Cutdown is Associated with Higher 30-day Unplanned Readmissions and Wound Complications than Percutaneous Access for EVAR.

BACKGROUND: A 2023 Cochrane review showed no difference in bleeding/wound infection complications, short-term mortality and aneurysm exclusion between the percutaneous and cut-down approach for femoral access in endovascular aortic aneurysm repair (EVAR). In contrast, single-center studies have shown bilateral cutdown resulting in higher readmission rates due to higher rates of groin wound infections. Whether 30-day readmission rates vary by type of access during EVAR procedures is unknown. The goal of this study was to ascertain which femoral access approach for EVAR is associated with the lowest risk of 30-day readmission. METHODS: The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing EVAR for aortic disease from 2012-2021. All ruptures and other emergency cases were excluded. Cohorts were divided into bilateral cutdown, unilateral cutdown, failed percutaneous attempt converted to open and successful percutaneous access. The primary 30-day outcomes were unplanned readmission and wound complications. Univariate analyses were performed using the Fisher's exact test, Chi-Square test and the Student's t-test. Multivariable analysis was performed using logistic regression. RESULTS: From 2012 to 2021, 14,002 patients met study criteria. Most (7,395 [53%]) underwent completely percutaneous access, 5,616 (40%) underwent bilateral cutdown, 849 (6%) underwent unilateral cutdown, and 146 (1%) had a failed percutaneous access which was converted to open. Unplanned readmissions by access strategy included 7.6% for bilateral cutdown, 7.3% for unilateral cutdown, 7.8% for attempted percutaneous converted to cutdown, and 5.7% for completely percutaneous access (P < 0.001, Figure 1). After multivariable analysis, unplanned readmissions compared to percutaneous access yielded: percutaneous converted to cutdown adjusted odds ratio (AOR): 1.38, 95% CI [0.76-2.53], P = 0.29; unilateral cutdown AOR: 1.18, 95% CI [0.92-1.51], P = 0.20; bilateral cutdown AOR: 1.26, 95% CI [1.09-1.43], P = 0.001. Bilateral cutdown was also associated with higher wound complications compared to percutaneous access (AOR: 4.41, CI [2.86-6.79], P < 0.001), as was unilateral cutdown (AOR: 3.04, CI [1.46-6.32], P = 0.003). CONCLUSIONS: Patients undergoing cutdown for EVAR are at higher risk for 30-day readmission compared to completely percutaneous access. If patient anatomy allows for percutaneous EVAR, this access option should be prioritized.

Concerning Trends in Vascular Surgery Trainee Operative Experience in Venous Disease.

BACKGROUND: Comprehensive vascular care includes both arterial and venous disease management. However, operative training in venous disease is often significantly overshadowed by arterial procedures, despite the public health burden of acute and chronic venous disease. The purpose of this study is to evaluate the case-mix and volume of venous procedures performed by graduating integrated vascular surgery residents and fellows in the United States. METHODS: Accreditation Council for Graduate Medical Education national operative log reports were compiled for graduating integrated VSR (vascular surgery residency) and traditional vascular surgery fellowship (VSF) trainees from academic years 2013 to 2022. Only cases categorized as "surgeon fellow", "surgeon chief", or "surgeon junior" were included. Linear regression analysis was utilized to evaluate trends in case-mix and volume. RESULTS: Over the 10-year study period, total vascular cases increased for both VSR (mean 870.5 ± 9.3 cases, annual change +9.5 cases/year, R2 = 0.77, P < 0.001) and VSF (mean 682.1 ± 6.9 cases, annual change +6.7 cases/year, R2 = 0.85, P < 0.001) trainees. Concurrently, the proportion of venous cases in the VSR group decreased from 12.5% to 7.3% (annual change -3.7 cases/year, R2 = 0.72, P < 0.001). VSR trainees experienced an annual decrease in 4 of the top 5 venous case types performed, including venous angioplasty/stenting (-1.6 cases/year, P = 0.002), vena cava filter placement (-0.9 cases/year, P = 0.002), endoluminal ablation (-0.2 cases/year, P = 0.47), diagnostic venography (-1.7 cases/year, P < 0.001), and varicose vein treatment (-1.0 cases/year, P < 0.001). Venous cases proportions also decreased in the VSF group from 8.4% to 6.2% (annual change -2.2 cases/year, R2 = 0.54, P = 0.002). VSF trainees experienced an annual decrease in 4 of the top 5 venous case types, including venous angioplasty/stenting (-1.5 cases/year, P = 0.003), diagnostic venography (-1.2 cases/year, P < 0.001), vena cava filter placement (-0.2 cases/year, P = 0.44), endoluminal ablation (-0.6 cases/year, P < 0.001), and varicose vein treatment (-0.1 cases/year, P = 0.04). Both VSR and VSF trainee groups graduated with fewer than 5 cases for each of the following venous procedures-percutaneous mechanical thrombectomy, venous thrombolysis, open venous reconstruction, sclerotherapy, venous embolectomy, portal-systemic shunting, venous ulceration treatment, and arteriovenous malformation treatment. CONCLUSIONS: Current vascular residents and fellows have limited exposure to venous procedures, in part due to a proportional decline in venous cases. More robust venous operative experience is needed during surgical training. Further studies are needed to understand whether this discrepancy in venous and arterial training impacts career progression and patient outcomes.

28-Year Experience with Ruptured and Symptomatic Type I-III Thoracoabdominal Aortic Aneurysms at a Large Tertiary Referral Center.

