Persistent malperfusion after central aortic repair in acute type I aortic dissections.

OBJECTIVE: Acute dissection involving the ascending aorta and extending beyond the innominate artery (DeBakey type I) may be associated with acute ischemic complications owing to branch artery malperfusion. The purpose of this study was to document the prevalence of noncardiac ischemic complications associated with type I aortic dissections that persisted after initial ascending aortic and hemiarch repair, necessitating vascular surgery intervention. METHODS: Consecutive patients presenting with acute type I aortic dissections between 2007 and 2022 were studied. Patients who underwent initial ascending aortic and hemiarch repair were included in the analysis. Study end points included the need for additional interventions after ascending aortic repair and death. RESULTS: There were 120 patients (70% men; mean age, 58 ± 13 years) who underwent emergent repair for acute type I aortic dissections during the study period. Forty-one patients (34%) presented with acute ischemic complications. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. After proximal aortic repair, 12 patients (10%) had persistent ischemia. Nine patients (8%) required additional interventions for persistent leg ischemia (n = 7), intestinal gangrene (n = 1), or cerebral edema (craniotomy, n = 1). Three other patients with acute stroke had permanent neurologic deficits. All other ischemic complications resolved after the proximal aortic repair despite mean operative times exceeding 6 hours. Comparing patients with persistent ischemia with those whose symptoms resolved after central aortic repair, there were no differences in demographics, distal extent of dissection, mean operative time for aortic repair, or need for venous-arterial extracorporeal bypass support. Overall, 6 of the 120 patients (5%) suffered perioperative deaths. Hospital deaths occurred in 3 of the 12 patients (25%) with persistent ischemia vs none of 29 patients who had resolution of the ischemia after aortic repair (P = .02). Over a mean follow-up of 51 ± 39 months, no patient required an additional intervention for persistent branch artery occlusion. CONCLUSIONS: One-third of patients with acute type I aortic dissections had associated noncardiac ischemia, prompting a vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Although the presence of acute ischemia at presentation did not increase hospital or 5-year mortality rates, persistent ischemia after central aortic repair seems to be a marker for increased hospital mortality after type I dissections.

Risk factors for lower extremity vascular complications in adult patients on veno-arterial extracorporeal membrane oxygenation.

OBJECTIVE: Utilization of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has increased significantly over the last decade. Prior studies have reported worse mortality for patients with vascular complications on VA-ECMO; however, these were limited by small sample size. The purpose of this study is to investigate predictive risk factors for vascular complications in VA-ECMO patients and their potential impact on mortality. METHODS: Patients who underwent peripheral VA-ECMO from January 2011 to December 2021 were identified. Primary outcomes were lower extremity vascular complications and in-hospital mortality. Multivariate stepwise logistic regression models were used to identify predictors of vascular complications and in-hospital mortality. RESULTS: A total of 605 VA-ECMO patients (25% female) were identified. The mean age was 56.3 ± 13 years, and 56 (10.4%) were black. In-hospital mortality was 63.8% (n = 386), and VA-ECMO ipsilateral vascular complications occurred in 72 patients (11.9%). Vascular surgical interventions (thromboembolectomy, fasciotomies, amputation, and surgical management of cannula bleeding) were required in 30 patients (41.7%). Same-side arterial and venous cannulas, cannula size, and absence of distal perfusion cannula did not increase risk of vascular complication. Multivariate analysis identified age (odds ratio, 0.948; 95% confidence interval, 0.909-0.988; P = .0116) and pre-existing peripheral arterial disease (odds ratio, 3.489; 95% confidence inteval, 1.146-10.624; P = .0278) as independent predictors of need for vascular surgery interventions. The mortality rate of patients who developed vascular complications was not significantly different compared with the mortality rate of those who did not develop vascular complications (61% vs 64%; P = .92). CONCLUSIONS: This study represents one of the largest series to date of lower extremity vascular outcomes in patients undergoing VA-ECMO. Our results confirm the high mortality rate associated with VA-ECMO; however, vascular complications did not represent a risk factor for mortality as previously reported. Same-sided VA-ECMO cannulas, cannula size, and the presence or absence of distal perfusion cannula did not predict vascular complications. Increasing age and presence of peripheral arterial disease are independent predictors of need for vascular surgery intervention in patients on VA-ECMO.

