Intravascular Ultrasound Use is Associated with Improved Patency in Lower Extremity Peripheral Arterial Interventions.

OBJECTIVES: Intravascular ultrasound (IVUS) facilitates detailed visualization of endoluminal anatomy not adequately appreciated on conventional angiography. However, it is unclear if IVUS use improves clinical outcomes of peripheral vascular interventions (PVI) for peripheral arterial disease (PAD). This study aimed to evaluate the impact of IVUS on 1-year outcomes of PVI in the vascular quality initiative (VQI). METHODS: The VQI-PVI modules were reviewed (2016-2020). All patients with available one-year follow up after lower extremity PVI were included and grouped as IVUS-PVI or non-IVUS PVI based on use of IVUS. Propensity matching (1:1) was performed using demographics and comorbidities. One-year major amputation and patency rates were compared. A generalized estimating equation (GEE) model was used to identify predictors of 1-year outcomes. Subgroup analysis based on Trans-Atlantic Inter-Society Consensus (TASC) classification, treatment length and treatment modalities were performed using same modeling approaches. RESULTS: There were 56,633 procedures (non-IVUS PVI=55,302 vs IVUS-PVI=1,331) in 44,042 patients. Propensity matching yielded a total cohort of 1,854 patients matched (1:1), with no baseline differences. LER for claudication was performed in 60.4%, while one-third (33.9%) had chronic limb threatening ischemia (CLTI). IVUS was more commonly used for lesions >15cm in length (46.6% vs 43.3%) and for aortoiliac disease (31.8% vs 27.2%). Rates of atherectomy and stenting were significantly higher with IVUS-PVI (21.1% vs 16.8%), while balloon angioplasty was less common (13.5% vs 24.4%). One-year patency was better with IVUS-PVI (97.7% vs 95.2%, p=0.004). On subgroup analysis, IVUS (OR 2.20, 95% CI 1.29- 3.75) was associated with improved patency in CLTI patients, TASC C or D lesions, and treatment length >15cm. Adjunctive IVUS use during PVI did not significantly impact 1-year amputation (OR 1.7, 95%CI 0.78-3.91). On multivariable regression, adjunctive use of IVUS (OR 2.46 95%CI 1.43-4.25) and aortoiliac interventions (OR 2.91, 95%CI 1.09-7.75) were independent predictors of patency. Treatment modalities such as atherectomy, stenting or balloon angioplasty did not significantly impact patency at 1-year. CONCLUSION: IVUS during lower extremity PVI is associated with improved 1-year patency, when compared to angiography alone. Certain subgroups, such as CLTI patients, lesions>15cm, and TASC C or D lesions might benefit from adjunctive use of IVUS.

Perioperative complications of minor and major reinterventions for peripheral arterial disease.

INTRODUCTION: Patients with peripheral arterial disease (PAD) frequently require reinterventions after lower-extremity revascularization (LER) to maintain perfusion. Current Society for Vascular Surgery guidelines define reinterventions as major or minor based on the magnitude of the procedure. While prior studies have compared primary LER procedures of different magnitudes, similar studies for reinterventions have not been performed. The objective of this study is to compare perioperative outcomes associated with major and minor reinterventions. METHODS: Patients undergoing LER for PAD at a tertiary care center from 2013 to 2017 were included. A retrospective review of electronic medical records was performed, and reinterventions were categorized as major or minor based on the procedure magnitude. Minor reinterventions included endovascular procedures and open revision with patch angioplasty, while major reinterventions were characterized by open surgical or endovascular LER with catheter-directed thrombolysis (CDT). Perioperative outcomes following LER were captured and compared for major and minor reinterventions. An additional subgroup analysis was performed comparing outcomes associated with major reinterventions stratified into open major surgical reinterventions and CDT. RESULTS: This study included 713 patients over a mean follow-up of 2.5 years. A total of 291 patients underwent 696 ipsilateral reinterventions (range = 1-12 reinterventions). Most reinterventions were minor (72.1%, N = 502) and 27.9% (N = 194) were major. Patients receiving reinterventions had an average age of 67.2 ± 11.5 and most were white (73.5%) males (60.1%) initially treated for claudication (58.2%) and CLTI (41.8%). There was significantly higher post-operative bleeding (9.8% vs 3.4%, p = .001), arterial thrombosis (3.1% vs 1.0%, p = .047), and acute renal failure (6.2% vs 2.4%, p = .014) after major reinterventions than minor. Additionally, major reinterventions had significantly higher return to the OR (17.0% vs 11.3%, p = .046) and longer hospital stays (7.5 vs 4.3 days, p = <.0001). Overall, major reinterventions were associated with significantly increased perioperative morbidity (37.6% vs 19.7%, p ≤ .001) with no difference in perioperative mortality. In the subgroup analysis, open reinterventions resulted in significantly longer hospital stays (8.6 days vs 5.5 days, p ≤ .001) and more wound infections than CDT (11.0% vs 0%, p = .017). However, there was no other significant difference in morbidity or mortality following treatment with open surgical reinterventions or CDT. CONCLUSIONS: In this study, major reinterventions after LER were associated with greater perioperative morbidity than minor reinterventions, with no difference in mortality. Major reinterventions performed via open surgery and CDT had similar morbidity and mortality.