BACKGROUND: Given the relative rarity of ruptured and symptomatic type I-III thoracoabdominal aortic aneurysms (TAAA), data is scarce with regard the outcomes of those who survive to repair. The goal of this study was to determine short and long-term outcomes after open repair of type I-III TAAA surgery for ruptured and symptomatic TAAA and compare the results to elective TAAA repairs. METHODS: All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated using an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse event (MAE), in-hospital death, spinal cord ischemia (SCI) and long-term survival. Ruptured, symptomatic and elective repair cohorts were created for comparison. Univariate analysis was performed using the Fisher's exact test for categorical variables and analysis of variance (ANOVA) for continuous variables. Logistic regression was used for in-hospital endpoints; survival analysis was performed with Cox proportional hazards modelling and Kaplan-Meier techniques. RESULTS: Five hundred-sixteen patients had an open type I-III TAAA repair during the study period. Fifty-nine (11.4%) were performed for rupture and 51 (9.9%) were performed for symptomatic aneurysms (RAs). Ruptured and symptomatic groups were more likely to be older, female, and have larger presenting aortic diameters. Most of the ruptured and symptomatic cases were transferred from an outside facility (59.3% and 54.9%, respectively). Intraoperatively, the elective cohort was more likely to receive left heart bypass as an operative adjunct; ruptures were less likely to receive a renal bypass, and operative time was highest for the elective cohort. Perioperative mortality was 18.6% for ruptured, 2.0% for symptomatic, and 7.4% for elective indications. Ruptures were most likely to require new hemodialysis after repair (20.3% vs. 10.3% for elective, P = 0.02). On adjusted analysis, ruptures were more likely to suffer from perioperative death (adjusted odds ratio [AOR]: 4.5, 95% confidence interval (CI): 1.7-11.4) and MAEs (AOR: 2.8, 95% CI: 1.4-5.4). Ruptured and symptomatic aneurysms were not independently associated with SCI; however, preoperative hemodynamic instability was predictive (AOR: 8.7, 95% CI: 1.7-44.2). Both rupture and symptomatic cases were associated with decreased survival on Kaplan-Meier analysis with 5-year survival for ruptures at 35%, symptomatic at 47.7% and elective at 63.7%, P < 0.001. Adjusted hazards of death were 1.2 (95% CI: 0.9-1.8) in the symptomatic cohort and 2.3 (95% CI: 1.5-3.7) in the ruptured cohort. CONCLUSIONS: Open ruptured and symptomatic type I-III TAAA repairs can be performed with acceptable morbidity and mortality. Most symptomatic and rupture repairs were performed after transfer from another institution. Postoperative SCI is most strongly related to the preoperative hemodynamic status of the patient.

A Systematic Review of Clopidogrel Resistance in Vascular Surgery: Current Perspectives and Future Directions.

BACKGROUND: Clopidogrel resistance is a well-described phenomenon that has been linked to adverse cardiovascular events in patients with coronary artery disease. The impact of clopidogrel resistance in patient outcomes after vascular and endovascular surgery is not well-established. METHODS: Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a literature review with the medical subject headings (MeSH) terms "(clopidogrel resistance) and (vascular)", "(clopidogrel resistance) and (vascular surgery)", "(clopidogrel resistance) and (endovascular)", and "(clopidogrel resistance) and (endovascular surgery)" was performed in PubMed and Cochrane databases, to identify all peer-reviewed studies performed on clopidogrel resistance in vascular and endovascular surgery. Studies written in the English language from inception to 2022 were included. Case reports, studies with limited information, nonhuman studies, and studies not pertaining to vascular or endovascular surgery were excluded from analysis. Each study was independently reviewed by 2 qualified researchers to assess eligibility. RESULTS: Of the 691 studies identified through the MeSH strategy, 16 studies met the inclusion criteria and were reviewed and summarized. These studies focused on extracranial cerebrovascular disease (n = 5) and peripheral arterial disease (PAD, n = 11), encompassing a total of 1,716 patients. The prevalence of clopidogrel resistance ranged from 0% to 83.3%, depending on the diagnostic assay and cutoff values used. In cerebrovascular disease, clopidogrel resistance may be associated with cerebral embolization, ischemic neurologic events, and vascular-related mortality. In PAD, clopidogrel resistance has been linked to recurrent stent thrombosis, target lesion revascularization, amputation-free survival, and all-cause mortality. CONCLUSIONS: This systematic review provides an up-to-date summary of clopidogrel resistance in vascular and endovascular surgery. The impact of clopidogrel resistance remains incompletely investigated, and future studies are needed to clarify the role of resistance testing in patients with vascular disease.

Multi-institutional outcomes after femoropopliteal bypass in octogenarians.

