"TCAR or nothing": the only options for some complex carotid stenosis.

Transcervical carotid artery revascularization has emerged as an alternative to carotid endarterectomy and transfemoral carotid artery stenting. We present four cases for which we believe transcervical carotid artery revascularization was the only option to treat the lesions. Each case presented with specific technical challenges that were overcome by intraoperative planning that allowed for safe deployment of the Enroute stent (Silk Road Medical) with resolution of each patient's stenosis.

Comparison of contemporary and historical outcomes of elective and ruptured open abdominal aortic aneurysm repair.

BACKGROUND: Recently, open abdominal aortic aneurysm (AAA) repair (OSR) has become less common and will often be reserved for patients with more complex aortic anatomy. Despite improvements in patient management, the reduced surgical volume has raised concerns for potentially worsened outcomes in the contemporary era (2014-2019) compared with an earlier era in which OSR was more widely practiced (2005-2010). In the present study, we compared the 30-day outcomes of open AAA repair between these two eras. METHODS: The American College of Surgeons National Quality Improvement Program general database was queried for open AAA repair using the Current Procedural Terminology and International Classification of Diseases, 9th and 10th, codes. The cases were stratified into two groups by operation year: 2005 to 2010 (early) and 2014 to 2019 (contemporary). In each era, the cases were further divided into elective and ruptured groups. The 30-day outcomes, including mortality, major morbidity, postoperative sepsis, and unplanned reoperation, were compared between the contemporary and early eras in the elective and ruptured groups. Preoperative variables with a P value <.25 were adjusted for in the multivariate analysis. RESULTS: In the contemporary and early eras, 3749 and 3798 patients had undergone elective OSR and 1148 and 907 had undergone ruptured OSR, respectively. These samples were of similar sizes owing to the National Quality Improvement Program sampling process and our relatively strict inclusion criteria. In the contemporary era, fewer patients were elderly and fewer were smokers or had hypertension or dyspnea in the elective and rupture cohorts. More patients had had American Society of Anesthesiologists class >3 in the elective contemporary era (39% vs 24%; P < .0001). The contemporary elective repair group demonstrated increased 30-day mortality (3.7% vs 3.2%; adjusted odds ratio [aOR], 1.36; P = .006), major adverse cardiac events (5.7% vs 3.4%; aOR, 1.87; P < .0001), and bleeding requiring transfusion (58.5% vs 13.7%; aOR, 8.96; P < .0001). The incidence of pulmonary complications (12.1% vs 15.2%; aOR, 0.80; P = .02) and sepsis (3.7% vs 8.4%; aOR, 0.47; P < .0001) had decreased in the contemporary era, with a similar rate of unplanned reoperations (8.4% vs 7.7%; aOR, 1.16; P = .09). The incidence of renal complications in the contemporary era had increased, with a statistically significant difference. However, the absolute increase of <0.5% was likely not clinically relevant (5.5% vs 5.1%; aOR, 1.23; P = .049). In the ruptured cohort, contemporary repair was associated with increased 30-day mortality (41.4% vs 40%; aOR, 1.53; P < .0001), major adverse cardiac events (25.8% vs 12.8%; aOR, 2.49; P < .0001), and bleeding requiring transfusion (88.2% vs 27%; aOR, 23.03; P < .0001). The incidence of pulmonary complications (36.9% vs 48.1%; aOR, 0.67; P < .0001), sepsis (14.6% vs 23%; aOR, 0.75; P = .03), and unplanned reoperations (18.1% vs 22.7%; aOR, 0.74; P = .008) had decreased in the contemporary OSR group. No differences were detected in the incidence of renal complications. CONCLUSIONS: The 30-day mortality has worsened after open AAA repair in the elective and rupture settings despite the improvements in perioperative management over the years. These complications likely stem from increased bleeding events and major cardiac events, which were increased in the contemporary era.

Single-Institution Learning Curve for Management of Mega-Fistulae Revision.

