A Prevention Protocol Reduces Spinal Cord Ischemia in Patients Undergoing Branched/Fenestrated Endovascular Aortic Repair.

OBJECTIVES: Spinal cord ischemia (SCI) is a devastating complication that is associated with thoracoabdominal aortic repair, with higher risk associated with increased aortic coverage length, making patients undergoing branched/fenestrated endovascular repair(B/FEVAR) particularly vulnerable. A bundled SCI prevention protocol was previously reported to reduce SCI rates when compared to a historic cohort in a single-center study. Therefore, this analysis aims to further validate and update outcomes associated with the protocol given the routine implementation of this strategy at two institutions (University of Florida [UF] and the University of Alabama at Birmingham [UAB]) since inception. METHODS: Components of the SCI prevention protocol include selective cerebrospinal fluid (CSF) drainage, specified blood pressure parameters, transfusion goals, and selective pharmacologic adjuncts (naloxone, steroids). This protocol was routinely implemented in May 2015. Patients undergoing B/FEVAR from May 2015-December 2022 constituted the post-protocol cohort(n=402) and were compared to the pre-protocol cohort (n=160, January 2010-April 2015). The primary outcome was SCI incidence and subgroup analysis was conducted among patients deemed to be high-risk (Crawford extent I- III thoracoabdominal aneurysms (TAAA) dissection-related disease, prior aortic repair, coverage proximal to zone 5). Survival analysis was performed using Kaplan-Meier methodology. RESULTS: The pre- and post-protocol cohorts were demographically similar, though more post-protocol patients were American Society of Anesthesiology(ASA) class IV (86.1% vs. 55.0%; p<0.001). TAAA was the most common indication in both groups. CSF drain placement was more common in the post-protocol group, particularly among high-risk patients. SCI occurred in 15.9% of pre-protocol patients versus 3.0% of post-protocol patients(p<0.001). In high-risk patients, the pre- and post-protocol cohort SCI incidence was 23.2% vs. 5.0%, respectively (p<0.001). 30-day mortality was decreased in the post-protocol cohort (6.3% vs. 2.2%, p=0.02). Although the post-protocol group had a trend toward improved 1-year survival, this was not statistically significant (84.4% vs. 88.3%, log-rank p=0.35). Among SCI patients, one-year mortality was 28% and 33.3% in the pre- and post-protocol groups, respectively(p=0.46). CONCLUSION: Implementation of a bundled SCI prevention protocol significantly reduces SCI rates in B/FEVAR patients, which has now been validated at two institutions, with the most significant reductions occurring among high-risk patients. Although the overall one-year mortality difference was not significantly different between the cohorts, the high mortality rates among SCI patients highlights the importance of preventative measures.

Open supraceliac aortic repair of an iatrogenic aortic partial ligation during laparoscopic nephrectomy.

Iatrogenic aortic injury is a rare complication of laparoscopic nephrectomy with potentially catastrophic complications. Delays in recognition and treatment contribute significantly to patient morbidity and mortality. We present the case of a patient with acute limb ischemia and mesenteric ischemia secondary to partial transection of the supraceliac aorta during laparoscopic nephrectomy with a staple ligature. The injury was successfully treated with resection of the stapled aorta and reconstruction of a thoracoabdominal aortic bypass with a jump graft to the celiac artery.

Vascular In-person for Students In the match Trial: An investigation of postinterview site visits to address the limitations of virtual interviews.

PURPOSE: The graduate medical education community implemented virtual residency interviews in response to travel restrictions during the COVID-19 pandemic, and this approach has persisted. Although many residency applicants wish to visit in-person prospective training sites, such opportunities could bias programs toward those who are able to meet this financial burden, exacerbating equity concerns. One proposed solution is to offer applicants the opportunity to visit only after a program's rank list is "locked," avoiding favoritism to applicants who visit, but allowing applicants to experience some of the camaraderie, geography, and local effects of an in-person visit. As debate about the optimal format of residency interviews continues, it is important to investigate whether in-person program visits, completed after program rank list certification, provide meaningful benefits to applicants in the residency match process. METHODS: All vascular programs entering the 2023 integrated vascular surgery residency match were invited to participate. Programs agreed to certify their National Resident Matching Program rank lists by February 1, 2023. Applicants then had the opportunity to visit the programs at which they interviewed. The particulars of the visit were determined by the individual programs. Applicants completed their standard rank list and locked on the standard date: March 1, 2023. Applicants then completed a survey regarding the impact of the visits on their rank order list decision-making. Program directors (PDs) completed a survey regarding their experiences as well. Data were collected using REDCap. RESULTS: Twenty-one of the 74 (28%) programs participated. Nineteen PDs completed the postinterview site visit survey (response rate 90%). Applicants interviewing at the participating programs (n = 112) were informed of the study, offered the opportunity to attend postinterview site visits, and received the survey. Forty-seven applicants responded (response rate 42%). Eighty-six percent of applicants stated that the visit impacted their rank list. Most important factors were esprit de corps of the program (86%), the faculty/trainees/staff (81%), and the physical setting (62%). Seventy-one percent of those participating spent ≤$800 on their visit. Eighty-one percent were satisfied with the process. Twenty-one percent of PDs would have changed their rank list if they could have based on the applicants' in-person visit. Sixty-three percent of the visit sessions cost the programs ≤$500, and 63% were satisfied with the process. CONCLUSIONS: This study is the first to document the impact of in-person site visits by applicants on a graduate medical education match process in one specialty. Our results suggest that this process provides meaningful data to applicants that helped them with their decision-making evidenced by most altering their rank lists, while avoiding some of the critical equity issues that accompany traditional in-person interviews. This may provide a model for future interview processes for residency programs.