Ankle-brachial index use in peripheral vascular interventions for claudication.

OBJECTIVE: The ankle-brachial index (ABI) has been recommended as the first-line noninvasive test to establish a diagnosis of peripheral arterial disease in patients with claudication (grade 1, level A evidence). The ABI can also be used to monitor disease progression and assess the benefits of treatment after peripheral vascular intervention (PVI). The Upper Midwest Region of the Vascular Quality Initiative has a unique balance of participation from vascular surgeons, interventional radiologists, and cardiologists performing PVI. We sought to identify the use of ABI and assess the functional outcomes of patients who had undergone PVI for claudication. METHODS: We conducted a review of the Upper Midwest Region of the Vascular Quality Initiative to identify PVI performed for claudication from native artery atherosclerotic occlusive disease in nondiabetic patients from 2010 to 2020. Patients who had undergone PVI with infection, tissue loss, rest pain, bypass graft stenosis, or aneurysmal disease were excluded. The primary outcomes included the ABI, ambulation status, and functional status before and after PVI. RESULTS: A total of 3787 patients (58.0% male, 42.0% female; mean age, 68.4 years) who had undergone 3830 procedures were identified. Of the 3787 patients, 2665 (69.5%) had had the ABI measured: 1803 (47.1%) before PVI only, 190 (4.9%) after PVI only, and 862 (22.5%) before and after PVI. In addition, 975 patients (25.5%) had never had the ABI performed. Statistical analysis of the entire cohort found no change in ambulation status (P = .33-.95 for all comparisons) or functional status (P = .42-.61 for all comparisons) regardless of the use of the ABI. However, a significant number of patients who had never had the ABI measured had decreased from full functional status before PVI to only being functional with light work after PVI (P = .015). CONCLUSIONS: Despite the grade 1, level A evidence, ABI had been used before and after PVI for only 22.5% of the patients who had undergone PVI for claudication. In addition, we found overall functional status had decreased significantly after PVI for those patients who had never had an ABI performed. Accurately identifying patients with claudication due to PAD using the ABI remains critically important before PVI. Given the lack of overall improvement in ambulation after PVI found in the present study, identifying the patients who will benefit from PVI to treat claudication remains elusive.

Emergency department visits after acute aortic syndromes.

OBJECTIVE: Recent reports document a high rate of readmission after hospitalization for acute aortic syndromes (AAS) that include acute aortic dissections, intramural hematomas, or penetrating aortic ulcers. We examined the rate of return to the emergency department (ED) to better understand the utilization of emergent health care services after AAS. METHODS: Consecutive patients with AAS admitted to the vascular surgery service from 2004 to 2020 were included. Patients with type A dissections, arch involvement, or chronic aortic pathology were excluded. The primary outcome was ED visits within 90 days of the original hospitalization. RESULTS: The study included 79 subjects (62% men, 38% women; mean age: 64 ± 14 years) with AAS (82% aortic dissections, 11% intramural hematomas, and 6% penetrating aortic ulcers). A total of 54 ED visits related to the AAS occurred within 90 days of the original discharge, each of which incurred a computed tomography angiogram. Twenty-eight (35%) subjects had a mean of 2 ± 2 ED visits, whereas 51 (65%) subjects had no ED visits. Ninety percent (25 of 28) of the first ED visits occurred within 1 month of discharge and 53% (15 of 28) within 1 week. A total of 17 (61%) subjects were readmitted to the hospital from the ED. Four subjects were found to have progression of AAS on imaging studies and underwent thoracic endovascular aortic repair during readmission. Comparing subjects who returned to the ED with those who did not, there were no significant differences in demographics, atherosclerotic risk factors except coronary artery disease, type of AAS, number of antihypertensive medications at admission or discharge, operative intervention, length of initial hospital stay, or discharge status. The chief complaints at the first ED visit were pain (n = 17), uncontrolled hypertension (n = 5), syncope (n = 3), and other (n = 3). CONCLUSIONS: These data show that one in three patients with AAS returned to the ED within 90 days of initial discharge. Although returning subjects had a higher number of readmissions, few had progression of AAS that required intervention. Because the vast majority were readmitted for medical therapy, early and frequent clinic follow-up may help decrease ED visits and readmissions after AAS.

