A Novel Hybrid Approach to Management of KD: Role of Robotic Surgery.

The management of Kommerell's Diverticulum (KD) has been evolving from open repair to a hybrid of open and endovascular repair. While there is no consensus regarding the optimal strategy, the need for less invasive treatment with less morbidity early recovery, and improved quality of life is a common goal for both the patient and the provider.

Comparison of endovascular therapies for chronic limb-threatening ischemia and claudication.

OBJECTIVE: Analysis of regional data from the Vascular Quality Initiative (VQI) suggested improved survival for patients undergoing stent placement compared with balloon angioplasty and atherectomy. Using national data from the VQI linked to Medicare claims data through the Vascular Implant Surveillance and Interventional Outcomes Network program, this study aimed to compare the rates of mortality, reintervention, and amputation after endovascular interventions (atherectomy, stenting, and balloon angioplasty) for two separate cohorts: patients with chronic limb-threatening ischemia (CLTI) and patients with claudication. METHODS: This was a secondary data analysis of Society for Vascular Surgery National VQI data linked to Medicare claims, between October 2016 and December 2019. Patients aged ≥65 years with symptoms of claudication or CLTI and a diagnosis of occlusive disease were included. Urgent or emergent interventions or those with concurrent procedures (endarterectomy, bypass, or bilateral intervention) were excluded. Interventions were grouped into (1) balloon angioplasty only; (2) stent (with or without balloon angioplasty); or (3) atherectomy (alone, with or without stent, with or without balloon angioplasty). Propensity score-matched cohorts were constructed to conduct pairwise intervention comparisons of mortality, reintervention, and amputation rates. Multivariable logistic regression was used to derive propensity scores for each patient. Kaplan-Meier estimates and Cox proportional hazards ratios (HRs) (95% confidence interval [CI]) analyses were performed. RESULTS: A total of 9785 (2665 claudication, 7120 CLTI) eligible patients were identified. After propensity score matching for the CLTI group, 2826, 3608, and 2796 pairs of cases were used to compare balloon angioplasty vs atherectomy, balloon angioplasty vs stent, and stent vs atherectomy, respectively. No statistically significant difference in mortality was observed among all interventions. However, atherectomy was associated with a significant increase in reintervention rate compared with balloon angioplasty (HR, 1.22; 95% CI, 1.06-1.39; P = .01) and compared with stenting (HR, 1.27; 95% CI, 1.10-1.46; P < .01) within the first year after the index procedure. Of note, both atherectomy (HR, 0.82; 95% CI, 0.68-0.98; P < .05) and stenting (HR, 0.76; 95% CI, 0.64-0.90; P < .01) showed lower rates of major amputation when compared with balloon angioplasty within 1 year after the index procedure. In the claudication group, there were no significant differences observed among interventions for peripheral arterial disease for mortality, reintervention, or amputation rates. CONCLUSIONS: Further studies are needed to identify appropriate indications for atherectomy, because there may be a subset of patients with CLTI who benefit from this therapy with respect to amputation rates. Until then, caution should be exercised when using atherectomy because it is also associated with higher reintervention rates.

Effect of hyperthermic intraperitoneal chemotherapy on survival and recurrence rates in advanced gastric cancer: a systematic review and meta-analysis.

BACKGROUND: Around 5-20% of patients who undergo surgery for advanced gastric cancer (AGC), which invades into the muscularis propria or beyond, have peritoneal carcinomatosis. The peritoneal recurrence rate is 10-54%, which is associated with a poor prognosis. The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in AGC with and without peritoneal carcinomatosis is not clearly defined. METHODS: The authors conducted a meta-analysis, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of the clinical trials and high-quality nonrandomized studies evaluating the role of HIPEC in AGC over the last 10 years. The studies were searched in PubMed, EMBASE, MEDLINE, and Cochrane databases between January 2011 to December 2021. Clinical data including overall survival, recurrence free survival, overall recurrence rate, peritoneal recurrence rate, and complications analyzed using RevMan 5.4. RESULTS: Six randomized controlled trials and 10 nonrandomized studies, comprising a total of 1700 patients were included. HIPEC was associated with significantly improved OS at 3 [odd ratio (OR) 1.89, 95% CI: 1.17-3.05] and 5 years (OR 1.87, 95% CI: 1.29-2.71). HIPEC was associated with reduced overall recurrence (OR 0.49, 95% CI: 0.31-0.80) and peritoneal recurrence (OR 0.22, 95% CI: 0.11-0.47). HIPEC was not associated with increased complications. The occurrence of postoperative renal dysfunction was significantly higher in the HIPEC group (OR 3.94, 95% CI: 1.85-8.38). CONCLUSION: The role of HIPEC in AGC has evolved over the past decade. HIPEC may improve survival rates and reduce recurrence rates in patients with AGC, without significant increase in complications and with a favorable impact on 3 and 5-year survival.