Clinical Impact of an Enhanced Recovery Program for Lower-extremity Bypass.

OBJECTIVE: To determine the association of Enhanced Recovery Program (ERP) implementation with length of stay (LOS) and perioperative outcomes after lower-extremity bypass (LEB). BACKGROUND: ERPs have been shown to decrease hospital LOS and improve perioperative outcomes, but their impact on patients undergoing vascular surgery remains unknown. METHODS: Patients undergoing LEB who received or did not receive care under the ERP were included; pre-ERP (January 1, 2016-May 13, 2018) and ERP (May 14, 2018-July 31, 2022). Clinicopathologic characteristics and perioperative outcomes were analyzed. RESULTS: Of 393 patients who underwent LEB [pre-ERP: n = 161 (41%); ERP: n = 232 (59%)], most were males (n = 254, 64.6%), White (n = 236, 60%), and government-insured (n = 265, 67.4%). Pre-ERP patients had higher Body Mass Index (28.8 ± 6.0 vs 27.4 ± 5.7, P = 0.03) and rates of diabetes (52% vs 36%, P = 0.002). ERP patients had a shorter total [6 (3-13) vs 7 (5-14) days, P = 0.01) and postoperative LOS [5 (3-8) vs 6 (4-8) days, P < 0.001]. Stratified by indication, postoperative LOS was shorter in ERP patients with claudication (3 vs 5 days, P = 0.01), rest pain (5 vs 6 days, P = 0.02), and tissue loss (6 vs 7 days, P = 0.03). ERP patients with rest pain also had a shorter total LOS (6 vs 7 days, P = 0.04) and lower 30-day readmission rates (32%-17%, P = 0.02). After ERP implementation, the average daily oral morphine equivalents decreased [median (interquartile range): 52.5 (26.6-105.0) vs 44.12 (22.2-74.4), P = 0.019], while the rates of direct discharge to home increased (83% vs 69%, P = 0.002). CONCLUSIONS: This is the largest single-center cohort study evaluating ERP in LEB, showing that ERP implementation is associated with shorter LOS and improved perioperative outcomes.

Hybrid Pelvic Revascularization in Complex Aortoiliac Aneurysm Repair.

Revascularization of complex pelvic vascular anatomy presents an ongoing clinical challenge when treating aortoiliac disease. As vascular surgeons continue to intervene upon increasingly complex aortoiliac pathology, the role of pelvic revascularization is important for the preservation of pelvic organ function and prevention of devastating spinal cord ischemia. In this study we describe the indications, techniques, and clinical outcomes of a novel hybrid pelvic revascularization repair that focuses on optimizing revascularization while limiting pelvic surgical dissection during the management of complex aortic pathology in patients physiologically or anatomically unsuitable for traditional pelvic revascularization techniques.

Aortic endarterectomy in patients with severe multivessel paravisceral and aortoiliac occlusive disease.

OBJECTIVE: Aortic endarterectomy (AE), once a treatment of choice for aortoiliac occlusive disease, is now rarely performed in favor of endovascular procedures or open aortobifemoral bypass. However, in select patients with paravisceral or aortoiliac occlusive disease, AE remains a viable alternative for revascularization, either as a primary procedure or after prior interventions have failed. Here, we evaluated outcomes for an extended series of patients undergoing paravisceral or aortoiliac endarterectomy, demonstrating that these procedures can be an excellent alternative with acceptable morbidity and mortality in properly selected patients. METHODS: A single institution retrospective review of 20 patients who underwent AE from 2017 to 2023 was performed. RESULTS: Five patients (25%) underwent paravisceral endarterectomy and 15 (75%) underwent aortoiliac endarterectomy. There were no perioperative mortalities. One paravisceral patient died 3 months postoperatively from complications of pneumonia. Three patients in the paravisceral group required reinterventions; one acutely due to thrombosis of the superior mesenteric artery (SMA) requiring extension of the endarterectomy and patch angioplasty on postoperative day 0, one due to stenosis at the distal edge of the endarterectomy 1 month postoperatively, successfully treated with SMA stenting, and one at 10-month follow-up due to SMA stenosis at the distal aspect of the endarterectomy, also successfully treated with SMA stenting. With these reinterventions, the 1-year primary patency in the paravisceral group was 40%, primary-assisted patency was 80%, and secondary patency was 100%. In the aortoiliac group, 1-year primary, primary-assisted, and secondary patency were 91%, 91%, and 100%, respectively. One patient developed iliac thrombosis 10 days postoperatively owing to an intimal flap distal to the endarterectomy site. She and one other patient, a young man with an undefined hypercoagulable disorder, ultimately required neoaortoiliac reconstructions at 18 and 32 months postoperatively, respectively (the latter in the setting of stopping anticoagulation). The remaining 13 patients experienced no complications. All patients had rapid resolution of clinical symptoms, and median postoperative ankle-brachial indexes of 1.06 on the right and 1.00 on the left, representing a median improvement from preoperative ankle-brachial indexes of +0.59 on the right and +0.56 on the left (P < .01 and P < .01). CONCLUSIONS: In this series of 20 patients undergoing paravisceral and infrarenal aortoiliac endarterectomy, AE was associated with no perioperative mortality, relatively low and manageable morbidity, and excellent clinical outcomes in patients with both paravisceral and aortoiliac occlusive disease. SMA-related early reintervention was not uncommon in the paravisceral group, and attention should be given particularly to the distal endarterectomy site. AE remains a viable treatment for severe multivessel paravisceral or aortoiliac occlusive disease isolated to the aorta and common iliac arteries in select patients.