BACKGROUND: Mega-fistulae are generalized aneurysmal dilations of a high flow (1500-4000 mL/min) autogenous arteriovenous (AV) access which may result in hemorrhage and/or high-output cardiac failure. Current treatments include ligation, ligation with prosthetic jump graft, and imbrication; however, these may not be suitable for advanced disease, or may result in loss of functioning access, poor cosmesis, or recurrence. We describe our early experience with a technique of complete mega-fistula resection and replacement with an early use prosthetic graft that both maintains existing AV access and eliminates the need for long-term catheter (LTC) placement; including lessons learned. METHODS: A single-center, retrospective review of medical records was conducted from March 2018-February 2021. Outcomes were technical success, LTC use, time to cannulation, and complications. Mega-fistulae were completely resected from the proximal to distal aneurysmal segment, including all pseudoaneurysms, followed by tunneling a prosthetic graft (Propaten later converted to Acuseal; W.L. Gore Assoc.) with an end-to-end anastomosis to the remaining arterial and venous ends of the previous AV access. RESULTS: We had 100% immediate technical success (n=12). Pre-operative long-term catheters were placed in all eight Propaten patients; one was already placed in an Acuseal patient.  Average time to cannulation was six weeks with Propaten and 4.5 days with Acuseal. At 30 days, three Propaten patients developed complications including one instance of skin necrosis, one seroma, and one hematoma. Two Acuseal patients developed complications including one central venous occlusion (CVO) and one graft infection. Of the six patients with long-term follow-up, five continue to use their access, however, two required thrombectomies and central venous angioplasties. One patient required a new contralateral access due to CVO. CONCLUSIONS: Complete mega-fistula resection and replacement with Acuseal graft maintains existing AV access and may eliminate the need for long-term catheter placement. Our early experience with this technique is encouraging, but further follow-up is required to determine the durability of this approach.

Fenestrated Endovascular Aneurysm Repair Affords Fewer Renal Complications than Open Surgical Repair for Juxtarenal Abdominal Aortic Aneurysms in Patients with Chronic Renal Insufficiency.

OBJECTIVE: Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. METHODS: All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. RESULTS: There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001). CONCLUSION: For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.

Open surgical repair of juxtarenal abdominal aortic aneurysms in the elderly is not associated with increased thirty-day mortality compared with fenestrated endovascular grafting.

OBJECTIVE: Endovascular repair of juxtarenal abdominal aortic aneurysms (JAAAs) with fenestrated grafts (fenestrated endovascular aneurysm repair [FEVAR]) has been reported to decrease operative mortality and morbidity compared with open surgical repair (OSR). However, previous comparisons of OSR and FEVAR have not necessarily included patients with comparable clinical profiles and aneurysm extent. Although FEVAR has often been chosen as the first-line therapy for high-risk patients such as the elderly, many patients will not have anatomy favorable for FEVAR. At present, a paucity of data has examined the operative outcomes of OSR in elderly patients for JAAAs relative to FEVAR. Therefore, we chose to perform a propensity-matched comparison of OSR and FEVAR for JAAA repair in patients aged ≥70 years. METHODS: Patients aged ≥70 years who had undergone elective nonruptured JAAA repairs from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted endovascular aneurysm repair (EVAR) and AAA databases. Patients who had undergone FEVAR were identified in the targeted EVAR database as those who had received the Cook Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind). Because our study specifically examined JAAAs, those patients who had undergone OSR with supraceliac proximal clamping or concomitant renal/visceral revascularization were excluded. A 1:1 propensity-match algorithm matched the OSR and FEVAR patients by preoperative clinical and demographic characteristics, operative indications, and aneurysm extent. The 30-day outcomes, including mortality, major adverse cardiovascular events, and pulmonary and renal complications, were compared between the propensity-matched OSR and FEVAR groups. RESULTS: A 1:1 propensity match was achieved, and the final analysis included 136 OSR patients and 136 FEVAR patients. No significant differences were found in 30-day mortality (4.4% vs 3.7%; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.36-4.06; P = .759) between the OSR and FEVAR groups. OSR was associated with a higher incidence of major adverse cardiovascular events compared with FEVAR; however, the trend was not statistically significant (8.1% vs 3.7%; OR, 2.31; 95% CI, 0.78-6.82; P = .131). Compared with FEVAR, the OSR group had significantly greater rates of pulmonary complications (19.1% vs 3.7%; OR, 6.19; 95% CI, 2.30-16.67; P < .001) and renal complications (8.1% vs 2.2%; OR, 3.90; 95% CI, 1.06-14.31; P = .040). CONCLUSIONS: In the samples assessed in the present study, the results with OSR of JAAAs in the elderly did not differ from those of FEVAR with respect to 30-day mortality despite a greater incidence of pulmonary and renal complications. Although FEVAR should remain the first-line therapy for JAAAs in elderly patients, OSR might be an acceptable alternative for select patients with anatomy unfavorable for FEVAR.