Endovascular interventions for peripheral arterial disease in patients with pre-existing endovascular aortic repair utilizing mother-and-child sheath system.

BACKGROUND: Peripheral interventions for Peripheral arterial occlusive disease involving the lower extremity vessels have been a challenge in patients who have undergone prior Endovascular Aneurysm repair. OBJECTIVE: To provide a solution to the above-mentioned challenge. RESEARCH DESIGN: Practical use of existing articulating sheath and catheter and wires to achieve the objective. RESULTS: Successful accomplishment of objective. CONCLUSION: Endovascular interventions for Peripheral arterial disease in patients with pre-existing Endovascular Aortic Repair utilizing mother-and-child sheath system have conferred success. This could be a useful technique in the armamentarium of the interventionist.

Mid-Term Results of Treating Kommerell's Diverticulum and Aberrant Subclavian Artery Anomalies Using a Patient-Centered Team Approach.

INTRODUCTION: The management of Kommerell's Diverticulum (KD) has evolved from open surgical resection and graft replacement of the aorta, to endovascular repair in asymptomatic patients due to its recognized possible sequelae - aortic rupture and dissection. Despite these technical advances, standard indications for intervention and treatment algorithms remain unclear. We will present our single-center experience in the treatment of KD, supporting a multidisciplinary endovascular-first approach. METHODS: All patients who underwent thoracic endovascular aortic repair (TEVAR) for KD between 2017 and 2020 were retrospectively identified from a prospectively maintained institutional surgery database. Chart review was used to characterize presenting symptoms, interventions, technical results, and complications. Revascularization was performed using carotid-axillary bypass. Routine endovascular subclavian artery occlusion was employed to eliminate retrograde diverticulum perfusion and avoid open ligation. RESULTS: 8 patients were identified, including 6 females and 2 males between the ages of 44-76. Patients presented with dysphagia (n = 3), acute embolic stroke (n = 1), transient ischemic attack (TIA) (n = 1), upper extremity embolization (n = 1), and acute type B aortic dissection (n = 1). One patient had a prior incomplete open repair that was successfully treated endovascularly. Another patient had a mediastinal neoplasm infiltrating an incidental aberrant subclavian artery and KD. All cases had symptomatic improvement and successful endovascular repair as demonstrated on post-operative imaging. Perioperative complications included percutaneous access site pseudoaneurysm (n = 2), stroke (n = 1), and subclavian artery rupture immediately recognized and treated (n = 1). There was no perioperative mortality. CONCLUSION: Endovascular techniques have resulted in technical success and symptomatic improvement for KD without open thoracotomy or sternotomy. Significant rates of endovascular complications and paucity of long-term durability data should be considered. Until formal criteria for repair are established, early application of TEVAR using a consistent multi-specialty approach may mitigate the risk of unpredictable aortic complications in these patients while avoiding the accepted morbidity and mortality of open surgery.

Transcarotid artery revascularization in reverse for innominate artery stenosis.