Anticoagulation in Patients with Premature Peripheral Artery Disease Undergoing Lower Extremity Revascularization.

BACKGROUND: Premature peripheral artery disease (PAD), defined by lower extremity revascularization (LER) at age ≤ 50 years, is associated with poor major adverse limb events. The early onset of disease is thought to be influenced by genetic factors that regulate homeostasis of the vascular wall and coagulation. The aim of this study is to investigate the effect of anticoagulation as an adjunct to antiplatelet therapy on the outcomes of LER in patients with premature PAD. METHODS: There were 8,804 patients with premature PAD on preoperative and postoperative antiplatelet therapy only and 1,236 patients on preoperative and postoperative anticoagulation plus antiplatelet therapy in the Vascular Quality Initiative peripheral vascular intervention, infrainguinal, and suprainguinal files. Propensity score matching (2:1) was performed between patients with premature PAD who were on antiplatelet therapy and those on anticoagulation plus antiplatelet therapy. Perioperative and 1-year outcomes were analyzed including reintervention, major amputation, and mortality. RESULTS: Patients on anticoagulation were more likely to have coronary artery disease (48.7% vs. 41.2%, P < 0.001), congestive heart failure (20.2% vs. 13.1%, P < 0.001), and have undergone prior LER (73.9% vs. 49.2%, P < 0.001) compared to patients on antiplatelet therapy only. They were also less likely to be independently ambulatory (74.2% vs. 81.8%, P < 0.001) and be on a statin medication (66.8% vs. 74.3%, P < 0.001) compared to patients on antiplatelet therapy only. Patients on anticoagulation were also less likely to be treated for claudication (38.1% vs. 48.6%, P < 0.001), and less likely to be treated with an endovascular procedure (64.8% vs. 73.8%, P < 0.001). After matching for baseline characteristics, there were 1,256 patients on antiplatelet therapy only and 628 patients on anticoagulation. Patients on anticoagulation were more likely to require a return to the operating room (3.7% vs. 1.6%, P < 0.001) and had higher perioperative mortality (1.1% vs. 0.3%, P = 0.032), but major amputation was not significantly different (1.8% vs. 1.6%, P = 0.798) compared to patients on antiplatelet therapy alone. At 1 year, amputation-free survival was higher in patients on antiplatelets only compared to patients on anticoagulation and antiplatelet medications (87.5% vs. 80.9%, log-rank P = 0.001). CONCLUSIONS: Anticoagulation in addition to antiplatelet therapy in patients with premature PAD undergoing LER is associated with increased reintervention and mortality at 1 year.

The development of a novel endovascular grasper for challenging inferior vena cava filter retrieval.

OBJECTIVE: Although inferior vena cava (IVC) filters are commonly retrieved using a snare, lateral tilt and fibrosis around struts can complicate the procedure and sometimes require the use of off-label devices. We describe the development of a novel articulating endovascular grasper designed to remove permanent and retrievable IVC filters in any configuration. METHODS: For in vitro testing, the IVC filters were anchored to the inner wall of a flexible tube in a centered or tilted configuration. A high-contrast backlit camera view simulated the two-dimensional fluoroscopy projection during retrieval. The time from the retrieval device introduction into the camera field to complete filter retrieval was measured in seconds. The control experiment involved temporary IVC filter retrieval with a snare. There were four comparative groups: (1) retrievable filter in centered configuration; (2) retrievable filter in tilted configuration; (3) permanent filter in centered configuration; and (4) permanent filter in tilted configuration. Every experiment was repeated five times, with median retrieval time compared with the control group. For in vivo testing in a porcine model, six tilted infrarenal IVC filters were retrieved with grasper via right jugular approach. Comparison analysis between animal and patient procedures was performed for the following variables: total procedure time, the retrieval time, and fluoroscopy time. RESULTS: The in vitro experiments showed comparable retrieval times between the experimental groups 1, 2, and 4 and the control. However, grasper removal of a centered permanent filter (group 3) required significantly less time than in the control (29 vs 79 seconds; P = .009). In the animal model, all IVC filters were retrieved using the grasper with no adverse events. The total procedure time (21.2 vs 43.5 minutes; P = .01) and the fluoroscopy time (4.3 vs 10 minutes; P = .044) were significantly shorter in the animal model compared with the patient group. Moreover, in the patient group, 16.7% of retrievals required advanced endovascular techniques, and one IVC filter could not be retrieved (success rate = 91.7%), whereas all the IVC filters were successfully retrieved in the animal model without the use of additional tools. CONCLUSIONS: The novel endovascular grasper is effective in retrieving different types of IVC filters in different configurations and compared favorably with the snare in the in vitro model. In vivo experiments demonstrated more effective retrieval when compared with matched patient retrievals.