OBJECTIVES: Open lower extremity revascularization is controversial among octogenarians; however, the indications for surgical bypass are higher in the elderly population. The aim of the study was to compare postoperative outcomes between octogenarians and non-octogenarians following femoropopliteal bypass surgery. METHODS: Our regional, multi-institutional database was queried for femoropopliteal bypass procedures performed between 1995 and 2020. Electronic medical records were individually reviewed for operative and postoperative data. Univariable and multivariable logistic regression were utilized to determine predictors of postoperative outcomes. RESULTS: Among 1315 patients who underwent femoropopliteal bypass, 234 (17.8%) were octogenarians. Octogenarians more frequently underwent bypass for lower extremity tissue loss (48.7% vs 30.2%), whereas claudication was more common among non-octogenarians (24.0% vs 9.8%) (p < .001). Below-knee bypass target (72.2% vs 59.3%) and prosthetic conduit utilization (58.5% vs 43.7%) were more frequent in octogenarians (p < .001 each). Overall hospital length of stay was longer among patients > 80 years (median 6 days [interquartile range [IQR] 4-9] vs 5 days [IQR 4-8], p = .017). The overall 30-day (5.6% vs 1.5%) and one-year mortality rates (25.6% vs 7.9%) were higher among octogenarians (p < .001 each). On multivariable analysis, age greater than 80 years was found to be an independent risk factor for postoperative mortality (OR 3.79 [1.75-8.20], p = .0007). CONCLUSIONS: Octogenarians undergoing bypass femoropopliteal bypass surgery have considerably worse postoperative outcomes, compared with non-octogenarians. These data may help inform elderly patients prior to undergoing open lower extremity revascularization.

Derivation and Validation of a Risk Score for Abdominal Compartment Syndrome after Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms.

BACKGROUND: Abdominal compartment syndrome (ACoS) is a devastating complication after endovascular aneurysm repair for ruptured abdominal aortic aneurysms (rEVAR). This study sought to develop a risk score for ACoS to identify patients who would benefit from early decompressive laparotomy. METHODS: Model derivation was performed with Vascular Quality Initiative data for rEVAR from 2013 to 2020. The primary outcome was evacuation of abdominal hematoma. A multivariable logistic regression was used to create and validate a scoring system to predict ACoS. The model was validated using institutional data for rEVAR from 1998 to 2019. RESULTS: The derivation cohort included 2,310 patients with rEVAR. Abdominal hematoma evacuation occurred in 265 patients (11.5%). Factors associated with abdominal hematoma evacuation on a multivariable analysis included transfer from an outside hospital, preoperative creatinine ≥1.4 mg/dL, preoperative systolic blood pressure ≤85 mmHg, preoperative altered mental status, ≥3.0 liters intraoperative crystalloid, and ≥4 units of red blood cells transfused intraoperatively. The validation cohort consisted of 67 rEVAR; ACoS occurred in 8 patients (11.9%). The c-statistic was 0.84 in the derivation and 0.87 in the validation cohort, whereas Hosmer-Lemeshow was P = 0.15 in the derivation and 0.84 in the validation cohorts, suggesting good model discrimination and calibration. Points were applied based on ß-coefficients to produce a risk score ranging from -1 to 13. A cutoff of risk score ≥8 resulted in a sensitivity and specificity of 87.5% and 83.1% for detecting patients with ACoS, respectively. ACoS conveyed a significantly higher mortality in both the derivation (ACoS: 49.8% vs. No ACoS: 17.8%; P < 0.001) and validation cohorts (ACoS: 75.0% vs. No ACoS: 15.2%; P < 0.001). CONCLUSIONS: In patients with equivocal signs/symptoms of ACoS, this scoring system can be used to guide surgeons on when to perform decompressive laparotomy prior to leaving the operating room for rEVAR. Patients with a risk score ≥8 would benefit from decompressive laparotomy at index rEVAR.

Risk factors and consequences of graft infection after femoropopliteal bypass: A 25-year experience.

OBJECTIVE: In this multi-institutional series, we aimed to determine the incidence, risk factors, and long-term outcomes of graft infection in patients post-femoropopliteal bypass. METHODS: A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures from 1995 through 2020. Cumulative incidence function estimated the long-term rate of bypass graft infection (BGI), and the Fine-Gray model was used to determine independent risk factors for BGI to account for death as a competing risk. RESULTS: Over the 25-year period, 1315 femoral popliteal bypasses were identified with a median follow-up of 2.89 years (interquartile range, 0.75-6.55 years). BGI was diagnosed in 34 patients (2.6%). BGI occurred between 9 days and 11.2 years postoperatively, with a median of 109 days. Estimated 1- and 5-year incidence of BGI was 2.1% (95% confidence interval [CI], 1.4%-3.1%) and 2.8% (95% CI, 1.9%-3.9%), respectively. Medical comorbidities, indications for bypass, and popliteal bypass targets (above- vs below-knee) were similar between patients with BGI and all patients (P = not significant for each). Patients with BGI were more frequently complicated by postoperative hematoma (14.7% vs 3.7%), superficial wound infection (38.2% vs 19.2%), lymphocele/lymphorrhea (8.8% vs 2.1%), and 30-day readmission rates (47.1% vs 21.3%) (P < .05 for each). Most commonly isolated pathogens were Staphylococcus aureus (n = 19; 55.9%) and polymicrobial cultures (n = 5; 14.7%). Reoperation for BGI involved incision and drainage (n = 7; 20.6%), graft excision without reconstruction (n = 12; 35.3%), graft excision with in-line reconstruction (n = 11; 32.4%), and graft excision with extra-anatomic reconstruction (n = 2; 5.9%). Nine patients with BGI (26.5%) ultimately required major amputation. Prosthetic bypass (subdistribution hazard ratio [SHR], 3.73; 95% CI, 1.64-8.51; P = .002), postoperative hematoma (SHR, 3.44; 95% CI, 1.23-9.61; P = .018), and 30-day readmission (SHR, 2.75; 95% CI, 1.27-5.44; P = .010) were independently associated with BGI. One-year amputation-free survival was 50% (95% CI, 31.9%-65.7%) after BGI. CONCLUSIONS: BGI is a rare complication of femoral-popliteal bypass with significant morbidity. Graft infection is associated with the use of prosthetic grafts, postoperative hematoma, and unplanned hospital readmission. Mitigation of these risk factors may decrease the risk of this dreaded complication.