Stenotic lesions of the supra-aortic vessels have been reported in 2-6% of patients presenting with corresponding symptoms. In the past, these lesions have been treated with open surgical techniques. More recently, endovascular treatment approaches have been proposed for occlusive lesions in the innominate (IA) or common carotid (CCA) arteries. Retrograde stenting of IA and CCA lesions using flow reversal has been described in a retrospective case series; however, a modification of their technique is proposed. Case Presentation: The patient is a 68-year-old male with symptoms of right upper extremity claudication. CT angiogram revealed critical stenosis of the innominate artery and high-grade stenosis of the right subclavian artery. The patient consented to retrograde stenting of the innominate stenosis with neuroprotection using flow reversal or transcarotid revascularization (TCAR) in reverse. Surgical cut-down was performed of the carotid bifurcation, and a U-stitch was placed on the anterior wall of the distal common carotid artery. Flow reversal was achieved by connecting the arterial sheath to the venous sheath. The innominate lesion was crossed, primarily stented with a VBX stent, and post-dilated with a non-compliant balloon. Just prior to crossing the lesion and primary stent placement, the vessel loop around the common carotid and internal carotid arteries were pulled up to ensure neuroprotection while the stent was expanded. This was continued for two minutes before restoring antegrade flow first in the external carotid and then in the internal carotid artery. There were no adverse events. At one month follow-up, the patient reported no right arm claudication symptoms. TCAR for the proximal lesion as described in other case series may not adequately attain flow based neuroprotection. Under that circumstance, the arterial sheath is acting as a conduit to deliver the stent. Risk of embolization to the brain may not be mitigated when the proximal lesion is stented and antegrade flow restored.

Learning curve and proficiency metrics for transcarotid artery revascularization.

BACKGROUND: When introduced to a new procedure, physicians improve their performance and reduce their procedural adverse event rates rapidly during the initial cases and then improvement slows, signaling that proficiency has been achieved. Determining when they have acquired proficiency has important implications for procedural innovation, education, credentialing, and patient safety. We analyzed the worldwide experience with transcarotid artery revascularization (TCAR), a hybrid approach to carotid revascularization, to identify the (1) procedural performance measures associated with clinical and technical adverse events; (2) target levels of performance measures that minimize adverse event rates; and (3) number of TCAR cases needed to achieve the target levels for the performance measures. METHODS: The patient, lesion, and physician characteristics were collected for each TCAR procedure performed by each physician worldwide in an international quality assurance database. Four procedural performance measures were recorded for each procedure: flow-reversal time, fluoroscopy time, contrast volume, and total skin-to-skin time. Composite clinical adverse events (ie, transient ischemic attack, stroke, myocardial infarction, death) and composite technical adverse events (ie, aborted procedure, conversion to surgery, bleeding, dissection, cranial nerve injury, device failure), occurring within 24 hours were also recorded. Correlations between each performance measure and the clinical and technical adverse event rates were computed. The inflection points in the performance measures were identified at which no further improvements occurred in the adverse event rates. Finally, the minimum number of TCAR cases required to achieve the target performance measure levels was computed. RESULTS: A total of 18,240 procedures performed by 1273 physicians were analyzed. Of the 18,240 patients, 34.9% were women and 62.5% were asymptomatic. The flow-reversal time correlated with clinical adverse events adjusted for age, sex, and symptomatic status (R2 = 0.91; P < .0001) and adjusted technical adverse events (R2 = 0.86; P < .0001). The skin-to-skin time correlated with adjusted technical adverse events (R2 = 0.92; P < .0001). A reduction in flow-reversal times to <13.1 minutes and the skin-to-skin time to <81 minutes did not translate into further improvements in the adverse event rates. A minimum of 26 TCAR cases was required to achieve the target flow-reversal time, and a minimum of 15 cases was required to achieve the target skin-to-skin time. CONCLUSIONS: The flow-reversal time and skin-to-skin time are appropriate performance measures for establishing the level of expertise of physicians as they acquire skills to perform TCAR. A target time of ≤13.1 minutes for flow-reversal and 81 minutes for skin-to-skin time minimized the adverse event rates. Familiarity with the steps involved in performing TCAR was achieved after ≥15 cases, and minimizing clinical adverse events occurred after ≥26 cases.

Retrograde Carotid Stenting Using Newly Released Venous Stent for Cerebral Malperfusion in Type A Aortic Dissection.