Thirty-day outcomes of open abdominal aortic aneurysm repair by proximal clamp level in patients with normal and impaired renal function.

OBJECTIVE: Open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) has often been reserved in contemporary practice for complex aneurysms requiring a suprarenal or supraceliac proximal clamp level. The present study investigated the associated 30-day outcomes of different proximal clamp levels in OSR of complex infrarenal/juxtarenal AAA in patients with normal renal function and those with chronic renal insufficiency (CRI). METHODS: All patients undergoing elective OSR of infrarenal and juxtarenal AAA were identified in the American College of Surgeons National Surgical Quality Improvement Program-targeted AAA database from 2012 to 2018. The patients were stratified into two cohorts (normal renal function [estimated glomerular filtration rate, ≥60 mL/min] and CRI [estimated glomerular filtration rate, <60 mL/min and no dialysis]) before further substratification into groups by the proximal clamp level (infrarenal, inter-renal, suprarenal, and supraceliac). The 30-day outcomes, including mortality, renal and pulmonary complications, and major adverse cardiovascular event rates, were compared within each renal function cohort between proximal clamp level groups using the infrarenal clamp group as the reference. Supraceliac clamping was also compared with suprarenal clamping. RESULTS: A total of 1284 patients with normal renal function and 524 with CRI were included in the present study. The proximal clamp levels for the 1808 patients were infrarenal for 1080 (59.7%), inter-renal for 337 (18.6%), suprarenal for 279 (15.4%), and supraceliac for 112 (6.2%). In the normal renal function cohort, no difference was found in 30-day mortality with any clamp level. Increased 30-day acute renal failure was only observed in the supraceliac vs infrarenal clamp level comparison (5.9% vs 1.5%; adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 1.04-5.18; P = .044). In the CRI cohort, supraceliac clamping was associated with an increased rate of renal composite complications (22.7% vs 5.6%; aOR, 8.81; 95% CI, 3.17-24.46; P < .001) and ischemic colitis (13.6% vs 3.0%; aOR, 4.78; 95% CI, 1.38-16.62; P = .014) compared with infrarenal clamping and greater 30-day mortality (13.6% vs 2.4%; aOR, 6.00; 95% CI, 1.14-31.55; P = .034) and renal composite complications (22.7% vs 10.8%; aOR, 2.87; 95% CI, 1.02-8.13; P = .047) compared with suprarenal clamping. Suprarenal clamping was associated with greater renal dysfunction (10.8% vs 5.6%; aOR, 2.77; 95% CI, 1.08-7.13; P = .035) compared with infrarenal clamping, with no differences in mortality. No differences were found in 30-day mortality or morbidity for inter-renal clamping compared with infrarenal clamping in either cohort. No differences were found in major adverse cardiovascular events with higher clamp levels in either cohort. CONCLUSIONS: In elective OSR of infrarenal and juxtarenal AAAs for patients with CRI, this study found a heightened mortality risk with supraceliac clamping and increased renal morbidity with suprarenal clamping, though these effects were not present for patients with normal renal function. Every effort should be made to keep the proximal clamp level as low as possible, especially in patients with CRI.

Outcomes of open and endovascular interventions in patients with chronic limb threatening ischemia.

OBJECTIVES: Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage. METHODS: Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events. RESULTS: A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain. CONCLUSIONS: Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.

Failed Prior Endovascular Interventions Do Not Affect 30-day Cardiovascular or Limb-related Outcomes of Infrainguinal Bypasses for Chronic Limb Threatening Ischemia.

BACKGROUND: It is often hypothesized that failed prior endovascular intervention could adversely affect the outcome of subsequent infrainguinal bypass in the corresponding limb. However, this perception is not well supported in the literature because of conflicting data. The aim of this study is to address this controversial issue via analysis of a multicenter prospectively collected database. METHODS: Patients who underwent infrainguinal bypass for chronic limb threatening ischemia (CLTI) were identified in the targeted American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2017. These patients were stratified into 4 groups: first time femoral-popliteal bypass, femoral-popliteal bypass after failed prior endovascular revascularization, first time femoral-tibial bypass, and femoral-tibial bypass after failed prior endovascular revascularization. Thirty-day outcomes including mortality, graft patency, major amputations, and major organ dysfunction were measured. RESULTS: We identified 7,044 patients who underwent surgical bypasses for CLTI. Patients were mostly well matched among the 4 groups except for differences in sex, hypertension, and preoperative renal function. In terms of major adverse cardiovascular events and major adverse limb events, femoral-popliteal or femoral-tibial bypasses after failed prior endovascular intervention had comparable 30-day outcomes to first-time bypasses. However, patients with failed prior endovascular intervention had increased rates of postoperative wound infection, required significantly more blood transfusions, and had longer operative time. CONCLUSIONS: Failed prior endovascular intervention does not adversely affect 30-day outcomes of subsequent infrainguinal bypass surgery in mortality, limb salvage, or other major cardiovascular complications.