Televascular consultation is one answer to rural vascular surgery shortage.

Telemedicine provides an opportunity for virtual consultation between physicians and patients in remote locations. We sought to evaluate whether telemedicine consultation for vascular surgery can replace direct visits for patients in remote areas. Patients undergoing telemedicine consultation from 2014-2019 at the Veterans Affairs Medical Center (VAMC) with a large rural catchment area, were reviewed. Primary outcomes included diagnosis, type and number of telemedicine visits, and types of surgical procedures scheduled after initial visit. 574 patients participated in 708 out-patient telemedicine consultations conducted by four vascular surgeons and two advanced practitioners. Visits took place at 21 clinics across Minnesota (n = 305), North Dakota (n = 96), South Dakota (n = 82), Wisconsin (n = 20), and Iowa (n = 2) with an average distance of 159 miles from the VAMC. There were 429 (75%) new patient visits and 279 (25%) follow-ups. After initial telemedicine consultation, 236 (55%) patients were booked for procedures. Telemedicine is feasible for vascular surgery consultation and increases patient convenience with decreased overall travel expense and wait time. Telemedicine can be a viable solution to the shortage of vascular surgeons in the rural United States.

The impact of pre-existing blood pressure control in patients with acute aortic dissections.

OBJECTIVES: Arterial hypertension (HTN) is considered a seminal risk factor for aortic dissection (AD). The purpose of this study is to evaluate whether pre-existing blood pressure (BP) control lessens the extent of dissection and has a favorable impact on outcome of patients with acute AD. METHODS: Consecutive acute AD patients who had at least two BPs recorded within the 12 months preceding the AD were retrospectively analyzed. The two most recent BPs were averaged and defined per published guidelines as normal (BP≤ 130/80), Stage I HTN (BP >130/80 and <139/89), or Stage 2 or greater HTN (BP > 140/90). The number of hypertensive medications (MEDs) was also used as a surrogate marker of HTN severity. Patients with known genetic causes of AD were excluded. RESULTS: 89 subjects (55% men, 45% women; mean age, 64±14 years) with acute AD (58% Stanford type A and 42% Stanford type B) were included. Two most recent BPs were recorded a mean of 5±3 and 3±2.7 months before the AD, respectively. Twenty-nine (33%) subjects had normal BP, including nine subjects with no history of HTN and on no MEDs. Sixty (67%) subjects had elevated BP, including 21 (35%) with Stage I HTN and 39 (65%) with Stage 2 HTN. Compared to subjects with normal BP, subjects with Stage 1 and Stage 2 HTN were younger (70±13 years vs 62±1 year, p = 0.01), but there were no differences in other demographics, risk factors, comorbidities, or history of drug use. There were no group differences in the distal extent of the dissections, complications requiring thoracic endograft repair, mean length of hospital stay, final discharge status, or 30-day mortality. Compared to the number of MEDs before AD, all three groups had a higher mean number of MEDs to achieve normal BP at discharge that persisted at a mean follow-up of 18±15 months. CONCLUSIONS: These data show that approximately one-third of patients with acute AD had well controlled or no antecedent history of HTN. The degree of pre-existing HTN control had no bearing on the type or extent of AD, length of stay, or early outcome. Regardless of the state of HTN control before AD, the consistent and sustained increase in the severity of HTN after AD suggests that the dissection process has a profound and lasting effect on BP regulation. Further studies are indicated to elucidate the pathologic mechanisms involved in AD.

Representation of women in vascular surgery science and societies.