Stanford Type A aortic dissections (TAAD) should be considered for repair, given the involvement of branch vessels which can result in malperfusion, specifically cerebral malperfusion secondary to dissection of the innominate and carotid arteries. This is a case report with a focus on four patients presenting with both acute and chronic symptomatic TAAD, with extension into the innominate and common carotid arteries. In all four cases, the decision to intervene utilizing a hybrid endovascular approach was made to increase perfusion to the brain and alleviate symptoms. Through the use of retrograde carotid stenting utilizing both the VICI venous stent (Boston Scientific, Marlborough, MA) and Abre self-expanding Nitinol stent (Medtronic, Minneapolis, MN) we obtained good results, specifically absence of symptoms and return to normal function of the patients.

Effects of Peripheral Arterial Disease Interventions on Survival: A Propensity-Score Matched Analysis Using VQI Data.

BACKGROUND: Atherectomy is currently being used extensively for occlusive peripheral artery disease (PAD) interventions without proven benefits. This analysis examines the effects of atherectomy and other endovascular interventions on patient survival. OBJECTIVES: The aim of this study is to compare overall survival for patients undergoing PAD endovascular interventions, such as plain old balloon angioplasty (POBA), stent deployment and atherectomy. METHODS: Propensity score matched cohorts were constructed to conduct pairwise comparisons of overall survival in patients who underwent stenosis and occlusive PAD interventions between May 2011 and February 2020 using Vascular Quality Initiative (VQI) regional registry data. Inverse probability treatment weighting method was used to compare secondary outcomes of in-hospital mortality, length of stay, complications and major amputations. Comparative analysis was performed for POBA vs stenting, POBA vs atherectomy, and stenting vs atherectomy. RESULTS: A total number of 15281 eligible cases were identified. After propensity score matching, 6094, 4032, and 3312 cases were used to compare POBA versus stent deployment, POBA versus atherectomy and stent versus atherectomy, respectively. Stent deployment had significantly better overall survival compared with POBA and atherectomy (P < 0.001). Multivariable Cox proportional hazard models suggested stenting was associated with a reduction in mortality hazard by 30% compared with POBA (HR: 0.7; 95% CI: 0.6-0.82; P < 0.001) and a 40% mortality reduction compared with atherectomy (HR: 0.6; 95% CI: 0.48-0.75; P < 0.001). No significant difference was found between POBA and atherectomy. There was no statistical difference in other secondary outcomes which were comparable among all cohorts. CONCLUSIONS: Stent deployment was significantly superior to POBA and atherectomy in terms of overall survival with comparable complication and amputation rates. The natural history of PAD patients presenting with claudication is associated with an extremely low annual mortality risk. Therefore, further examinations of outcomes, especially in regards to mortality rates, both POBA and atherectomy on the management of PAD patients especially those presenting with claudication is warranted.

A study on infant and young child feeding practices and its associated factors among mothers of under two years children attending immunisation clinic in a medical college of Kolkata.

Introduction: Appropriate feeding practices play a crucial role in achieving optimal health outcome. Feeding practices since birth at least up to young infancy has vital physical and mental health-related implications. Exclusive breast feeding (EBF) has an important role in prevention of diarrhoea and other leading causes of childhood morbidity and mortality. In this background, this study was conducted with the following objectives. Objectives: To assess the birth history of child and their feeding history, to find out the various socio-demographic profile of the mothers, to assess the knowledge on EBF and to find out the factors associated (if any) with the practice of EBF. Methodology: A cross-sectional study was conducted among mothers of children aged 0 to 24 months, who were attending the immunisation clinic in a medical college in Kolkata. As per NFHS-4, 47.7% of the children were breast fed within 1 hour of birth in Kolkata. This value is considered to calculate sample size. With 95% confidence interval, 10% allowable absolute error and 5% non-respondent, final sample size came to be 101. Data was collected by interviewing the mothers, using a semi-structured, pre-designed and pre-tested oral schedule which was mainly based on Infant and Young Child Feeding (IYCF) practices mentioned by the World Health Organization. Data was collected from 6 January 2020 to 21 February 2020. Results: In this study, male was 45 (44.6%), female was 56 (55.4%). Majority (75.2%) belonged to urban area. About 18.8% of mothers were educated up to secondary level. 53.5% were delivered in private facility and 55.4% delivered by caesarean section. Only 32.7% of new-borns were initiated breast feeding within 1 hour and 31.7% of new-borns given pre lacteal feeding. Majority (88.1%) of the children received colostrum and 52.5% of the children were given EBF. Majority (63.4%) of mothers had knowledge about EBF. EBF was significantly associated with mothers' knowledge about EBF, [OR (95%CI) = 5.52 (2.26-13.51). EBF also had significant association with the normal vaginal type of delivery of the baby [OR (95%CI) = 3.42 (1.49-7.83)] as well as with the mother who were homemaker [OR (95%CI) = 4.29 (1.52-12.09)]. Conclusion: Considerable proportion of children were born at private facility and delivered by caesarean section. A significant percentage of new-borns were given pre-lacteal feeding. EBF were significantly more among educated mothers.