Five-year outcomes of endosuture aneurysm repair in patients with short neck abdominal aortic aneurysm from the ANCHOR registry.

OBJECTIVE: Hostile aortic neck anatomies such as proximal short necks are known to put patients at an increased risk for type IA endoleaks, migration, and need for reinterventions. The Heli-FX EndoAnchor System was designed to improve seal of aortic stent grafts. Endosuture aneurysm repair (ESAR) using EndoAnchors with the Endurant stent graft has been shown to be safe and effective for the treatment of patients with short necks through one year. This study reports the 5-year patient outcomes of the Aneurysm Treatment using the Heli-FX EndoAnchor System Global Registry (ANCHOR) short neck regulatory cohort. METHODS: The 70 patients from the ANCHOR Registry were cohort submitted to regulators for approval of the Endurant short neck indication. Patients had an infrarenal neck length of ≥ 4 mm and <10 mm. At 5 years, this short neck cohort had clinical and imaging follow-up compliance rates of 85% (28/33) and 70% (23/33), respectively. RESULTS: The short neck cohort had a mean age of 71.3±8.1 years and was 27.1% (19/70) female. Kaplan Meier freedom from all-cause mortality was 68.5 ± 6.2%, freedom from aneurysm-related mortality was 90.1 ± 4.5%, freedom from any endovascular or surgical secondary procedure was 76.9 ± 7.2%, and freedom from rupture was 95.6 ± 3.2%. Eight patients had a total of nine type IA endoleaks detected through 5 years, of which three resolved spontaneously by the next follow-up visit. There were two patients with renal complications who did not undergo reintervention and there were no device migrations reported through 5 years. After 5 years, 68.2% of patients (15/22) had sac regression, 13.6% (3/22) had stable sacs, and 18.2% (4/22) had increased sac diameter as compared with their 1-month measurements. CONCLUSIONS: After ESAR treatment using Heli-FX EndoAnchors with Endurant, the 5-year outcomes of the short neck cohort from the ANCHOR registry had encouraging results with regards to proximal neck-related complications, secondary procedures, and sac regression. This review of ESAR in patients with short proximal necks showed positive outcomes through 5 years although follow-up of a larger cohort is necessary.

Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications.

Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.

Investigating glycemic control in patients undergoing lower extremity bypass within an enhanced recovery pathway at a single institution.

BACKGROUND: Enhanced recovery pathways (ERPs) aim to lower perioperative stress to facilitate recovery. Limited fasting combined with carbohydrate loading is a common ERP element. The effect of limited fasting has not been elucidated in patients with diabetes. Given the known deleterious effects of poor glycemic control in the perioperative period, such as increased rates of surgical site infection, the associations of preoperative limited fasting with perioperative glycemic control and early outcomes after lower extremity bypass (LEB) were investigated. METHODS: A single institutional retrospective review of patients who underwent infrainguinal LEB from 2016 to 2022 was performed. The ERP was initiated in May 2018. Patients were stratified by diabetes diagnosis and preoperative hemoglobin A1C (HbA1C) levels. Perioperative glycemic control was compared between the limited fasting and traditional fasting patients (nil per os at midnight). Limited fasting was defined as a clear liquid diet until 2 hours before surgery with recommended carbohydrate loading consisting of 400 cc of a clear sports drink (approximately 30 g of carbohydrates). All limited fasting patients were within the ERP. Early perioperative hyperglycemia (EPH) was defined as blood glucose of >180 mg/dL within the first 24 hours of surgery. Perioperative outcomes such as surgical site infection, readmission, reinterventions, and complications were also compared. RESULTS: A total of 393 patients were included (limited fasting patients N = 135; traditional fasting patients N = 258). A trend toward EPH was seen in all limited fasting groups. Evaluating limited fasting within diabetic patients revealed that 74.5% of limited fasting-diabetic patients had EPH compared with 49.6% of traditional fasting-diabetic patients (P = .001). When stratified by the HbA1C level, a significantly higher rate of EPH was seen in the HbA1c >8.0% groups, with 90.5% in the limited fasting patients compared with 67.9% in traditional fasting patients (P = .05). Limited fasting-diabetic patients experience a longer postoperative length of stay at 5.0 days (interquartile range: 3, 9) vs 4.0 days (2, 6) in nondiabetic patients (P = .016). CONCLUSIONS: ERP limited fasting was associated with early perioperative hyperglycemia after LEB, particularly in patients with HbA1C >8.0%. Due to the high prevalence of diabetic patients undergoing LEB under ERP, the role of limited fasting and common glycemic elements of ERP may need to be re-evaluated in this subpopulation.

Progressive aortic enlargement in medically managed acute type B aortic dissections with visceral aortic involvement.