Effect of Doxycycline on Progression of Arterial Calcification in the Noninvasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA(3)CT).

BACKGROUND: Doxycycline has been shown to prevent arterial calcification via attenuation of matrix metalloproteinases (MMP) in preclinical models. We assessed the effects of doxycycline on progression of arterial calcification in patients enrolled in the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT). METHODS: Two hundred and sixty-one patients were randomized to 100 mg doxycycline twice daily or placebo. Arterial calcification was measured in abdominal vessels on noncontrast computed tomography scans. Patients with baseline computed tomography scan and 1 or more follow-up scans within the 2-year study were included for analysis. For individual arteries, mean change in iliofemoral artery calcification over time was calculated via linear regression. Serum MMP-3 and MMP-9 levels were measured at baseline and 6 months. RESULTS: Sixty-five patients in the doxycycline and 66 in the placebo arm were included in this analysis. Baseline characteristics between the groups were similar. The unadjusted mean change in iliofemoral calcium score per year trended toward higher values in patients treated with doxycycline compared with placebo (322 ± 399 units/year vs. 217 ± 307 units/year, P = 0.09). After 6 months, changes in serum MMP-3 and MMP-9 levels were not significantly different between study arms. CONCLUSIONS: In patients with small aortic aneurysm, treatment with doxycycline 100 mg twice daily did not decrease circulating levels of the matrix degrading enzymes MMP-3 and 9 or alter the progression of arterial calcification.

High-Risk Characteristics for Clinical Failure after Isolated Femoropopliteal Peripheral Vascular Interventions.

BACKGROUND: Recent studies suggesting increased late mortality with paclitaxel-coated devices (PCDs) in femoropopliteal peripheral vascular interventions (PVIs) prompted the US Food and Drug Administration to recommend limiting the use of PCDs to "patients at particularly high risk for restenosis". This study's aim is to characterize patients at high risk for restenosis and develop a risk score to guide clinicians in selecting patients for treatment with PCDs. METHODS: Patients who underwent isolated femoropopliteal PVI for claudication or rest pain from 2016-2019 in the Vascular Quality Initiative were included. Patients who received intervention with a PCD, hybrid procedures, died within 1 year, or had missing follow-up data were excluded. The primary end point was clinical failure at 1 year defined as > 50% restenosis, loss of patency, reintervention, or major amputation. Data were split randomly into 2/3 for development and 1/3 for validation. A parsimonious multivariable hierarchical logistic regression for clinical failure was developed and a risk score was created using beta-coefficients. The risk score was applied to the validation dataset and tested for goodness-of-fit and discrimination. RESULTS: Among 4,856 treated patients, 718 (14.8%) experienced clinical failure within 1 year. Clinical failure was associated with age ≤ 50 years, female sex (48.1% vs. 39.5%), insulin-dependent diabetes (29.9% vs. 23.1%), creatinine > 2.0 mg/dL (9.9% vs. 5.7%), prior ipsilateral lower extremity revascularization (48.5% vs. 38.5%), prior ipsilateral minor amputation (5.3% vs. 1.7%), rest pain versus claudication (30.8% vs. 18.7%), occlusion length ≥ 20 cm (18.8% vs. 15.0%), and Trans-Atlantic Inter-Society Consensus II Classification C or D (40.4% vs. 28.0%), all P ≤ 0.01. Risk score development was performed using a multivariable regression. The model demonstrated good fit and discrimination (C-statistic 0.71 in development and 0.72 in validation dataset). Predicted clinical failure was 8.9% for standard-risk (45.9% of interventions), 15.5% for high-risk (44.2% of interventions), and 33.8% for very high-risk patients (9.8% of interventions). CONCLUSIONS: A novel risk score was created with good discrimination for identifying patients at high risk for clinical failure at 1 year after femoropopliteal PVI for claudication and rest pain. Patients at high risk and very high risk for clinical failure may benefit from alternative strategies including PCDs.