Surgical Considerations in the Treatment of Axillary-Subclavian Venous Thrombosis in the Era of COVID-19.

PURPOSE: Traditional treatment of axillary-subclavian venous thrombosis is resource intensive due to the need for advanced nursing care and increased utilization of intensive care units for thrombolysis procedures. We recently encountered this in the management of 2 patients with effort-induced upper extremity venous thrombosis following COVID-19 infection and offer a treatment paradigm for consideration. CASE REPORTS: A 30-year-old presented with 2 weeks of left upper extremity symptoms following COVID-19 infection. Duplex ultrasound demonstrated axillary-subclavian venous thrombosis and venogram confirmed total occlusion of the axillary and subclavian veins with profuse collaterals around the occlusion. Suction thrombectomy was performed successfully and veins remained patent at 6 month follow up. The patient declined first rib resection and stopped lifting weights. A 16-year-old presented with 4 days of right arm symptoms 1 month after testing positive for COVID-19. Duplex ultrasound revealed acute axillary and subclavian vein thrombosis and she underwent successful thrombectomy followed by balloon angioplasty with improvement in symptoms. CONCLUSION: The pandemic has strained health care resources such that the treatment of non-life-threatening conditions must be triaged to conserve resources. While axillary-subclavian venous occlusion is usually not life-threatening, timely treatment leads to decreased morbidity and better outcomes. Percutaneous aspiration and thrombectomy without adjunctive thrombolysis may be of benefit in reducing healthcare resource utilization while still achieving good outcomes during the COVID pandemic and beyond.

Endovascular Repair of Symptomatic Right Subclavian and Innominate Artery Aneurysms Arising From a "Bovine Arch" in a Patient With a "Hostile" Chest.

Symptomatic aneurysms of the innominate and subclavian arteries are rare and pose unique challenges for endovascular repair particularly in a patient with a "bovine" arch. Previous publications have described back table modifications of standard iliac endografts to conform to the innominate artery for exclusion of the lesion. Others have proposed extra-anatomic bypass or carotid-subclavian transposition with occlusion of the innominate artery. We were unable to find a report of repair when aneurysms of the innominate and subclavian arteries were in continuity. We present such a case of endovascular repair using commercially available endografts without compromise of the left common carotid artery origin as this patient had a "bovine" arch. Surgeons will benefit from adding this endovascular option to their "tool box" when confronted with such a challenging clinical scenario.

Management of large bore access complications in the era of trans-catheter aortic valve replacement.