OBJECTIVE: Aortic remodeling of the thoracic aorta has been studied in patients treated with medical or endovascular therapy for the treatment of acute aortic dissections; however, particular attention has not yet focused on identifying specific growth patterns and rates across all aortic zones. Additionally, previous studies have not delineated between dissections with and without visceral aortic involvement, and we hypothesize that these two cohorts may exhibit distinct differences. The aim of this study is to investigate aortic behavior over time in medically managed acute Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) type B dissections with visceral aortic involvement and identify potential associations of subsequent aortic behavior with clinical outcomes. METHODS: A single-center retrospective review was performed of all patients between 2010 and 2020 with acute SVS/STS type B aortic dissections with visceral aortic involvement that were not surgically managed. Short-axis centerline measurements of the true/false lumen and total aortic diameter (TAD) were taken at standardized locations relative to aortic anatomy within each aortic zone, including nondissected zones. Measurements were taken at the time of diagnosis and at six subsequent yearly intervals. Diameter changes over time were evaluated using repeated measures mixed models linear growth analysis. Aortic enlargement was classified by growth in TAD ≥5 mm in either the thoracic (thoracic segment enlargement [TSE], zone 0-4) or visceral segments (visceral segment enlargement [VSE], zone 5-9). RESULTS: A total of 78 patients were identified with a median length of follow-up of 3.3 years (interquartile range [IQR], 1.3-6.6 years). Follow-up past 5 years was seen in 31% of the cohort. For the entire cohort, mean thoracic growth in TAD was 2.0 ± 2.0 mm/year, and visceral growth in TAD was 2.5 ± 2.4 mm/year. TSE was observed in 65% of patients, with a median time until onset of 0.8 years (IQR, 0.4-2.3 years). VSE was observed in 57% of the cohort, with a median time until onset of 1.6 years (IQR, 0.9-3.3 years). Repeat measures mixed models linear growth analysis identified significant predictable linear growth in all aortic zones except for the nondissected zones 0-2. Odds for TSE are significantly increased in patients with known genetically triggered aortic conditions (odds ratio [OR], 2; 95% confidence interval [CI], 1.8-4.5; P = .044) and in cases where the dissection entry tear was in either zone 1 or 2 (OR, 4.8; 95% CI, 1.2-8.4; P = .044). In adjusted regression analysis, odds for intervention in the thoracic aorta were significantly increased in patients with rapid TSE in zone 3 (OR, 3.6; 95% CI, 1.1-8.4; P = .045). Similarly, odds for intervention targeting the visceral aortic segment were significantly increased in patients with zone 9 VSE (OR, 9.3; 95% CI, 1.1-13.3; P = .014). Odds for 5-year all-cause mortality were significantly increased in cases with large thoracic aneurysms (OR, 6.1; 95% CI, 1.1-14.9; P = .042). CONCLUSIONS: Aortic enlargement was present in the majority of patients with medically managed acute SVS/STS Type B aortic dissections with visceral aortic involvement, with analysis demonstrating predictable linear growth in all dissected zones. Patients with aortic enlargement demonstrated higher gross changes in diameter in addition to higher yearly rates of change compared with all comers. Odds for enlargement were impacted by both patient demographic and anatomic dissection characteristics. Growth in zone 3 and zone 9 significantly increased odds for aortic intervention. Odds for 5-year mortality were significantly increased in the presence of large thoracic aneurysms. Results highlight risk of progressive degeneration beyond acute phase in SVS/STS Type B aortic dissections with visceral aortic involvement, with life-long surveillance remaining crucial in management of dissections.

Migration of High Cardiac Risk Patients from Open to Endovascular Procedures is Evident within the Society for Vascular Surgery Vascular Quality Initiative.

BACKGROUND: In this study, pre-operative medical complexity is estimated by the independently validated Vascular Quality Initiative VQI Cardiac Risk Index (CRI). This study aims to identify and correlate trends of CRI for open abdominal aortic aneurysm (OAR) with trends in the CRI for corresponding endovascular aortic repair (EVAR). This assessment of differences in estimated procedural risks will be used to support the theory that, patient migration is an important factor contributing to decreased POMI following open vascular procedures. METHODS: A retrospective review of VQI data from 2003 to 2020 for all patients undergoing elective aortic repairs (OAR and EVAR) was conducted. The CRI scoring developed for the open repair (oCRI) was applied to both the OAR and EVAR cohorts, with variables specific to EVAR translated from similar open repair factors in the model where feasible. To evaluate for changes across time, patients were grouped into Eras based on year of procedure, subsequently, univariate analysis of post-operative myocardial infarction (POMI) rates and CRI scores were perfomed between each era. RESULTS: A total of 56,067 elective aortic repairs were identified (83% EVAR, 17% OAR). Within the OAR cohort, the average oCRI estimate was 7.1% with significant decrease across the studied timeframe (8% ± 4.6%→6.9% ± 4.4%, P < 0.001), which corresponded to a significant decrease in observed clinical myocardial infarction (MI) rate (4.1%→1.4%, P < 0.001). Over that same time period, the open CRI was applied to the EVAR cohort, and the average oCRI estimate was 7.2% and showed a significant increase (6.6% ± 2.8%→7.2% ± 4.4%, P < 0.001). Within the EVAR cohort, the eCRI estimate did not show any significant changes over time (average 0.48%), while the actual rate of clinical MI showed a significant decrease (1.1%→0.3%, P = 0.002). Gap analysis was conducted within the EVAR cohort between CRI estimates of procedural risks from an open operation versus an EVAR, which demonstrated that patients within the EVAR cohort would, on an average, has had 6.7% higher risk of POMI had they undergone an open procedure. CONCLUSIONS: Paradigm shifts with regard to patient selection for aortic repair is evident within this large national cohort. Over time, OAR patients had fewer preoperative estimated cardiac comorbidities and there is a corresponding decrease in POMI rates. As high-risk patients migrate from OAR to EVAR, there has been a subsequent increase in EVAR estimated pre-operative risks as the patients become more medically high-risk. Despite increasing complexity, rates of POMI in EVAR significantly decreased, potentially explained by improved operative technique and peri-operative care.