Inferior mesenteric artery replantation does not decrease the risk of ischemic colitis after open infrarenal abdominal aortic aneurysm repair.

BACKGROUND: Ischemic colitis after an open abdominal aortic aneurysm (AAA) repair remains a serious complication with a nationally reported rate of 1% to 6% in elective cases and up to 60% after an aneurysmal rupture. To prevent this serious complication, inferior mesenteric artery (IMA) replantation is performed at the discretion of the surgeon based on his or her intraoperative findings, despite the lack of clear evidence to support this practice. The purpose of this study was to determine whether replantation of the IMA reduces the risk of ischemic colitis and improves the overall outcome of AAA repair. METHODS: Patients who underwent open infrarenal AAA repair were identified in the multicenter American College of Surgeons National Surgical Quality Improvement Program Targeted AAA Database from 2012 to 2015. Emergency cases, patients with chronically occluded IMAs, ruptured aneurysms with evidence of hypotension, and patients requiring visceral revascularization were excluded. The remaining elective cases were divided into two groups: those with IMA replantation (IMA-R) and those with IMA ligation. We measured the 30-day outcomes including mortality, morbidity, and perioperative outcomes. A multivariable logistic regression model was used for data analysis, adjusting for clinically relevant covariates. RESULTS: We identified 2397 patients who underwent AAA repair between 2012 and 2015, of which 135 patients (5.6%) had ischemic colitis. After applying the appropriate exclusion criteria, there were 672 patients who were included in our study. This cohort was divided into two groups: 35 patients with IMA-R and 637 patients with IMA ligation. There were no major differences in preoperative comorbidities between the two groups. IMA-R was associated with increased mean operative time (319.7 ± 117.8 minutes vs 242.4 ± 109.3 minutes; P < .001). Examination of 30-day outcomes revealed patients with IMA-R had a higher rate of return to the operating room (20.0% vs 7.2%; P = .006), a higher rate of wound complications (17.1% vs 3.0%; P = .001), and a higher incidence of ischemic colitis (8.6% vs 2.4%; P = .027). There were no significant differences in mortality, pulmonary complications, or renal complications between the two groups. In multivariable analysis, IMA-R was a significant predictor of ischemic colitis and wound complications. CONCLUSIONS: These data suggest that IMA-R is not associated with protection from ischemic colitis after open AAA repair. The role of IMA-R remains to be identified.

Extremity Vascular Injury Management: Good Outcomes Using Selective Referral to Vascular Surgeons.

Revascularization after extremity vascular injury has long been considered an important skill among trauma surgeons. Increasingly, some trauma surgeons defer vascular repair in response to training or practice patterns. This study was designed to document results of extremity revascularization surgery to evaluate trauma surgeon outcomes and judicious referral of more complex injuries to vascular surgeons (VAS). The trauma registry of an urban level I trauma center was used to identify all patients from 2003 to 2013 who underwent an early (<24 hours) procedure for urgent management of acute injury to extremity vessels. Patients were managed by trauma (TRA) versus VAS based on the practice pattern of the on-call trauma surgeon. Injury and outcome variables were recorded. Of 115 patients, 84 patients were revascularized by trauma and 31 vascular surgeries. There was no difference in complication rates or frequency of any type of complication associated with repairs performed by VAS or TRA. There were similar rates between the two groups for patients with multiple injuries, such as venous, bone or tendon, and nerve injury to the affected extremity. One VAS patient and two TRA patients developed compartment syndrome. In appropriately selected patients, trauma surgeons achieve good outcomes after revascularization of injured extremities.

Contemporary results of carotid endarterectomy in "normal-risk" patients from the Society for Vascular Surgery Vascular Registry.