OBJECTIVES: Trans-catheter aortic valve replacement is a commonplace procedure for patients with aortic valvular stenosis who are at a high risk for surgery, evidenced by the 34,892 trans-catheter aortic valve replacements performed in 2016. Trans-catheter aortic valve replacement's rate of major vascular complications with second-generation closure devices is 4.5% according to a meta-analysis of 10,822 patients. To manage those complications, percutaneous approaches to arterial repairs show shorter length of stay, higher rate of direct to home discharge and equivalent outcomes at long-term follow-up. This study's goal is to show that one center's vascular access strategy can decrease open repairs and improve patient outcomes. METHODS: Our team began accessing the mid-common femoral artery at least 1-2 cm proximal to the takeoff of the profunda femoris. This allowed an endovascular stent to be deployed if necessary via contralateral femoral access. We performed a completion angiogram following every trans-catheter aortic valve replacement to ensure no arterial complications. We conducted a retrospective review of a prospectively maintained database for all trans-catheter aortic valve replacement cases at a tertiary care center from 1 January 2016 to 30 June 2018. RESULTS: A total of 699 trans-catheter aortic valve replacement procedures were performed with 25/31 (80.6%) cases met inclusion criteria. An increase was noted in the number of stent procedures versus cutdown procedures over time (P < 0.001). A decrease was noted in the number of vascular surgery team activations following trans-catheter aortic valve replacement (P = 0.004). A non-significant trend was noted toward a shorter median length of stay for the stent group (P = 0.149). There was no increase in 30-day mortality rate (0.0% for both groups) or 30-day readmissions (4/15 (26.7%) for stents vs. 2/10 (20.0%) for open repairs; P > 0.999). CONCLUSIONS: This strategy is safe and feasible to implement and reduces the number of open repairs following trans-catheter aortic valve replacement, activation of surgical resources, and possibly the length of stay.

Carotid-Axillary Bypass as an Alternative to Carotid-Subclavian Bypass Following Coverage of Left Subclavian Artery During TEVAR.

INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass. METHODS: All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries. RESULTS: 35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8). CONCLUSION: Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.

A novel technique using long segment patch angioplasty maturation to increase the maturation rate of arteriovenous fistulas.

OBJECTIVE: Given the superior patency of arteriovenous fistulas (AVFs) and the decreased risk of infection compared with arteriovenous grafts, the Kidney Disease Outcomes Quality Initiative guidelines have recommended the fistula-first approach. However, ∼20% to 60% of all fistulas will fail to mature. We have described our experience with a novel technique using bovine pericardial patch angioplasty to increase the rate of AVF maturation. METHODS: We used 2-cm × 9-cm-long or 2.5-cm × 15-cm-long segment pericardial patch angioplasty to assist in the maturation of AVFs. A single-center, retrospective cohort study was conducted of all patients who had undergone patch angioplasty maturation (PAM) for AVFs that had failed to mature. The outcomes of interest were maturation status and patency, censored by the death and last known follow-up dates. RESULTS: From March 2007 to October 2019, 139 patients had undergone PAM. Follow-up data were available for 137 of the 139 patients (98.6%), with 126 AVFs (92.0%) progressing to maturation. Of the 126 patients with AVFs that had progressed to maturity, the previous hemodialysis (HD) method was known for 88 patients (69.8%). Of these 88 patients, 70 (79.5%) had previously been receiving HD via an HD catheter. Using a Kaplan-Meier estimator censored for death and loss to follow-up, the assisted primary patency rates at 1, 2, and 3 years were 87.3%, 78.1%, and 68.0%, respectively. Of the 137 patients, 69 (54.8%) had required no additional interventions after patch angioplasty. The complications requiring intervention were stenosis (n = 45; 32.8%), thrombosis (n = 10; 7.3%), infection (n = 3; 2.2%), steal syndrome (n = 3; 2.2%), noninfected wound complications (n = 1; 0.8%), and pseudoaneurysm (n = 1; 0.8%). The average interval to intervention after patch angioplasty was 4.56 months. CONCLUSIONS: Long-segment bovine pericardial PAM can be performed safely to treat nonmaturing AVFs, with a 92.0% successful maturation rate and patency rates comparable to those for AVFs. PAM should be a consideration for patients with nonmaturing AVFs.

Clinical competence statement of the Society for Vascular Surgery on training and credentialing for transcarotid artery revascularization.