Pregnancy conditions and complications associated with the development of varicose veins.

BACKGROUND: Pregnancy is a known risk factor for developing varicose veins (VV). However, pregnancy is often considered a homogeneous entity and few studies have examined if specific characteristics and complications of pregnancy may influence VV formation. This study sought to identify which pregnancy-specific factors are associated with the development of VV. METHODS: All women who gave birth (live or still) between 1998 and 2020 within a multicenter health care system were identified retrospectively and followed through all hospital encounters (inpatient and outpatient). The primary outcome was VV, defined as any encounter with a primary diagnosis code for VV or a procedure for VV. The study period for each woman was the time from the first to last encounter. Extended Cox regression modeling evaluated the association between VV and pregnancy-related factors as a time-varying covariates while controlling for patient comorbidities. RESULTS: There were 156,622 women with a median follow-up of 8.3 years (interquartile range, 2.7-16.6 years) included. During this time, 225,758 deliveries occurred. The 10- and 20-year freedom from VV was 97.0% (95% CI, 96.8%-97.1%) and 92.7% (95% CI, 92.4%-93.0%), respectively, from the estimated start of first pregnancy. Overall, 4028 patients (2.57%) developed VV during the follow-up period and 1594 (1.02%) underwent a procedure for VV. After risk adjustment, increasing parity was significantly associated with VV, with each subsequent pregnancy increasing hazard of developing VV (parity = 1: hazard ratio [HR], 1.78; 95% CI, 1.55-1.99; P < .001; parity ≥6: HR, 4.83; 95% CI, 2.15-1.99-10.9; P < .001), Other significant pregnancy factors included excessive weight gain in pregnancy (HR, 1.44; 95% CI, 1.09-1.91; P = .011), post-term pregnancy (HR, 1.12; 95% CI, 1.02-1.21; P = .021), pre-eclampsia (HR, 0.79; 95% CI, 0.70-0.90; P < .001), and postpartum transfusion of platelets, plasma, or cryoprecipitate (HR, 2.05; 95% CI, 1.19-3.53; P = .001). CONCLUSIONS: Increasing parity, excessive weight gain in pregnancy, post-term pregnancy, and pre-eclampsia affect the development of VV after pregnancy. Although VV after pregnancy are likely underreported and true incidence is unknown, women should be counseled about the impact of these factors on VV development after pregnancy.

Rates of Conversion from Dry to Wet Gangrene Following Lower Extremity Revascularization.

BACKGROUND: There is a paucity of data regarding the conversion rate from dry gangrene to wet gangrene after lower extremity revascularization. This study aimed to determine the rate of conversion from dry to wet gangrene within 30 days post-procedure in patients who underwent endovascular or open revascularization for critical limb ischemia. Secondary aims included determining the time to conversion and associated risk factors with conversion. METHODS: A multicenter, retrospective review was performed utilizing the MGH/Brigham Healthcare System's Research Patient Data Registry (RPDR). All adult patients who had lower extremity dry gangrene that underwent a revascularization procedure (endo, open, hybrid) from April 2002 to March 2020 were included. Patients who had no lower extremity gangrene, a concurrent amputation with the revascularization procedure, or wet gangrene on initial presentation were excluded. Univariate analysis was performed using the Fisher's exact test and Wilcoxon rank-sum test. RESULTS: There were 1,518 patients identified who underwent revascularization; 194 (12.8%) patients met inclusion criteria and served as our study cohort. There were 15 (7.7%) conversions from dry to wet gangrene within 30 days post-procedure. The mean time to conversion was 13.5 ± 8.6 days. Univariate analysis did not identify any associated risk factors for conversion. CONCLUSIONS: The rate of dry to wet gangrene conversion post revascularization is 7.7% within 30 days. The mean time of conversion is 13.5 ± 8.6 days.

A systematic review of spinal cord ischemia prevention and management after open and endovascular aortic repair.

OBJECTIVE: Spinal cord ischemia (SCI) is one of the most devastating complications after descending thoracic aortic (DTA) and thoracoabdominal aortic (TAA) repairs. Patients who develop SCI have a poor prognosis, with mortality rates reaching 75% within the first year after surgery. Many factors have been shown to increase the risk of this complication, including the extent of TAA repair, length of aortic and collateral network coverage, embolization, and reduced spinal cord perfusion pressure. As a result, a variety of treatment strategies have been developed. We aimed to provide an up-to-date review of SCI rates with associated treatment algorithms from open and endovascular DTA and TAA repair. METHODS: Using PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, a literature review with the MeSH (medical subject headings) terms "spinal cord ischemia," "spinal cord ischemia prevention and mitigation strategies," "spinal cord ischemia rates," and "spinal cord infarction" was performed in the Cochrane and PubMed databases to find all peer-reviewed studies of DTA and TAA repair with SCI complications reported. The search was limited to 2012 to 2021 and English-language reports. MeSH subheadings, including diagnosis, complications, physiopathology, surgery, mortality, and therapy, were used to further restrict the included studies. Studies were excluded if they were not of humans, had not pertained to SCI after DTA or TAA operative repair, and if the study had primarily discussed neuromonitoring techniques. Additionally, studies with <40 patients or limited information regarding SCI protection strategies were excluded. Each study was individually reviewed by two of us (S.L. and A.D.) to assess the type and extent of aortic pathology, operative technique, SCI protection or mitigation strategies, rates of overall and permanent SCI symptoms, associations with SCI on multivariate analysis, and mortality. RESULTS: Of the 450 studies returned by the MeSH search strategy, 41 met the inclusion criteria and were included in the final analysis. For the endovascular DTA repair patients, the overall SCI rates ranged from 0% to 10.6%, with permanent SCI symptoms ranging from 0% to 5.1%. The rate of overall SCI after endovascular and open TAA repair was 0% to 35%. The permanent SCI symptom rate was reported by only one study of open repair at 1.1%. The permanent SCI symptom rate after endovascular TAA repair was 2% to 20.5%. CONCLUSIONS: The present review has provided an up-to-date review of the current rates of SCI and the prevention and mitigation strategies used during DTA and TAA repair. We found that a multimodal approach, including a bundled institutional protocol, staging of multiple repairs, preservation of the collateral blood flow network, augmented spinal cord perfusion, selective cerebrospinal fluid drainage, and distal aortic perfusion during open TAA repairs, appears to be important in reducing the risk of SCI.