OBJECTIVE: Acceptable complication rates after carotid endarterectomy (CEA) are drawn from decades-old data. The recent Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) demonstrated improved stroke and mortality outcomes after CEA compared with carotid artery stenting, with 30-day periprocedural CEA stroke rates of 3.2% and 1.4% for symptomatic (SX) and asymptomatic (ASX) patients, respectively. It is unclear whether these target rates can be attained in "normal-risk" (NR) patients experienced outside of the trial. This study was done to determine the contemporary results of CEA from a broader selection of NR patients. METHODS: The Society for Vascular Surgery (SVS) Vascular Registry was examined to determine in-hospital and 30-day event rates for NR, SX, and ASX patients undergoing CEA. NR was defined as patients without anatomic or physiologic risk factors as defined by SVS Carotid Practice Guidelines. Raw data and risk-adjusted rates of death, stroke, and myocardial infarction (MI) were compared between the ASX and SX cohorts. RESULTS: There were 3977 patients (1456 SX, 2521 ASX) available for comparison. The SX group consisted of more men (61.7% vs 57.0%; P = .0045) but reflected a lower proportion of white patients (91.3% vs 94.4%; P = .0002), with lower prevalence of coronary artery disease (P < .0001), prior MI (P < .0001), peripheral vascular disease (P = .0017), and hypertension (P = .029), although New York Heart Association grade >3 congestive heart failure was equally present in both groups (P = .30). Baseline stenosis >80% on duplex imaging was less prevalent among SX patients (54.2% vs 67.8%; P < .0001). Perioperative stroke rates were higher for SX patients in the hospital (2.8% vs 0.8%; P < .0001) and at 30 days (3.4% vs 1.0%; P < .0001), which contributed to the higher composite death, stroke, and MI rates in the hospital (3.6% vs 1.8; P = .0003) and at 30 days (4.5% vs 2.2%; P < .0001) observed in SX patients. After risk adjustment, the rate of stroke/death was greater among SX patients in the hospital (odds ratio, 2.05; 95% confidence interval, 1.18-3.58) although not at 30 days (odds ratio, 1.36; 95% confidence interval, 0.85-2.17). No in-hospital or 30-day differences were observed for death or MI by symptom status. CONCLUSIONS: The SVS Vascular Registry results for CEA in NR patients are similar by symptom status to those reported for CREST and may serve as a benchmark for comparing results of alternative therapies for treatment of carotid stenosis in NR patients outside of monitored clinical trials. The contemporary perioperative risk of stroke after CEA in NR patients continues to be higher for SX than for ASX patients.

The influence of contralateral occlusion on results of carotid interventions from the Society for Vascular Surgery Vascular Registry.

OBJECTIVE: Data on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS. METHODS: We evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes. RESULTS: There were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs. 4.2% for CEA), death (1.1% for CAS vs. 0.7% for CEA), stroke (2.1% for CAS vs. 3.1% for CEA), and MI (0.3% for CAS vs. 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs. 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs. 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs. 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs. 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs. 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs. 2.0%; P = .0095) and symptomatic (1.7% vs. 4.9%; P = .0012) patients. CONCLUSIONS: Although CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.

Elective endovascular aneurysm repair in the elderly: trends and outcomes from the Nationwide Inpatient Sample.

OBJECTIVES: This study attempted to identify trends in the use of endovascular aneurysm repair (EVAR) and outcomes in elective abdominal aortic aneurysm (AAA) repair over a 5-year period in a nationwide dataset, with specific attention to patients older than 80 years. METHODS: The Nationwide Inpatient Sample database was queried for elective AAA repair during 2005 to 2009. Number of EVAR cases, ratio of EVAR/open aneurysm repair (OAR), major clinical outcomes, and discharge status were analyzed by decade. Interval data were compared with analysis of variance (ANOVA) and proportions via chi-squared tests. RESULTS: A total of 174,714 AAA repairs (124,869 EVARs) were identified. The ratio of EVAR/OAR increased with increasing age. Between 2005 and 2009, the total number of AAA repairs increased by 21% (7,179 vs. 8,554) and EVARs increased by 50% (5,057 vs. 7,650; P < 0.05) in patients older than 80 years. In 2009, 85% of AAA repairs in patients older than 80 years were EVARs. Patients older than 80 years constituted 25% of the total EVAR cohort. Although the in-hospital mortality rate remained acceptable in all age groups, EVAR-associated mortality, length of stay, and discharge to a skilled nursing facility increased with each successive decade of life (P < 0.05). Rates of postoperative myocardial infarction and acute renal failure also increased with increasing age (P < 0.05). EVAR results are presented by decade. CONCLUSIONS: EVAR is being performed with increasing frequency in patients older than 80 years, with one-quarter of EVAR performed in patients aged 80 years and older in the current sample. Although mortality rates remain acceptable in this elderly population, EVAR and OAR are associated with an age-dependent increase in death, complications, and discharge to extended care facilities. These factors, in addition to long-term risk of aneurysm rupture, should be considered when evaluating the appropriateness of elective aneurysm repair in the elderly.