OBJECTIVE: Medical schools and surgical residencies have seen an increase in the proportion of female matriculants, with 30% of current vascular surgery trainees being women over the past decade. There is widespread focus on increasing diversity in medicine and surgery in an effort to provide optimal quality of patient care and the advancement of science. The presence of gender diversity and opportunities to identify with women in leadership positions positively correlates with women choosing to enter traditionally male-dominated fields. The purpose of this study was to evaluate the representation of women in regional and national vascular surgical societies over the last 20 years. METHODS: A retrospective review of the meeting programs of vascular surgery societies was performed. Data were collected on abstract presenters, moderators, committee members and chairs, and officers (president, president-elect, vice president, secretary, and treasurer). The data were divided into early (1999-2009) and late (2010-2019) time periods. RESULTS: Five regional and five national societies' data were analyzed, including 139 meetings. The mean percentage of female abstract presenters increased significantly from 10.9% in the early period to 20.6% in the late period (P < .001). Female senior authors increased slightly from 8.7% to 11.5%, but this change was not statistically significant (P = .22). Female meeting moderators increased significantly from 7.8% to 17.2% (P < .001), as well as female committee members increased from 10.9% to 20.3% (P = .003). Female committee chairs increased slightly from 10.9% to 16.9%, but this difference was not statistically significant (P = .13). Female society officers increased considerably from 6.4% to 14.8%. (P = .002). Significant variation was noted between societies, with five societies (three regional and two national) having less than 10% women at the officer level in 2019. There was a wide variation noted between societies in the percentage of female abstract presenters (range, 7.6%-34.9%), senior authors (3.9%-17.9%), and meeting moderators (5.4%-40.7%). CONCLUSIONS: Over the past two decades, there has been a significant increase in the representation of women in vascular surgery societies among those presenting scientific work, serving as meeting moderators, and serving as committee members. However, the representation of women among committee chairs, senior authors, and society leadership has not kept up pace with the increase noted at other levels. Efforts to recruit women into the field of vascular surgery as well as to support the professional development of female vascular surgeons are facilitated by the presence of women in leadership roles. Increasing the representation of women in vascular society leadership positions may be a key strategy in promoting gender diversity in the vascular surgery field.

Giant cell aortitis masquerading as intramural hematoma.

Giant cell aortitis is a rare cause of acute aortic syndrome. We describe the cases of two patients who had presented with chest pain, hypertension, and computed tomography angiographic evidence of mural thickening typical of thoracic aortic intramural hematoma. Although the patients' symptoms improved with hypertension control, elevated inflammatory markers and persistent fever to 103°F raised concern for an inflammatory etiology. Empiric steroids were administered, resulting in prompt cessation of fever and decreasing inflammatory markers. The findings from temporal artery biopsies were positive in both patients. Follow-up axial imaging after 2 weeks of steroid therapy revealed improvement in aortitis with decreased wall thickening. Giant cell aortitis should be considered in patients presenting with acute aortic syndrome in the setting of elevated inflammatory markers and noninfectious fever.

Vascular surgery presence in carotid endarterectomy YouTube videos.