Relationship between blood type and outcomes following COVID-19 infection.

Since the onset of the COVID-19 pandemic, a concentrated research effort has been undertaken to elucidate risk factors underlying viral infection, severe illness, and death. Recent studies have investigated the association between blood type and COVID-19 infection. This article aims to comprehensively review current literature and better understand the impact of blood type on viral susceptibility and outcomes.

Prognostication of Asymptomatic Penetrating Aortic Ulcers: A Modern Approach.

BACKGROUND: Literature detailing the natural history of asymptomatic penetrating aortic ulcers (PAUs) is sparse and lacks long-term follow-up. This study sought to determine the rate of asymptomatic PAU growth over time and adverse events from asymptomatic PAU. METHODS: A cohort of patients with asymptomatic PAU from 2005 to 2020 was followed. One ulcer was followed per patient. Primary end points were change in size over time and the composite of symptoms, radiographic progression, rupture, and intervention; cumulative incidence function estimated the incidence of the composite outcome. Ulcer size and rate of change were modeled using a linear mixed-effects model. Patient and anatomic factors were evaluated as potential predictors of the outcomes. RESULTS: There were 273 patients identified. The mean age was 75.5±9.6 years; 66.4% were male. The majority of ulcers were in the descending thoracic aorta (53.9%), followed by abdominal aorta (41.4%) and aortic arch (4.8%). Fusiform aneurysmal disease was present in 21.6% of patients at a separate location; 2.6% had an associated intramural hematoma; 23.6% had at least 1 other PAU. Symptoms developed in 1 patient who ruptured; 8 patients (2.9%) underwent an intervention for PAU (1 for rupture, 2 for radiographic progression, 5 for size/growth) at a median of 3.1 years (interquartile range, 1.0-6.5) after diagnosis. Five- and 10-year cumulative incidence of the primary outcome, adjusted for competing risk of death, was 3.6% (95% CI, 1.6%-6.9%) and 6.5% (95% CI, 3.1%-11.4%), respectively. For 191 patients with multiple computed tomography scans (760 total computed tomographies) with a median radiographic follow-up of 3.50 years (interquartile range, 1.20-6.63 years), mean initial ulcer width, ulcer depth, and total diameter were 13.6 mm, 8.5 mm, and 31.4 mm, respectively. A small but statistically significant change over time was observed for ulcer width (0.23 mm/y) and total diameter (0.24 mm/y); ulcer depth did not significantly change over time. Hypertension, hyperlipidemia, diabetes, initial ulcer width >20 mm, thrombosed PAU, and associated saccular aneurysm were associated with larger changes in ulcer size over time; however, the magnitude of difference was small, ranging from 0.4 to 1.9 mm/y. CONCLUSIONS: Asymptomatic PAU displayed minimal growth and infrequent complications including rupture. Asymptomatic PAU may be conservatively managed with serial imaging and risk factor modification.

Natural history of penetrating atherosclerotic ulcers in aortic branch vessels.

OBJECTIVE: Penetrating atherosclerotic ulcers (PAUs) in aortic branch vessels are rare. There is a paucity of data regarding their long-term natural history and associated management. This study aimed to determine the prevalence and natural history of aortic branch PAUs. METHODS: Institutional data on all patients with an aortic branch PAU from 2005 to 2020 were retrospectively reviewed. Branch PAUs were defined as any PAU in the iliac, mesenteric, or arch vessels. End points included symptoms, end-organ events, and interventions. All computed tomography angiographies (CTAs) for each patient were reviewed, and total diameter, ulcer width, and ulcer depth were recorded on each computed tomography scan for the branch PAUs. Rate of change was compared between groups (iliac vs arch and visceral vessels) using a linear mixed-effects model. RESULTS: Among 58,800 patients who underwent a CTA, 367 patients had an aortic PAU (prevalence: 0.6%) and 58 patients had a branch PAU (prevalence: 0.1%). Among those 58 patients, there were 66 ulcerated branches. There were 50 iliac (42 common iliac, 7 internal, and 1 external), 11 arch (8 left subclavian, 3 innominate), and 5 visceral ulcers (3 superior mesenteric artery, 1 celiac, and 1 renal). Mean age was 74.0 ± 8.8 years, and 86% of patients were male; 74% had hypertension, 79% had hyperlipidemia, and 59% had a concomitant aortic aneurysm. There were 45 PAU vessels with >1 CTA (total of 167 CTAs) with a median follow-up of 4.0 years (interquartile range: 2.0-6.2 years). Total vessel diameter increased in size by 0.27 mm/y but did not differ between groups (iliac vs visceral/arch vessels). PAU width and depth also did not significantly change over time, nor did it differ between groups. No branch PAUs caused symptoms, end-organ events, or rupture, nor required intervention due to symptoms and/or progression. Four PAUs spontaneously resolved (2 iliac, 2 other), and 1 iliac PAU progressed to a saccular aneurysm. CONCLUSIONS: This is one of the largest studies evaluating the natural history of branched PAUs objectively via CTA. Branch PAUs are rare-the prevalence was one-sixth that of aortic PAUs. There was minimal growth noted in a median follow-up of 4 years, and no PAUs required intervention for symptoms or progression. Asymptomatic branch PAUs may be safely observed.