Trends in treatment of ruptured abdominal aortic aneurysm: impact of endovascular repair and implications for future care.

OBJECTIVE: Our aim was to determine national trends in treatment of ruptured abdominal aortic aneurysm (RAAA), with specific emphasis on open surgical repair (OSR) and endovascular aneurysm repair (EVAR) and its impact on mortality and complications. METHODS: Data from the Nationwide Inpatient Sample (NIS) from 2005 to 2009 were queried to identify patients older than 59 years with RAAA. Three groups were studied: nonoperative (NO), EVAR, and OSR. Chi-square analysis was used to determine the relationship between treatment type and patient demographics, clinical characteristics, and hospital type. The impact of EVAR compared with OSR on mortality and overall complications was examined using logistic regression analysis. RESULTS: We identified 21,206 patients with RAAA from 2005 to 2009, of which 16,558 (78.1%) underwent operative repair and 21.8% received no operative treatment. In the operative group, 12,761 (77.1%) underwent OSR and 3,796 (22.9%) underwent EVAR. Endovascular aneurysm repair was more common in teaching hospitals (29.1% vs 15.2%, p < .0001) and in urban versus rural settings. Nonoperative approach was twice as common in rural versus urban hospitals. Reduced mortality was seen in patients transferred from another institutions (31.2% vs 39.4%, p = 0.014). Logistic regression analysis demonstrated a benefit of EVAR on both complication rate (OR = 0.492; CI, 0.380-0.636) and mortality (OR=0.535; CI, 0.395-0.724). CONCLUSIONS: Endovascular aneurysm repair use is increasing for RAAA and is more common in urban teaching hospitals while NO therapy is more common in rural hospitals. Endovascular aneurysm repair is associated with reduced mortality and complications across all age groups. Efforts to reduce mortality from RAAA should concentrate on reducing NO and OSR in patients who are suitable for EVAR.

Pylephlebitis and acute mesenteric ischemia in a young man with inherited thrombophilia and suspected foodborne illness.

We report on a young man who developed complicated pylephlebitis after foodborne illness. Despite antibiotics and resection of the focus of infectious colitis, he developed extensive small bowel infarction. He was treated with anticoagulation, local thrombolytic infusion, and resection of irreversibly ischemic small bowel. Thrombophilia workup demonstrated heterozygosity for factor V Leiden and the prothrombin G20210A mutation. The complications of pylephlebitis can be minimized by using systemic anticoagulation, thrombectomy, and/or local thrombolytic infusion along with antibiotics and surgical management of the infection. Evaluation for thrombophilic states should be considered, particularly if a patient does not respond to initial therapy.

Durability of saphenous vein grafts: 44-year follow-up of a saphenous vein interposition graft in a pediatric patient.

We report the 44-year follow-up of a 9-year-old girl who underwent a saphenous vein interposition graft in 1964 after suffering extensive pelvic trauma with complete disruption of the right common femoral artery. The patient recovered from this injury and experienced no disability or pain until 2008, when she suddenly developed numbness in the right leg. Evaluation at that time showed a new occlusion of the saphenous vein graft, and she underwent uneventful repeat revascularization with autogenous vein. To our knowledge, this 44-year patency is the longest reported for a saphenous vein graft.

Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease.

Management of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents.[corrected] The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy.

Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary.

In 2008, the Society for Vascular Surgery published guidelines for the treatment of carotid bifurcation stenosis. Since that time, a number of prospective randomized trials have been completed and have shed additional light on the best treatment of extracranial carotid disease. This has prompted the Society for Vascular Surgery to form a committee to update and expand guidelines in this area. The review was done using the GRADE methodology.[corrected] The perioperative risk of stroke and death in asymptomatic patients must be below 3% to ensure benefit for the patient. Carotid artery stenting (CAS) should be reserved for symptomatic patients with stenosis 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as first line therapy. In this Executive Summary, we only outline the specifics of the recommendations made in the six areas evaluated. The full text of these guidelines can be found on the on-line version of the Journal of Vascular Surgery at http://journals.elsevierhealth.com/periodicals/ymva.