Density functionals with spin-density accuracy for open shells.

Electrons in zero external magnetic field can be studied with the Kohn-Sham (KS) scheme of either density functional theory (DFT) or spin-DFT (SDFT). The latter is normally used for open-shell systems because its approximations appear to model better the exchange and correlation (xc) functional, but also because, so far the application of DFT implied a closed-shell-like approximation. In the first part of this Communication, we show that correcting this error for open shells allows the approximate DFT xc functionals to become as accurate as those in SDFT. In the second part, we consider the behavior of SDFT for zero magnetic field. We show that the KS equations of SDFT emerge as the generalized KS equations of DFT in this limit, thus establishing a so far unknown link between the two theories.

Aortic visceral segment instability is evident following thoracic endovascular aortic repair for acute and subacute type B aortic dissection.

BACKGROUND: Anatomic remodeling within the thoracic aorta following thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) has been well documented. However, less is known about the response of the untreated visceral aorta. In the present study, we investigated the visceral aortic behavior after TEVAR for acute or subacute TBAD to identify any associations with the clinical outcomes. METHODS: A multicenter retrospective review was performed of all imaging studies for all patients who had undergone TEVAR for acute (0-14 days) and subacute (14-90 days) nontraumatic TBAD from 2006 to 2020. The cohort was inclusive of those with uncomplicated, high-risk, and complicated (defined in accordance with the Society for Vascular Surgery reporting guidelines) dissections. Centerline aortic measurements of the true and false lumen and total aortic diameter (TAD) were taken at standardized locations relative to the aortic anatomy within each aortic zone (the zones were defined by the Society for Vascular Surgery reporting guidelines). Diameter changes over time were evaluated using repeated measures mixed effects linear growth modeling. Visceral segment instability (VSI) was defined as any growth in the TAD of ≥5 mm within aortic zones 5 through 9. RESULTS: A total of 82 patients were identified. The median length of imaging follow-up was 2.1 years (interquartile range, 0.75-4.5 years), with 15% of the cohort having follow-up >5 years. VSI was present in 55% of the cohort, with an average maximal increase in the TAD of 10.4 ± 6.3 mm during a median follow-up of 2.1 years (interquartile range, 0.75-4.5 years). Approximately one third of the cohort had experienced rapid VSI (growth ≥5 mm in the first year), and 4.8% of the cohort had developed a large paravisceral aortic aneurysm (TAD ≥5 cm) secondary to VSI. Linear growth modeling identified significant predictable growth in the TAD across all visceral zones. Zone 7 had the highest rate of TAD dilation, with a fixed effect estimated rate of 1.3 mm/y (95% confidence interval [CI], 0.23-2.1; P = .022). The preoperative factor most strongly associated with VSI was a cumulative number of zones dissected of six or more (odds ratio, 6.4; 95% CI, 1.07-8.6; P = .041). The odds for aortic reintervention were significantly increased for cases in which VSI led to the development of a paravisceral aortic aneurysm of ≥5 cm (odds ratio, 3.7; 95% CI, 1.1-13; P = .038). CONCLUSIONS: VSI was identified in most patients who had undergone TEVAR for management of acute and subacute TBAD. The preoperative anatomic features such as the dissection extent, rather than the procedural details of graft coverage, might play a more significant role in VSI occurrence. Significant TAD growth had occurred in all visceral segments. These results highlight the importance of lifelong surveillance following TEVAR and identified a subset of patients who might have an increased risk of reintervention.

Association of Statin and Antiplatelet Use with Survival in Patients with AAA with and without Concomitant Atherosclerotic Occlusive Disease.

BACKGROUND: Statin therapy has been associated with improved clinical outcomes in patients undergoing treatment for vascular disease. Current guidelines do not address statin therapy in isolated abdominal aortic aneurysm (AAA) in the absence of other atherosclerotic cardiovascular disease (ASCVD). This study aims to elucidate effects of statin therapy, either as monotherapy or combined with antiplatelet agents, on the long-term mortality of patients with and without ASCVD who undergo elective AAA repair. METHODS: A retrospective review was performed on all AAA patients treated electively with endovascular (EVAR) and open aortic repair (OAR) in the Society for Vascular Surgery Vascular Quality Initiative from 2003-2020. Long-term mortality was evaluated based on the presence of statin and antiplatelet medication use at discharge stratified by those with and without a history of ASCVD. Unadjusted survival was estimated by Kaplan Meier methodology. Cox proportional hazards modeling was used to determine mortality risk after adjusting for key factors. RESULTS: A total of 47,012 AAA repairs were selected for analysis: 80.7% EVAR (N = 40,153) and 19.3% OAR (N = 6,859). EVAR patients on combined statin/antiplatelet (AP) therapy had significantly better survival irrespective of whether they had known ASCVD. In the presence of ASCVD, EVAR patients on statin alone had improved survival compared to those not on a statin (10.9 ± 0.5 vs. 10.5 ± 0.4 years, Log Rank < 0.001), with survival being even greater among those receiving combined statin/AP therapy (12.2 ± 0.2 vs. 10.5 ± 0.4 years, Log Rank < 0.001). In the absence of ASCVD, EVAR patients on statin alone also had better mean survival compared to patients not on a statin (8.7 ± 0.5 vs. 8.4 ± 0.4 years, Log Rank<.001), with higher survival among statin/AP therapy patients (9.4 ± 0.2 years vs. 8.7 ± 0.5 years, Log Rank < 0.001). Comparison of adjusted survival via Cox multivariable regression demonstrated a protective effect of statins (HR = 0.737, P = 0.04, vs. no medication) and combined statin/AP therapy (HR = 0.659, P = 0.001, vs no medication) in patients with ASCVD history. A similar protective effect (statin: HR 0.826, P = 0.05. Combination statin/AP: HR 0.726, P < 0.001, vs. no medication) was identified in patients without ASCVD history. Within the OAR cohort, statin therapy was not associated with improved survival among patients without ASCVD; however, combined statin/AP therapy had a protective effect for patients with a known ASCVD diagnosis. Based on KM analysis, OAR patients with ASCVD on combined statin/AP therapy had significantly higher mean survival compared to isolated statin therapy (12.7 ± 0.2 vs. 10.3 ± 0.65 years) and no medical therapy (10.5 ± 0.8 years, Log Rank < 0.001). In KM analysis, OAR patients without known ASCVD indications (N = 3591) had no significant survival differences based on the presence of combined statin/AP therapy (8.4 ± .07 vs. 8.5 ± .11 years, Log Rank = 0 638). CONCLUSION: Isolated statin therapy and combined statin/AP therapy showed significant survival benefit in all EVAR and OAR patients with ASCVD indications, as well as among EVAR patients without a known ASCVD diagnosis. OAR patients without ASCVD did not have a significant survival benefit from statin therapy, but low numbers in this group may have confounded the findings. Combined statin/AP therapy appears to have significant post-repair survival benefits even in isolated AAA without ASCVD, as demonstrated in post-EVAR patients in this study. Expansion of statin use recommendations within aneurysm treatment guidelines may be warranted.