The long-term fate of renal and visceral vessel reconstruction after open thoracoabdominal aortic aneurysm repair.

OBJECTIVES: In the ever-advancing era of endovascular thoracoabdominal aneurysm (TAAA) repair, understanding long-term patency of renovisceral reconstructions after open TAAA repair provides important benchmarks. METHODS: Institutional open TAAA repair patient data were queried. Patients dying during index admission or with incomplete operative detail were excluded. Visceral and renal reconstructions were categorized as bypass, incorporation into a proximal or distal beveled aortic anastomosis, inclusion button, Carrel patch, or hybrid stent along with endarterectomy/stent adjuncts. Axial imaging or angiography determined long-term patency. Vessel event was defined as new occlusion or reintervention after repair. Overall time-to-event analysis was performed as well as separate analyses for each vessel (celiac, superior mesenteric artery [SMA], right renal, left renal) by reconstruction type utilizing Kaplan-Meier methods. Log-rank testing was employed to compare reconstructive strategies. RESULTS: Over 28 years, 604 repairs (type I, 106 [18%]; type II, 73 [12%]; type III, 195 [32%]; and type IV, 230 [38%]) were identified. Follow-up (median, 500 days) was available in 410/570 (72%) celiac, 406/573 (71%) SMA, 379/532 (71.2%) right renal, and 370/515 (72%) left renal reconstructions. There were five celiac, one SMA, eight right renal, and 10 left renal events. No type of reconstruction or adjunct was significantly associated with event. Overall 5-year patency of all renal/visceral reconstructions was 94% (95% confidence interval, 90%-96%). Estimated 5-year patency of the celiac, SMA, left renal, and right renal were similar, and were 99%, 100%, 97%, and 96%, respectively (P = .09). CONCLUSIONS: Visceral and renal long-term patency after open TAAA repair is excellent regardless of reconstructive technique. No differences are appreciated even when target vessel disease is addressed at the time of reconstruction. These findings continue to substantiate the effective long-term durability of open TAAA repair and are particularly germane to the ongoing evolution of endovascular strategies.

Evolution in the Presentation, Treatment, and Outcomes of Patients with Acute Mesenteric Ischemia.

OBJECTIVES: Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes of AMI over the past two decades. METHODS: AMI patients presenting at a single institution were reviewed (1993-2016). Venous thrombosis patients were excluded. Primary outcome was 30-day mortality. Patients were stratified by etiology and diagnosis date (before 2004 versus 2004 and later). Ordered logistic regression was performed for longitudinal temporal analysis. RESULTS: 303 patients were identified. AMI mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive (NOMI) (22%). The majority were women (55%), 50% had atrial fibrillation, and 23% were on anticoagulation (AC) therapy. Mean age was 72±13 years. 345 procedures were performed in 242 patients: 321 open and 24 hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n=85) underwent mesenteric revascularization while 39 (21%) had findings of non-survivable bowel necrosis (NSBN). Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). 30-day mortality was 61% and stable over time (P=0.91); when stratified by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since 2000, there was a significant decrease in the percentage of embolic AMI events (P=0.04). The percentage of patients who underwent operative management decreased also over time (P=0.01, 81% → 61%), which was correlated with an increasing number of patients being made comfort measures only (CMO) prior to surgical intervention (50% → 70%, P=0.02). The majority of patients (55%) were ultimately made CMO during their hospitalization. Predictors of 30-day mortality included a preoperative white blood cell count (WBC) ≥ 25 K/ µL. (OR 3.0, P=0.002) and lactate ≥ 2.3 mmol/L (OR 2.8, P=0.045). NSBN predictors included WBC ≥ 24 K/ µL. (OR 3.4 P=0.03) and lactate ≥ 3.8 mmol/L (OR 3.6, P=0.04). CONCLUSIONS: Despite advances in critical care over the past 25 years, AMI continues to be associated with poor prognosis. The survival benefit observed in patients who undergo revascularization supports an aggressive approach towards early vascular intervention, although this requires further study. The importance of early diagnosis, prognostication and advanced directives is highlighted given the high morbidity, mortality and use of comfort measures associated with AMI.