Medial artery calcification in peripheral artery disease.

Medial artery calcification (MAC) is a distinct, highly regulated process that is often identified in small and mid-sized arteries of the lower extremities. It is associated with advanced age, diabetes, and chronic kidney disease. MAC often occurs in conjunction with atherosclerotic occlusive disease in lower extremity arteries, and when seen together or in isolation, long-term limb outcomes are negatively affected. In patients with peripheral artery disease (PAD), the extent of MAC independently correlates with major amputation and mortality rates, and it predicts poor outcomes after endovascular interventions. It is associated with increased arterial stiffness and decreased pedal perfusion. New endovascular methods aimed at treating calcified lower-extremity lesions may improve our ability to treat patients with limb-threatening ischemia. Although recent developments have increased our understanding of the mechanisms contributing to MAC, further investigations are needed to understand the role of medial calcification in PAD, and to develop strategies aimed at improving patient outcomes.

Major Adverse Limb Events Among Patients with Premature Peripheral Artery Disease Compared with Those at the Common Age Undergoing Revascularization in the Vascular Quality Initiative.

BACKGROUND: Premature peripheral artery disease (PAD), defined as ≤ 50 years of age, is associated with poor outcomes following lower extremity revascularization (LER). However, the specific characteristics and outcomes of this group of patients compared to those at the common age undergoing revascularization have not been examined. The aim of this study is to compare patients with early versus late onset premature PAD undergoing LER focusing on major adverse limb events (MALEs). METHODS: All LER procedures (open and endovascular) in the Vascular Quality Initiative (VQI) were reviewed. A histogram of patient age at the time of initial LER (no prior LER) was used to define the common age, which included all patients within one standard deviation of the mean. Characteristics and outcomes of patients with premature PAD were compared to patients treated at the common age of presentation undergoing LER. RESULTS: A histogram of all patients undergoing LER was used to define 60 to 80 years as the common age. Patients with premature PAD were more likely to be female, African American, and Hispanic compared to patients at the common age. Patients with premature PAD were also more likely to have insulin-dependent diabetes, be current smokers, on dialysis, and be treated for claudication. Patients with premature PAD were less likely to have Transatlantic Intersociety Consensus (TASC II) C or D disease and were less likely to be on antiplatelets and statins. These differences were more pronounced in patients with chronic limb-threatening ischemia (CLTI). Cox proportional hazards regression demonstrated that premature PAD was independently associated with major adverse limb events (MALEs) at 1-year for patients with claudication (HR:1.7, 95% CI:1.4-2.0) and CLTI (HR:1.3, 95% CI:1.2-1.5) compared to patients 60 to 80 years of age. CONCLUSIONS: Patients with premature PAD have significant differences in characteristics compared to patients treated at the common age. Vascular providers should emphasize medical therapy prior to LER given the lower rates of medical optimization and worse 1-year MALEs in patients with premature PAD.

Endovascular revascularization of an occluded persistent sciatic artery for chronic limb-threatening ischemia in a patient with Coronavirus Disease 2019.

A persistent sciatic artery (PSA) is a rare embryologic variant that usually presents with aneurysmal degeneration. This report describes a 66-year-old man with severe comorbidities who presented with right forefoot gangrene and severe acute respiratory syndrome coronavirus 2 infection. Imaging revealed a unilateral PSA with a chronic occlusion at the level of the knee joint with no aneurysm. After coronavirus disease 2019 resolution, he underwent CO2 angiography with successful recanalization of the PSA, followed by transmetatarsal amputation that healed uneventfully. At follow-up after 16 months, he was noted to have asymptomatic thrombosis of his stent and, hence, no intervention was performed.

Common femoral artery erosion as a source of thromboembolic acute limb ischemia.

We have reported a case of delayed hip prosthetic erosion into the common femoral artery (CFA) 3 years after implantation. The patient had initially presented with left lower extremity acute limb ischemia secondary to a popliteal artery embolism. However, the metal artifact around the hip joint prevented CFA evaluation using conventional imaging. Diagnostic angiography with intraoperative intravascular ultrasound revealed CFA dilatation with adherent intraluminal thrombus. Open surgical repair showed hip prosthesis erosion through the posterior wall of the CFA. Our findings emphasize the necessity for a thorough, multimodal embolic workup and the usefulness of intravascular ultrasound as an adjunctive tool for intravascular anatomy evaluation.