Clinical practice and volume trends of inferior vena cava filter usage at a single tertiary care center during a 19-year period.

BACKGROUND: We investigated the clinical practice and volume trends of inferior vena cava filter (IVCF) usage at a single institution for an extended period and identified the potential factors affecting the clinical decision for placement, follow-up, and retrieval. METHODS: An institutional database was queried for IVCFs placed from 2000 to 2018 using the Current Procedural Terminology codes. The medical records were reviewed to evaluate the demographics, economic status, placement indication, IVCF type, follow-up evaluation for retrieval, and retrieval success rates. Statistical analysis was performed using SPSS, and t tests for continuous and χ2 for categorical variables. RESULTS: A total of 3915 IVCFs were placed from 2000 to 2018. The placement of IVCFs had increased steadily from 2000 (127 IVCFs/y), peaking in 2010 at 371 IVCFs/y and representing a 292% increase in IVCF usage. Since 2010, the number of IVCFs placed has steadily declined until 2016 to 2018, with a 426% decrease from the peak. In a subgroup of IVCFs placed for prophylaxis, the total volume trends paralleled a shift in clinical indications, peaking in 2010 and accounting for 45% of all IVCFs placed and then decreasing from 2013 to 2018 to ≤10%. Overall, 989 permanent IVCFs (25.3%) and 2926 retrievable IVCFs (74.7%) were placed during the entire study period. Before dedicated efforts to implement retrieval follow-up visits, the successful retrieval rate was ∼1% from 2000 to 2006 and had increased to ∼10% to 15% from 2007 to 2015, 36.7% in 2016, 40.2% in 2017, and 40.3% in 2018 after implementation of more active retrieval follow-up protocols. The predictors for the lack of evaluation for IVCF retrieval included an extended length of stay (P = .004) and geographic distance (P < .001). CONCLUSIONS: The use of IVCFs during the past 19 years at our institution reflected increased usage from 2000 to 2010, corresponding to an increase in prophylactic placement, followed by a decreasing total volume from 2011 to 2018, largely attributable to decreased prophylactic IVCF placement. Improved retrieval rates were seen after implementation of an active IVCF retrieval program.

Vascular complications based on mode of extracorporeal membrane oxygenation.

BACKGROUND: Vascular complications remain a prevalent and devastating complication of extracorporeal membrane oxygenation (ECMO). Risks for vascular complications have risen as the volume and medical complexity of ECMO cases has rapidly increased in recent years. This study assesses occurrence and clinical impact of vascular complications across all ECMO modes and cannulation methods in a high-volume academic center. METHODS: A retrospective single-institution review was performed of all ECMO cannulations for central or peripheral venovenous (VV) or venoarterial (VA) ECMO in 2019-2020. Patients who expired during cannulation were excluded. Primary outcomes of vascular consultation rates at or after ECMO placement, limb loss, and mortality were assessed during index hospitalization. RESULTS: A total of 229 patients were identified during the 2-year study period. VA ECMO was used in the majority of patients (n = 137, 60%), with 83% (N = 114) undergoing peripheral cannulation. Vascular surgery was consulted in 54 (23.6%) patients. Complication rates ranged from 33.9% in peripheral VA cannulation to 7% in jugular VV cannulation. Overall, 65% of vascular consults required operative intervention; interventions were highest in peripheral VA ECMO (n = 30 of 114, 26.3%). Across all ECMO types, acute limb ischemia (ALI) was the most common complication (n = 38, 16.5%), with rates ranging from 26.1% in central VA ECMO to 4.8% in jugular VV ECMO. Distal antegrade perfusion catheters (DPCs) were employed in n = 68 of 114 (59.6%) of all peripheral VA ECMO cases. Prophylactic DPCs were found to be incorrectly placed in 10.2% (n = 7 of 68) of cases, which obscured the ability to fully evaluate the effect of prophylactic DPCs on reducing rates of ALI. Major amputation (Below Knee Amputation/Above Knee Amputation) occurred in six peripheral VA patients (5.3%), two central VA patients (8.65), and two femoral-femoral VV patients (4%). Patients with ALI experienced significantly lower rates of in-hospital survival in Kaplan-Meier analysis (32.5% vs 54%, log-rank = 0.023). CONCLUSIONS: This study highlights the prevalence of vascular complications, and their associated mortality impact, across all modes of ECMO and additionally identifies several areas for institutional performance improvement. ALI was the most common complication across all cohorts and was associated with decreased in-hospital survival. The impact of DPC on ALI was difficult to elucidate due to nonstandardized placement patterns and selective use. In the care of these medically complex patients on multidisciplinary teams, review of outcomes and group discussions targeting areas for improvement are critical to success; in this study, findings resulted in the development of a lower extremity perfusion management protocol.