Short- and long-term outcomes after concurrent splenectomy during thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Splenectomy is often performed during open thoracoabdominal aortic aneurysm (TAAA) repair, because capsular tears are common and can be associated with significant bleeding. It is unknown whether splenectomy affects the short- or long-term outcomes after TAAA repair. METHODS: All open type I to IV TAAA repairs performed from 1987 to June 2015 were evaluated using a single institutional database. The primary endpoints were in-hospital death, major adverse events (MAE) and long-term survival. The secondary endpoint was hospital length of stay (LOS). All repairs performed for aneurysm rupture were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic and linear multivariable regression were used for the in-hospital endpoints, and survival analyses were performed using Cox proportional hazards modeling and Kaplan-Meier techniques. RESULTS: A total of 649 patients met the study inclusion criteria. Of the 649 patients, 150 (23%) underwent concurrent splenectomy (CS) and six required emergency splenectomy secondary to bleeding postoperatively, leading to 156 cases of total in-hospital splenectomy. The perioperative mortality rate was 5.2% in the CS group and 5.2% in the non-CS group (P = 1.0). MAE were experienced by 48% of the CS patients compared with 34% of the non-CS patients (P = .003). Multivariable analysis revealed splenectomy was not independently predictive of perioperative death (adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.41-2.23; P = .9). However, splenectomy was independently associated with any MAE (adjusted odds ratio, 1.78; 95% CI, 1.19-2.65; P = .005). Splenectomy was also associated with a longer length of stay (+5.39 days; 95% CI, 1.86-8.92; P = .003). No survival difference was found between the cohorts in the total splenectomy cohort in the unadjusted (log-rank P = 1.0) or adjusted (splenectomy adjusted hazard ratio, 1.02; 95% confidence interval, 0.78-1.35; P = .9). CONCLUSIONS: CS during open TAAA repair did not lead to increased perioperative mortality but did lead to significantly increased perioperative morbidity and longer hospital lengths of stay. We found no difference in long-term survival outcomes when CS was performed. Splenectomy during TAAA repair did not affect long-term survival.

Venous mesenteric ischemia carries high procedural burden and elevated mortality in patients with severe presentation.

OBJECTIVE: Venous mesenteric ischemia (VMI) presents with variable severity resulting in a spectrum of outcomes. This study sought to characterize the natural history of VMI and identify drivers of intervention and adverse outcomes. METHODS: All patients who presented to our institution with acute and subacute VMI between 1993 and 2016 were identified. Images were reviewed to determine thrombosis location and charts were reviewed to identify clinical factors and outcomes. Univariate analysis was performed for demographics, comorbidities, and presenting characteristics, with primary outcomes of intervention, readmission, and 30-day mortality. A survival analysis was performed with log-rank difference testing for demographics, comorbidities, and presenting characteristics. RESULTS: We identified 103 patients with acute and subacute VMI. The locations of the thrombosis included the superior mesenteric vein (SMV) (31.1%); SMV and portal vein (35.9%); SMV, portal, and splenic veins (15.5%); and other combinations of portomesenteric veins (17.4%), without correlation between the location and outcomes. Most patients were male (60.6%), 22.3% were actively smoking, and the median Charlson comorbidity score was 4 (interquartile range, 2-7). The mean patient age was 61.3 years. More than one-half had a known hypercoagulability (52.4%), 22.3% had prior bowel resection, and 8.7% had prior mesenteric venous intervention, including transjugular intrahepatic portosystemic shunt procedures. Thirty-five patients underwent 83 procedures during their hospitalization, and 23 patients underwent surgical intervention specifically. Prior mesenteric venous procedure, abdominal tenderness, and lactatemia of more than 1.5 mmol/L were associated with an increased need for surgical intervention (P < .05). Patients with leukocytosis of greater than 10K/µL had increased surgical intervention (P = .10), although without statistical significance. However, symptoms for less than 2 weeks (P < .05) were associated with decreased surgical intervention. The 30-day mortality was low in this cohort (6.8%), but was increased in patients requiring intervention (11.4%). For those undergoing procedures, a shorter time to intervention was associated with an improved 30-day mortality (8.7% for procedures on hospital days 0-1 vs 16.7% for hospital day 2 or later; P = .01). Abdominal tenderness and lactatemia were associated with increased 30-day mortality (6.8% vs 3.6% [P < .01] and 16.0% vs 3.8% [P = .03], respectively). A Kaplan-Meier survival analysis revealed a median survival of 7.1 years, with a 1-year survival rate of 74.9%, a 3-year survival rate of 67.1%, and a 5-year survival rate of 57.9%. Negative predictors of survival included a higher Charlson comorbidity index (hazard ratio, 3.7; P < .01) and malignancy (hazard ratio, 3.1; P < .01). CONCLUSIONS: The 30-day mortality of VMT is low, but more than one-third of patients required an intervention beyond anticoagulation. Comorbidity, a prior mesenteric vessel or intestinal operation, and presentation with tenderness or relevant laboratory abnormalities portend worse outcomes. Early intervention is associated with improved outcomes.

Utility of unilateral versus bilateral venous reflux studies for venous insufficiency.