OBJECTIVE: YouTube videos have become a common resource for trainees to learn about surgical procedures. Carotid endarterectomy (CEA) is one example procedure that may be performed by multiple specialties and with a variety of techniques. Little is known about educational content and the representation of vascular surgeons in these videos. We sought to compare the educational quality of CEA YouTube videos, techniques demonstrated, and prevalence of each specialty. METHODS: YouTube was programmatically searched for the terms "carotid endarterectomy," "carotid endarterectomy surgery," "carotid endarterectomy technique," "carotid endarterectomy CEA," and "carotid artery surgery." Videos that met inclusion criteria were analyzed for surgical technique, procedural steps, surgeon specialty, video length, and date. Videos were determined to have high-quality educational content if the video included English-language captions or narration and demonstrated key steps of the procedure: division of the common facial vein; exposure of the common, external, and internal carotid arteries; vascular control and clamping; and arteriotomy, endarterectomy, and arteriotomy closure. RESULTS: Forty-six videos met inclusion criteria. Vascular surgery was associated with 12 (26.1%) CEA videos, cardiac surgery with 13 (28.3%), and neurosurgery with 14 (30.4%). Surgeon specialty was unknown for seven (17.4%) videos. Eight videos were high quality, of which vascular surgery was associated with three (37.5%). Conventional endarterectomy was the most common technique demonstrated, whereas a total of seven videos demonstrated eversion technique. Vascular and cardiac surgeons were more likely to demonstrate patch angioplasty than neurosurgeons, who exclusively performed primary closure (P < .05). Compared with cardiac surgeons, vascular surgeon CEA videos had more views (25,956 ± 9613 vs 1200 ± 368; P < .05) and were more likely to be published by user accounts with an academic affiliation (11 vs 6; P < .05). Vascular surgery videos were older than videos by cardiac surgeons (6.0 ± 1.1 years vs 3.0 ± 0.5 years; P < .05) and neurosurgeons (6.0 ± 1.1 years vs 3.1 ± 0.8 years; P < .05). CONCLUSIONS: Despite more views, the field of vascular surgery is under-represented in YouTube videos demonstrating CEA. Vascular surgery videos tend to be older and make up a minority of high-quality videos. As more learners turn to YouTube for information about surgical procedures, vascular surgeons should expand their online presence through the production and collection of high-quality videos for trainees.

Development of a pulsatile cadaver-based simulation for training of open abdominal vascular surgery skills.

OBJECTIVE: Developing competence in open aortic surgery is increasingly challenging in vascular surgery training programs. Although static cadaver models provide an opportunity for dissection and exposure, the lack of pulsatility limits further education in managing blood vessels. We developed an affordable pulsatile cadaver simulation model to improve training in open abdominal aortic surgery with the primary objective of determining whether it incorporated the fidelity required to teach critical surgical techniques. METHODS: The University of Minnesota Bequest program supported a pilot project to develop a fresh pulsatile cadaver. A written pretest on exposure of the aorta in various locations was given to all trainees. The external iliac artery was exposed, cannulated, then perfused in a pulsatile fashion using normal saline and a pump. Trainees were then evaluated and timed on location of the aorta, retractor placement, dissection, and creation of an aortic anastomosis. RESULTS: Twenty-six pulsatile cadaver procedures were performed with five fellows over 13 months. All procedures were performed under the supervision of the same faculty member. Total cost over the study period was $8800. Four abdominal aortic aneurysms were found (15%). With bilateral iliac artery ligation, adequate pulsatility was created for blind supraceliac aortic dissection. Abdominal wall and organ relationships were ideal for teaching proper retractor placement and techniques for vascular dissection, endarterectomy, and anastomosis. Although 100% of fellows documented written understanding of the steps for procedures on the pretest, no fellow successfully placed a supraceliac aortic clamp, properly positioned retractors for proper open AAA exposure, or placed all proximal aortic back wall sutures transmurally on the initial assessment. After training for a variable number of cases, all were able to place a supraceliac clamp blindly within 4 minutes from skin incision. Retractor placement and suturing technique improved significantly for all trainees during the study period. CONCLUSIONS: The implementation of a pulsatile cadaver-based simulation model for abdominal vascular surgery has the potential to be both affordable and provide necessary haptics and fidelity for training fellows in critical abdominal vascular techniques.

Pre-emptive thoracic endovascular aortic repair is unnecessary in extended type A (DeBakey type I) aortic dissections.