Trends in the use of cerebrospinal drains and outcomes related to spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair in the Vascular Quality Initiative database.

BACKGROUND: Spinal cord ischemia (SCI) is a dreaded complication of thoracic and complex endovascular aortic repair (TEVAR/cEVAR). Controversy exists surrounding cerebrospinal fluid drain (CSFD) use, especially preoperative prophylactic placement, owing to concerns regarding catheter-related complications. However, these risks are balanced by the widely accepted benefits of CSFDs during open repair to prevent and/or rescue patients with SCI. The importance of this issue is underscored by the paucity of data on CSFD practice patterns, limiting the development of practice guidelines. Therefore, the purpose of the present analysis was to evaluate the differences between patients who developed SCI despite preoperative CSFD placement and those treated with therapeutic postoperative CSFD placement. METHODS: All elective TEVAR/cEVAR procedures for degenerative aneurysm pathology in the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2019 were analyzed. CSFD use over time, the factors associated with preoperative prophylactic vs postoperative therapeutic CSFD placement in patients with SCI (transient or permanent), and outcomes were evaluated. Survival differences were estimated using the Kaplan-Meier method. RESULTS: A total of 3406 TEVAR/cEVAR procedures met the inclusion criteria, with an overall SCI rate of 2.3% (n = 88). The SCI rate decreased from 4.55% in 2014 to 1.43% in 2018. Prophylactic preoperative CSFD use was similar over time (2014, 30%; vs 2018, 27%; P = .8). After further exclusions to evaluate CSFD use in those who had developed SCI, 72 patients were available for analysis, 48 with SCI and prophylactic CSFD placement and 24 with SCI and therapeutic CSFD placement. Specific to SCI, the patient demographics and comorbidities were not significantly different between the prophylactic and therapeutic groups, with the exception of previous aortic surgery, which was more common in the prophylactic CSFD cohort (46% vs 23%; P < .001). The SCI outcome was significantly worse for the therapeutic group because 79% had documented permanent paraplegia at discharge compared with 54% of the prophylactic group (P = .04). SCI patients receiving a postoperative therapeutic CSFD had had worse survival than those with a preoperative prophylactic CSFD (50% ± 10% vs 71% ± 9%; log-rank P = .1; Wilcoxon P = .05). CONCLUSIONS: Prophylactic CSFD use with TEVAR/cEVAR remained stable during the study period. Of the SCI patients, postoperative therapeutic CSFD placement was associated with worse sustained neurologic outcomes and overall survival compared with preoperative prophylactic CSFD placement. These findings highlight the need for a randomized clinical trial to examine prophylactic vs therapeutic CSFD placement in association with TEVAR/cEVAR.

Association between thoracoabdominal aneurysm extent and mortality after complex endovascular repair.

OBJECTIVE: Traditional open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) has historically resulted in 30-day mortality rates ranging from 6% to 20%, depending on the Crawford anatomic extent. Although short-term survival is important, long-term survival is essential for patients to benefit from these often elective and potentially morbid procedures. The aneurysm extent affects the long-term survival after open repair; however, effect on endovascular repair is unknown and could influence the decision process for repair. We evaluated the association between aneurysm extent and survival and identified patient and perioperative factors associated with mortality after endovascular repair. METHODS: A retrospective cohort of patients treated for TAAAs recorded in the Society for Vascular Surgery Vascular Quality Initiative thoracic and complex endovascular aneurysm repair registry were evaluated. All patients treated for asymptomatic degenerative aneurysms from 2010 to 2019 were included. Crawford extent I to V was defined according to the proximal and distal landing zones documented in the registry. Patients without extension into the visceral aorta were used for comparison and categorized as having extent 0a or 0b, depending on the distal landing zone in the thoracic aorta. Kaplan-Meier plots were used to estimate survival, and Cox proportional hazard regression models were created to identify the predictors of mortality. RESULTS: From 2010 to 2019, 15,333 patients were entered into the registry, of whom 2062 met the inclusion criteria. The Crawford extent was 0a for 379, 0b for 848, I for 81, II for 98, III for 130, IV for 454, and V for 72. Three groups were created in accordance with the similar outcomes noted on a preliminary analysis: (1) extent 0a and 0b; (2) extent I, II, and III; and (3) extent IV and V. The mean survival time for the extent 0a and 0b group was 70.7 ± 1.43 months and was 48.6 ± 1.65 months for the extent I, II, and III group and 57.6 ± 1.24 months for the extent IV and V group. The corresponding 1-year mortality was 8.4%, 18.4%, and 7.8%. Cox regression analysis identified the following preoperative factors were associated with mortality: chronic obstructive pulmonary disease (odds ratio [OR], 1.70; P < .001), Crawford extent I to III (OR, 1.64; P = .015), preexisting chronic kidney disease (OR, 1.37; P = .024), and age per year (OR, 1.03; P < .001). A number of postoperative factors were also associated with mortality. CONCLUSIONS: Similar to open TAAA repair, patients with more extensive aortic disease treated with endovascular repair had worse 1-year and long-term survival. The extent of aortic disease and anticipated postoperative survival should factor prominently into the surgical decision-making process for elective endovascular TAAA repair.

