sided aortic arch. PRESENTATION OF CASE: The patient is a 66-year-old male with chronic kidney disease (CKD) admitted with right sided chest pain and hypotension. Computed tomography angiography (CTA) revealed a 5cm ruptured TAA in the setting of a TBAD and right-sided aortic arch. The TBAD began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). Using a totally percutaneous approach, a conformable Gore® TAG® thoracic endoprosthesis was placed in proximal descending thoracic aorta covering the left SCA. Aside from progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak with degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a Medtronic Valiant® thoracic stent graft. The left subclavian artery was subsequently coil embolized to treat an additional retrograde endoleak. The patient has done well with no further evidence of endoleak or aneurysm expansion. CONCLUSION: Right-sided aortic arch presents challenges in the emergency setting. CTA and post-processing reconstructions are very helpful. While the endoleaks prompted additional interventions, the end result was excellent. This case displays the importance of careful attention to detail and follow-up in these complicated patients.