OBJECTIVE: Pre-emptive thoracic endovascular aortic repair (TEVAR) improves late survival and limits progression of disease after type B aortic dissection, but the potential value of pre-emptive TEVAR has not been evaluated after type A dissection extending beyond the aortic arch (DeBakey type I). The purpose of this study was to compare disease progression and need for aortic intervention in survivors of acute, extended type A (ExTA) dissections after initial repair of the ascending aorta versus acute type B aortic dissections. METHODS: Consecutive patients presenting with ExTA or type B dissections between 2011 and 2018 were studied. Forty-three patients with ExTA and 44 with type B dissections who survived to discharge and had follow-up imaging studies were included in the analysis. Study end points included progression of aortic disease (>5 mm growth or extension), need for intervention, and death. RESULTS: The groups were not different for age, sex, atherosclerotic risk factors, or extent of dissection distal to the left subclavian artery. Following emergent ascending aortic repair, five ExTA patients (12%) underwent TEVAR within 4 months after discharge. Despite optimal medical treatment, 29 type B patients (66%) underwent early or late TEVAR (P < .001). During a mean follow-up of 38 ± 30 months, 38 ExTA patients (88%) did not require intervention-23 (53%) of whom showed no disease progression. In comparison, during a mean follow-up of 18 ± 6 months, 14 type B patients (32%) did not require intervention-nine (20%) of whom showed no disease progression (P = .003). There was one aortic-related late death in the ExTA group and two in the type B group. Compared with ExTA patients, type B patients had significantly worse intervention-free survival and intervention/growth-free survival (log rank, P < .001). CONCLUSIONS: In contrast with type B dissections, these midterm results demonstrate that one-half of ExTA aortic dissections show no disease progression in the thoracic or abdominal aorta, and few require additional interventions. After initial repair of the ascending aorta, pre-emptive TEVAR does not seem to be justified in patients with acute, ExTA dissections.

Angiosarcoma of the abdominal aorta after endovascular aneurysm repair.

Primary aortic sarcoma is a rare diagnosis that carries a poor prognosis. This case report features a 68-year-old man, treated 4 years earlier with an endovascular aortic aneurysm repair, who presented with fever, low back discomfort, and abdominal pain. Given the concern for an infected endograft, the patient underwent explantation and replacement with a cadaveric aortoiliac cryograft. Ultimately, the pathology returned as an angiosarcoma. Although endovascular aortic aneurysm repair is the gold standard for abdominal aortic aneurysm repair in patients with suitable anatomy, there are trade-offs associated with less invasive approaches compared with open approaches.

Increased Duration of Operating Time for Carotid Endarterectomy Is Associated with Increased Mortality.

BACKGROUND: Carotid endarterectomy is the gold standard operation to prevent stroke in patients with symptomatic carotid artery stenosis and asymptomatic high-grade carotid artery stenosis. Longer operative times for different operations have been shown to affect the outcomes adversely. The purpose of this study was to determine the incidence of postoperative complications after carotid endarterectomy, and their relation to the operative times. METHODS: The American College of Surgeons database was queried for all patients who underwent carotid endarterectomies from 2005 to 2007. Patients were divided into 2 groups based on the operative time (<140 min and >140 min). The incidence of preoperative morbidities and postoperative complications was then compared among these groups. RESULTS: A total of 10,423 patients underwent carotid endarterectomies during this time period. Longer operative time (>140 min) is associated with higher incidence of 30-day mortality (1.3% vs. 0.7%, P = 0.013), length of stay ≥7 days (12.7% vs. 8.1%, P < 0.001), postoperative pneumonias (1.6% vs. 0.9%, P = 0.001), failure to wean from ventilator for more than 48 hr (1.8% vs. 0.6%, P < 0.001), and return to the operating room (6.5% vs. 5.2%, P = 0.010). Factors associated with longer operative times were the following: age <65 years (odds ratio [OR] 1.3, confidence interval [CI] 1.1-1.6), male gender (OR 1.6, CI 1.4-1.7), black race (OR 1.5, CI 1.2-1.8), history of myocardial infarction (OR 1.7, CI 1.2-2.4), higher American Society of Anesthesiologist score (OR 1.3, CI 1.1-1.6), presence of surgical trainees (OR 3.6, CI 1.7-7.4), and presence of surgical fellows (OR 1.7, CI 1.4-2.2). CONCLUSIONS: Longer operative times for carotid endarterectomy are associated with increased risk of postoperative complications. Factors associated with longer operative times for carotid endarterectomy can be identified preoperatively.