The association between preoperative length of stay and surgical site infection after lower extremity bypass for chronic limb-threatening ischemia.

OBJECTIVE: Surgical site infection (SSI) is an important complication of lower extremity bypass (LEB) and the rate of SSI after LEB varies widely in the existing literature, ranging from 4% to 31%. Prolonged length of stay (LOS) has been implicated in the occurrence of SSI across multiple surgical disciplines. The impact of preoperative LOS in patients with chronic limb-threatening ischemia (CLTI) undergoing LEB is unknown. We examined the association of preoperative LOS on SSI after LEB. METHODS: A retrospective analysis of the Society for Vascular Surgery Vascular Quality Initiative Infrainguinal Bypass Registry identified patients undergoing elective LEB for chronic limb-threatening ischemia from 2003 to 2019. Patients undergoing LEB for acute limb ischemia, urgent/emergent procedures, aneurysm, or who had concomitant suprainguinal bypass were excluded. The primary outcome measure was postoperative SSI. Multivariable forward stepwise logistic regression was then performed including all variables with a P value of less than .10 in both matched and unmatched cohorts to evaluate for demographic and perioperative predictors of SSI. Propensity score matching was used to create matched cohorts of patients for each LOS group. RESULTS: A total of 17,883 LEB procedures were selected for inclusion: 0 days (12,362 LEB), 1 to 2 days (1737 LEB), and 3 to 14 days (3784 LEB). Patients with the greatest preoperative LOS were more likely to have vein mapping (0 days preoperative LOS, 66.3%; 1-2 days, 65.2%; 3-14 days, 73.2%; P < .01) or computed tomography angiography/magnetic resonance angiography (0 days, 32.1%; 1-2 days, 34.4%; 3-14 days, 38.4%; P < .01). Patients with 3 or more days of preoperative LOS had longer procedure lengths (0 days, 244 minutes; 1-2 days, 243 minutes; 3-14 days, 255 minutes; P < .01) and were more likely to have completion angiogram (0 days, 27.1%; 1-2 days, 29.5%; 3-14 days, 31.6%; P = .02). Multivariable logistic regression demonstrated that preoperative LOS of 3 to 14 days was associated with increased rate of SSI (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.20-3.07; P = .01). Transfusion of 3 or more units (OR, 2.87; 95% CI, 1.89-4.36; P < .01) and prolonged procedure length (>220 minutes; OR, 1.86; 95% CI, 1.26-2.73; P < .01) were also significantly associated with postoperative SSIs. CONCLUSIONS: Many factors including preoperative comorbidities and operative complexity covary with preoperative LOS as risk factors for SSI. However, when patients are matched based on comorbidities and factors that would predict overall clinical complexity, preoperative LOS remains important in predicting SSI.

Prevalence and Outcomes of Endovascular Infrapopliteal Interventions for Intermittent Claudication.

BACKGROUND: Although endovascular peripheral vascular interventions (PVI) are typically limited to vessels above the knee in intermittent claudication (IC), some patients have concomitant or isolated infrapopliteal disease with IC. The benefits and risks of undergoing tibial intervention remain unclear in IC patients. The purpose of this study is to evaluate the prevalence and outcomes of infrapopliteal PVI for IC. METHODS: The Vascular Quality Initiative was queried for PVI procedures performed for IC between 2003 and 2018. Patients were divided into 3 groups: isolated femoropopliteal (FP), isolated infrapopliteal (IP), and combined above and below knee interventions (COM). Multivariable logistic regression models identified predictors of minor and major amputation, as well as freedom from reintervention. Kaplan-Meier plots estimate amputation-free survival. RESULTS: We identified 34,944 PVI procedures for IC. There were 31,110 (89.0%) FP interventions, 1,045 (3.0%) IP interventions, and 2,789 (8.0%) COM interventions. Kaplan-Meier plots of amputation-free survival revealed that patients with any IP intervention had significantly higher rates of both minor and major amputation (log rank <0.001). Freedom from reintervention at 1-year was 89.2% for the FP group, 91.3% for the IP group, and 85.3% for the COM group (P < 0.0001). In multivariable analysis, factors associated with an increased risk of major amputation included isolated IP intervention (OR 6.47, 95% CI, 6.45-6.49; P < 0.0001), COM interventions (OR 2.32, 95% CI, 2.31-2.33; P < 0.0001), dialysis dependence (OR 3.34, 95% CI, 3.33-3.35; P < 0.0001), CHF (OR 1.86, 95% CI, 1.85-1.86; P = 0.021) and, nonwhite race (OR 1.64, 95% CI, 1.63-1.64; P = 0.013). CONCLUSIONS: PVI in the infrapopliteal vessels for IC is associated with higher amputation rates. This observation may suggest the need for more careful patient selection when performing PVI in patients with IC where disease extends into the infrapopliteal level.