Outcomes of bypass and endovascular interventions for advanced femoropopliteal disease in patients with premature peripheral artery disease.

OBJECTIVE: Patients with premature peripheral artery disease (PAD), defined as age ≤50 years at presentation, have had poor outcomes with open and endovascular lower extremity revascularization. It is unclear whether either strategy is associated with better outcomes because comparative studies have been limited to case series in this patient population. The aim of the present study was to compare the outcomes of patients with premature PAD who had undergone bypass or endovascular revascularization for advanced femoropopliteal disease. Our hypothesis was that open bypass would provide superior long-term outcomes compared with endovascular intervention for patients with premature advanced femoropopliteal PAD. METHODS: All the patients with premature PAD who had undergone isolated femoropopliteal lower extremity revascularization and included in the Vascular Quality Initiative infrainguinal bypass and peripheral vascular intervention files were reviewed from 2003 through 2019. Propensity score matching (1:1) was performed between patients who had undergone femoropopliteal bypass and endovascular interventions for isolated femoropopliteal Trans-Atlantic Classification System C or D lesions. The 1-year outcomes, including reintervention, patency, major amputation, and mortality, were analyzed. RESULTS: Of the 2538 included patients, 902 had undergone isolated femoropopliteal endovascular intervention and 1636 had undergone femoropopliteal bypass. The endovascular intervention group were more likely to have diabetes (68.9% vs 54.0%; P < .001), coronary artery disease (31.0% vs 23.0%; P < .001), renal failure requiring dialysis (14.2% vs 7.2%; P < .001), and claudication (45.1% vs 36.6%; P < .001) compared with the bypass group. After propensity score matching, 466 patients were in each group with no significant differences in the baseline characteristics. Perioperative morbidity was higher with femoropopliteal bypass compared with endovascular intervention (12.0% vs 7.9%; P = .038); however, the rates of major amputation and mortality were not different. At 1 year, patients who had undergone femoropopliteal bypass were less likely to require reintervention (17.0% vs 25.2%; P = .012). However, no differences were found in major amputation (7.7% vs 7.9%; P = .928) or mortality (5.2% vs 5.2%; P = 1.00). Propensity score matching was also performed between femoropopliteal bypass with the great saphenous vein and isolated femoropopliteal endovascular interventions, and the outcomes were similar. CONCLUSIONS: For patients with premature PAD and advanced femoropopliteal disease, bypass surgery decreased the reintervention rate at 1 year but was associated with increased perioperative morbidity and hospital length of stay compared with endovascular therapy. No differences were found in major amputation or mortality between the two strategies.

Complex endovascular retrieval of an intravascular foreign body.

We report a case of a 54-year-old man who developed bilateral multifocal pneumonia as a result of septic thromboembolization from an ingested ballpoint pen that migrated through the gastrointestinal system and lodged in the inferior vena cava. The ballpoint pen was removed from the inferior vena cava with a complex endovascular approach using internal jugular and common femoral vein access with the combination of a snare device and atraumatic laparoscopic grasper. He was also found to have a duodenal perforation requiring primary repair in a staged fashion after endovascular removal of the ballpoint pen.

Long-term outcomes of transposed femoral vein arteriovenous fistula for abandoned upper extremity dialysis access.

BACKGROUND: The number and longevity of patients with end-stage renal disease requiring dialysis access have continued to increase, leading to challenging situations, including exhausted upper extremity access and severe central venous stenosis. This has led to an increase in the use of alternative access sites, including the lower extremities. The transposed femoral vein arteriovenous fistula for dialysis access is a previously described alternative, although limited data are available on its long-term patency. METHODS: Patients treated with a transposed femoral vein fistula were retrospectively reviewed. A transposed femoral vein fistula was created by harvesting the femoral vein and transposing it to the distal superficial femoral artery at the level of the adductor canal. The demographic information, perioperative characteristics, complications, and long-term outcomes were recorded and analyzed. RESULTS: A total of 21 patients had undergone transposed femoral vein fistula for dialysis access after an average of 5.3 ± 2.8 failed dialysis access procedures and a duration of 6.1 ± 4.9 years from the initiation of dialysis. The average age at the procedure was 53.5 ± 12.8 years. Ten patients (47.6%) had a history of diabetes mellitus and nine (42.9%) had a history of coronary artery disease. Technical success was achieved in 100% of cases, and 16 patients (76.2%) were discharged with anticoagulation therapy. The primary patency at 1, 3, and 5 years was 93%, 74%, and 74%, respectively. The secondary patency at 1, 3, and 5 years was 100%, 89%, and 89%, respectively. Two patients had compartment syndrome requiring fasciotomy, and six patients experienced wound complications. CONCLUSIONS: Transposed femoral vein fistula for dialysis access is a viable alternative for patients with an exhausted upper extremity access, with good long-term patency.