As the practice of medicine grows in complexity, the process of defining the expertise required for the competent execution of specific procedures has also become complex. The Society for Vascular Surgery therefore constituted a task force to provide informed recommendations on the knowledge, technical skills, resources, and infrastructure required to obtain and to maintain privileges for the safe and effective performance of transcarotid artery revascularization (TCAR). The TCAR procedure is being adopted rapidly, and it is therefore important that informed guidance be available expeditiously. Formal training in the pathophysiology and diagnosis of carotid occlusive disease and all management options is essential. Appropriate diagnostic, imaging, endovascular, surgical, and monitoring infrastructure is required, as are resources to maintain quality control. Credentialing and privileging require a combination of both open surgical and endovascular skills. As such, physicians must have hospital privileges to perform carotid endarterectomy. They should attend an appropriate program for education and simulated training in TCAR. In addition, physicians must have performed ≥25 endovascular procedures as the primary operator using low-profile rapid-exchange platforms plus ≥5 TCAR procedures as the primary operator (pathway 1); or they may have acquired ≥25 endovascular procedures as the primary operator using low-profile rapid-exchange platforms and a supplement of 5 TCAR procedures under proctored guidance if they have not performed sufficient TCAR procedures (pathway 2); or a team of two physicians can collaborate, combining the endovascular and surgical requirements plus at least 5 TCAR procedures under proctored guidance (pathway 3).

The study of transcarotid artery revascularization under local versus general anesthesia with results from the Society for Vascular Surgery Vascular Quality Initiative.

OBJECTIVE: The primary purpose of this study was to examine any potential difference in clinical outcomes between transcarotid artery revascularization performed under local anesthesia compared with general anesthesia by utilizing a large national database. METHODS: The primary outcome of the study was a composite endpoint of postoperative in-hospital stroke, myocardial infarction and mortality following transcarotid artery revascularization for the index procedure. Secondary outcomes included a composite outcome of postoperative in-hospital stroke, transient ischemic attack, myocardial infarction and mortality along with several subsets of its components and each individual component, flow reversal time (min), radiation dose (GY/cm2), contrast volume utilized (mL), total procedure time (min), extended total length of stay (>1 day) and extended postoperative length of stay (>1 day). Statistical analyses employed both descriptive measures to characterize the study population and analytic measures such as multivariable mixed-effect linear and logistic regressions using both unmatched and propensity-score matched cohorts. RESULTS: A total of 2609 patients undergoing transcarotid artery revascularization between the years 2016 and 2018 in the US were identified, with 82.3% performed under general anesthesia and 17.7% under local anesthesia. The primary composite outcome was observed in 2.3% of general anesthesia patients versus 2.6% of local anesthesia patients (p = 0.808). The rate of postoperative transient ischemic attack and/or myocardial infarction was 1.6% with general anesthesia versus 1.1% with local anesthesia (p = 0.511). For adjusted regression analysis, general anesthesia and local anesthesia were comparable in terms of primary outcome (OR: 0.72; 95% CI: 0.27-1.93, p = 0.515). As for the secondary outcomes, no significant differences were found except for contrast, where the results demonstrated significantly less need for contrast with procedures performed under general anesthesia (coefficient: 4.94; 95% CI: 1.34-8.54, p = 0.007). A trend towards significance was observed for lower rate of postoperative transient ischemic attack and/or myocardial infarction (OR: 0.33; 95% CI: 0.09-1.18, p = 0.088) and lower flow reversal time under local anesthesia (coefficient: -0.94: 95% CI: -2.1-0.22, p = 0.111). CONCLUSIONS: Excellent outcomes from transcarotid artery revascularization for carotid stenosis were observed in the VQI database between the years 2016 and 2018, under both local anesthesia and general anesthesia. The data demonstrate the choice of anesthesia for transcarotid artery revascularization does not appear to have any effect on clinical outcomes. Surgical teams should perform transcarotid artery revascularization under the anesthesia type they are most comfortable with.

Resection of Internal Carotid Artery Aneurysm Under Neuroprotection With Flow Reversal Technique.

Extracranial internal carotid artery (ICA) aneurysms account for <1.0% all aneurysms and a rare indication for carotid intervention. Causes include atherosclerotic degeneration, trauma, dissection, previous carotid surgery, connective tissue disorders, and infection. Authors report a case of a middle-aged male found to have a large aneurysm of the left ICA who underwent repair by resection and reconstruction with end-to-end anastomosis under neuroprotection with flow reversal. Our discussion includes a recommendation for this particular surgical repair. The patient in this case report has granted the authors consent for review of records and subsequent publication submission.