Outcomes of treatment with paclitaxel-coated devices for peripheral arterial disease.

OBJECTIVE: The treatment of femoropopliteal peripheral artery disease (PAD) using paclitaxel-coated devices (PCDs) has been shown to improve patency in several randomized trials. However, a recent meta-analysis of trial data suggested an increased risk of mortality with PCD usage. Although subsequent studies have found no association with mortality, the subject has remained controversial. Thus, the aim of the present study was to further investigate the outcomes and causes of mortality for patients treated with PCDs. METHODS: Patients who had undergone endovascular interventions for PAD from 2013 to 2016 at a single institution were reviewed. The patients were stratified by the use of PCDs, which included drug-coated balloons and drug-eluting stents. The cumulative dose of paclitaxel was calculated for the patients who had received multiple interventions. The causes of mortality were identified and compared between the two groups. RESULTS: Of the 366 included patients, 138 (38%) had received a PCD and 228 (62%) had received a non-drug-coated (NDC) device. Patients treated with PCDs were less likely to have undergone open surgery compared with patients treated with NDC devices. No differences were found in the indications or 30-day outcomes between the two groups. After a mean follow-up of 3.1 ± 1.8 years, no differences were found in the primary patency, reintervention rate, mean number of reinterventions, major amputation (5% vs 4%; P = .465), or mortality (16% vs 20%; P = .363) between the PCD and NDC groups. Also, no overall difference was found in the cause of mortality with and without PCD use or in the Kaplan-Meier survival curves. Furthermore, PCD use was not associated with an increased risk of mortality in Cox regression analysis. The cumulative dose of paclitaxel in patients treated with PCDs ranged from 383 to 49,259 µg (median, 7561 µg). A comparison of the patients treated with a cumulative dose of paclitaxel in the upper 50th percentile compared with the lower 50th percentile showed no significant differences in mortality (13% vs 19%; P = .333). CONCLUSIONS: PCD use was shown to be safe and not associated with an increased risk of long-term mortality in the present study. Continued monitoring of PCD use is warranted to ensure the safety of this technology.

Patient Characteristics, Patterns, and Repair of Aneurysms in Human Immunodeficiency Virus-Positive Patients.

BACKGROUND: Human immunodeficiency virus (HIV) is a multisystem disease and is associated with vascular complications including aneurysm formation. HIV-associated aneurysms are well documented and may present in unusual locations with concerning features. However, the literature regarding aneurysms in HIV-positive patients is limited to case series with limited data regarding aneurysm patterns. Furthermore, several small series have documented poor outcomes with surgical repair. Thus, our aim was to investigate the characteristics, patterns, and repair of aneurysms in HIV-positive patients in a multicenter study. METHODS: All patients with a diagnosis of aneurysms and HIV were retrospectively identified from 2013 to 2018 across 2 institutions. Comorbidities, HIV-related characteristics, aneurysm characteristics, and repair were reviewed. RESULTS: There were a total of 104 HIV-positive patients with 129 aneurysms. The mean age at the time of diagnosis was 57.7 ± 10.3 years, 80.8% of patients were male, and 32.0% had a history of acquired immunodeficiency syndrome. The average time from HIV diagnosis to aneurysm diagnosis was 14.1 ± 10.1 years. There were 53 (41.1%) ascending aortic, 25 (19.4%) abdominal aortic, 14 (10.9%) cerebral artery aneurysms, 13 (10.1%) descending thoracic, 9 (7.0%) iliac, 6 (4.7%) femoropopliteal, 4 (3.1%) visceral, 3 (2.9%) axillosubclavian, 1 (0.8%) carotid, and 1 (0.8%) coronary artery aneurysms. There were 23 (22.1%) patients with aneurysms in multiple vascular beds, 10 (9.6%) saccular aneurysms, and 1 (0.8%) inflammatory aneurysm. There were 7 ruptures (cerebral, descending thoracic, and iliac), 3 type A dissections (ascending aorta), and 1 thrombosis (popliteal). There were 26 (25.0%) patients who underwent surgical repair. This included 8 endovascular aneurysm repairs for abdominal aortic aneurysms, 6 endovascular coiling, clipping, and stent procedures for cerebral aneurysms, 4 open ascending aorta repairs, 2 bypasses for popliteal artery aneurysms, 2 endovascular stents for axillosubclavian artery aneurysms, 1 open descending aortic aneurysm repair, 1 endovascular aneurysm repair for an iliac aneurysm, 1 endovascular coiling for a renal artery aneurysm, and 1 open repair of a femoral artery aneurysm. Perioperative complications were common at 46.2%, although mortality was low at 3.8%. CONCLUSIONS: Although aneurysms were widespread, most HIV-positive patients had large vessel aneurysms in this study. There was a high prevalence of saccular and multiple aneurysms, and repair was associated with low rates of mortality despite high rates of complications. Additional studies are necessary to characterize this rare entity.

Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia among Patients at the Extremes of Age.

BACKGROUND: Patients with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationships among age, risk factor profiles, and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups. METHODS: Patients undergoing LER for CLTI in the Vascular Quality Initiative suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention files were reviewed through 2019. Patients were stratified into 3 groups: premature peripheral artery disease (PAD) (≤50 years old), 51-84 years old, and elderly (≥85 years old). Trends in major amputation and mortality by age group were analyzed. RESULTS: There were 156,513 patients who underwent LER for CLTI. Of these, 9,063 (5.79%) patients had premature PAD, 131,694 (84.14%) patients were 51-84 years old, and 15,756 (10.07%) were elderly. Patients with premature PAD were more likely to have insulin-dependent diabetes, be dialysis-dependent, and be active smokers compared to patients 51-84 years old and the elderly. Elderly patients were more likely to undergo an endovascular procedure for tissue loss compared to younger groups. Perioperative and 1-year major amputation rates were highest among patients with premature PAD and decreased with increasing age (P < 0.001), while perioperative and 1-year mortality increased with age (P < 0.001). On multivariable analysis, premature PAD was associated with an increased risk of major amputation (odds ratio, OR = 1.41 [1.22-1.62]), while elderly age was associated with decreased odds of major amputation compared to patients 51-84 years old (OR = 0.61 [0.51-0.73]). CONCLUSIONS: Patients at the extremes of age have significantly different outcomes after LER for CLTI. Although mortality increases with age, the risk of major amputation decreases. Patients with premature PAD constitute a group of patients with a high risk of perioperative and 1-year major amputation.

Trends of hospital-based surgery for varicose veins in the elderly.

OBJECTIVE: The treatment of varicose veins has shifted during the past decade to the office setting. Although recent studies have demonstrated the safety of venous ablation for the elderly in the office, a paucity of data is available on the contemporary outcomes of surgery for varicose veins in the operating room. The present study analyzed the trends and outcomes of varicose vein surgery in the elderly using a large national database. METHODS: The American College of Surgeons National Surgical Quality Initiative Program database (2005-2017) was reviewed. Patients undergoing vein ablation or open surgery (ie, high ligation, stripping, phlebectomy) for venous insufficiency were identified using Current Procedural Terminology codes and the principal diagnosis. The patients were stratified into 3 age groups <65, 65 to 79, and ≥80 years. The preoperative and operative characteristics and outcomes were compared. Logistic regression was performed to identify the risk factors associated with any adverse event, defined as any morbidity or mortality. RESULTS: A total of 48,615 venous surgeries had been performed, with 9177 (18.9%) performed in patients aged 65 to 79 years and 1180 (2.4%) in patients aged ≥80 years. The proportion of patients in the 65- to 79-age group had steadily increased during the study period from 12.8% in 2005 to 22.3% in 2017 (P < .01). The proportion of patients aged ≥80 years had remained stable (P = .23). Patients aged ≥80 years had significantly more comorbidities, were more likely to have undergone vein ablation alone (P < .01), were more likely to be treated for ulceration (P < .01) and less likely to have received general anesthesia (P < .01) compared with the younger age groups. Overall morbidity increased significantly with increased age group (P < .01) but remained low (2.5%). Mortality was very low (0.02%) and not significantly different among the age groups. The factors independently associated with any adverse event were dialysis (odds ratio [OR], 7.12; 95% confidence interval [CI], 3.3-15.6), American Society of Anesthesiologists classification per unit increase (OR, 1.2; 95% CI, 1.02-1.3), use of general anesthesia (OR, 1.2; 95% CI, 1.0-1.4), and combined venous ablation and open procedures compared with venous ablation alone (OR, 1.3; 95% CI, 1.0-1.5). However, age was not associated with adverse events (OR, 1.0; 95% CI, 1.0-1.0). CONCLUSIONS: Varicose vein surgery is safe for all age groups and is being increasingly offered to the elderly. High-risk patients might benefit from the avoidance of hybrid procedures and general anesthesia when possible to minimize the occurrence of adverse events. Conservative measures should be exhausted before surgery for the dialysis population.

Multiple Reinterventions for Claudication are Associated with Progression to Chronic Limb-Threatening Ischemia.

BACKGROUND: Claudication has a relatively benign natural history, associated with a low risk of limb loss. However, rates of progression to chronic limb-threatening ischemia (CLTI) following lower extremity revascularization (LER) for claudication remain unclear. This study examines the long-term outcomes and risk factors associated with progression to CLTI after LER for claudication. METHODS: A single-center retrospective review of patients undergoing LER for claudication was performed from 2013-2016. Patients were stratified based on whether they progressed to CLTI or not. RESULTS: There were 448 patients (502 limbs) treated for claudication, and 57 (12.7%) progressed to CLTI with a mean follow up time of 3.7 ± 1.5 years. Among patients who progressed, 23 (5.1%) developed tissue loss, 34 (7.6%) developed rest pain, and 6 (1.2%) underwent major amputation. The mean time of progression to CLTI was 1.6 ± 1.5 years after index LER. Patients who progressed to CLTI were more likely to have a history of congestive heart failure and prior open revascularizations compared with those who did not progress. There was no difference in type or level of index revascularization between the two groups and no difference in perioperative complications. Patients who developed CLTI had significantly higher rates of reinterventions and a mean number of reinterventions after index LER prior to developing CLTI compared to those who did not progress. Multivariable logistic regression demonstrated that history of congestive heart failure (OR = 2.8 [1.2-6.6]), stroke (OR = 2.6 [1.1-6.1]), prior open procedure (OR = 2.8 [1.3-5.9]) and increasing number of reinterventions after index LER (OR = 2.9 [1.5-5.7]) were independently associated with disease progression to CLTI. CONCLUSIONS: Multiple reinterventions and previous open revascularization are associated with progression to CLTI following LER for claudication. Patients with atherosclerosis in the coronary and cerebrovascular beds are also more likely to have a progression of claudication to CLTI after LER.

A Review and Proposed Classification System for the No-Option Patient With Chronic Limb-Threatening Ischemia.

A growing, but poorly defined subset of patients with chronic limb-threatening ischemia (CLTI) have "no option" for revascularization. One notable subgroup includes patients with severe ischemia and advanced pedal artery occlusive disease, termed "desert foot," who are at high risk for major amputation due to a lack of conventional revascularization options. Although new therapies are being developed for no-option patients with desert foot anatomy, this subgroup and the broader group of no-option patients are not well defined, limiting the ability to evaluate outcomes. Based on a systematic review, a classification of the no-option CLTI patient was constructed for use in clinical practice and studies. Several no-option conditions were identified, including type I-severe and pedal occlusive disease (desert foot anatomy) for which there is no accepted method of repair; type II-lack of suitable venous conduit for bypass in the setting of an acceptable target for bypass; type III-extensive tissue loss with exposure of vital structures that renders salvage impossible; type IV-advanced medical comorbidities for which available revascularization options would pose a prohibitive risk; and type V-presence of a nonfunctional limb. While type I and type II patients may have no option for revascularization, type III and type V patients have wounds, infection, comorbidities, or functional status that may leave them with few options for revascularization. As treatment strategies continue to evolve and novel methods of revascularization are developed, the ability to identify no-option patients in a standardized fashion will aid in treatment selection and assessment of outcomes.

Multiple duplications of the superficial femoral artery - Case report and review of the literature.

OBJECTIVES: Lower extremity arterial anatomic variations are rare, with duplication of the superficial femoral artery being an extremely uncommon variant with few prior reports in the literature.Methods/Results: We report the case of a 68-year-old male with calf claudication who underwent angiography and was found to have two separate areas of vessel duplication along the superficial femoral artery, which has not previously been described in the literature. CONCLUSION: Although uncommon, recognition of a duplicated superficial femoral artery is important to avoid difficulties and complications that may arise during open or endovascular procedures.