OBJECTIVE: Duplex ultrasonography is the reference standard for diagnosing chronic venous insufficiency. Bilateral venous reflux ultrasound studies are among the most time-consuming and physically demanding tests for vascular ultrasound technologists to perform. Furthermore, if a venous procedure is required, many insurance policies require that a diagnostic venous ultrasound scan for reflux must be performed within 1 year of the procedure. If the intervention is scheduled for >1 year after the ultrasound scan, the insurance company might require a repeat venous ultrasound scan before granting insurance authorization. Hence, ordering bilateral venous duplex ultrasound scans to evaluate for reflux when an intervention might only be performed on one limb within the year could be a waste of time and resources. The aim of the present study was to determine the utility of ordering bilateral vs unilateral studies to evaluate for reflux in patients with suspected chronic venous insufficiency and to determine whether a resource-saving potential exists for vascular laboratories through optimization of the process of ordering venous duplex ultrasound studies. METHODS: A retrospective review of all patients who had undergone bilateral lower extremity ultrasound scanning to evaluate for reflux from January 1, 2016 to December 31, 2016 at the Massachusetts General Hospital vascular laboratory was performed. The demographics, indications for ultrasound scanning, comorbidities, time required to perform the ultrasound study, and interval to intervention were documented. The data were analyzed using SPSS statistical software (IBM Corp, Armonk, NY). RESULTS: During the study period, 13,854 ultrasound studies had been performed in our vascular laboratory, of which 606 (4.4%) had been bilateral ultrasound scans for venous insufficiency. The time allotted for a bilateral study was 2 hours. Of the 606 studies evaluated, 152 (25.1%) showed no evidence of reflux, 284 (46.9%) showed bilateral lower extremity reflux, and 170 (28.1%) showed only venous insufficiency in one leg. Venous ablation, phlebectomy, and/or sclerotherapy were performed for 28.7% of the patients. However only 6.2% of patients had undergone venous procedures on both legs within 1 year after the ultrasound studies. Ablation was the most common procedure performed (54.6%), followed by phlebectomy (27.%) and sclerotherapy (17.9%). Overall, 94.7% of patients had not undergone a venous procedure on both legs within 1 year after the ultrasound studies and, hence, would have required a repeat duplex ultrasound scan to ensure insurance coverage for future procedures. CONCLUSIONS: Most bilateral ultrasound scans for venous insufficiency will not result in an intervention. Thus, most patients (95%) could have undergone a unilateral scan before the initial intervention instead of bilateral duplex ultrasound scanning.

Effect of occult malignancy on femoropopliteal bypass graft thrombosis.

OBJECTIVE: The presence of cancer increases arterial thromboembolic events, specifically myocardial infarction and stroke, before a formal diagnosis of cancer. To the best of our knowledge, this increase in thrombotic risk has not been studied in patients with lower extremity bypass grafts. In the present study, we aimed to determine the effect of occult cancer on femoropopliteal bypass patency. METHODS: A retrospective review of femoropopliteal bypass procedures completed from 2001 to 2018 was performed. International Classification of Diseases, 9th and 10th revision, codes corresponding to breast, lung, prostate, colorectal, skin, brain, and hematologic cancer were used to identify patients who had had occult cancer. Occult cancer was defined as cancer diagnosed within ≤1 year after the bypass procedure. The demographics, comorbidities, bypass configuration and conduit, 1-month, 3-month, 6-month, and 1-year occlusion rates, major adverse limb events, and mortality rates were analyzed. Statistical analysis included t tests, χ2 tests, and Cox regression analysis. RESULTS: A total of 621 procedures in 517 patients met the inclusion criteria. Of the 621 procedures, 36 (5.8%) were classified as procedures in patients with occult cancer. The patients with occult cancer had had higher occlusion rates at 3 months (27.8% vs 8.0%; P < .001), 6 months (30.5% vs 15.1%; P < .01), and 1 year (44.4% vs 19.8%; P < .001). In Cox regression analysis for bypass thrombosis at 1 year, the only significant predictors were occult cancer (hazard ratio [HR], 2.03; P = .01), below-the-knee distal target (HR, 1.88; P < .01), and a compromised conduit (HR, 2.14; P < .001). CONCLUSIONS: We found an increase in bypass graft thrombosis rates in patients who had undergone femoropopliteal bypass who had had occult cancer. Thrombosis of the graft within 1 year postoperatively might be a sign of occult cancer.

Editor's Choice - Mortality is High Following Elective Open Repair of Complex Abdominal Aortic Aneurysms.

OBJECTIVE: To evaluate the 30 day mortality of elective open complex abdominal aortic aneurysm (cAAA) repair and identify factors associated with death. METHODS: This was a retrospective cohort study using a Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). All patients undergoing elective repair for juxta- and suprarenal abdominal aortic aneurysm (AAA), or type IV thoraco-abdominal aneurysms (TAAA) from 2011 to 2017 were identified. Thirty day mortality and complication rates for open repair were established. A comparison endovascular aneurysm repair (EVAR) group was extracted from the same time period, and inverse probability weighting was applied for comparison. Logistic regression was used to identify factors independently associated with open repair mortality. RESULTS: Of the 957 patients who underwent an elective open cAAA repair over the study period, 65 (6.8%) died. The mean age of the patient was 71.3 ± 8.0 years. The distribution by aneurysm type was 605 juxtarenal AAA (28 deaths, 4.6%); 284 suprarenal AAA (16 deaths, 9.5%), and 68 type IV TAAA (10 deaths, 14.7%). During the same time period, there were 1149 endovascular repairs for cAAA, with 43 deaths (3.7%). After inverse probability weighting and weighted logistic regression, open repair 30 day mortality yielded an OR 1.9, 95% CI 1.2-3.1, p = .01 compared with EVAR. Factors independently associated with death included more proximal extent aneurysm (referent [ref]: juxtarenal: OR 2.0 per extent increase, 95% CI 1.4-3.0, p < .001), BMI < 18.5 (OR 4.0, 95% CI 1.6-10.1, p = .003), history of severe chronic obstructive pulmonary disease (COPD) (OR 2.6, 95% CI 1.5-4.4, p = .001), more severe chronic kidney disease (CKD) (ref: none/mild): OR 1.9, 95% CI 1.2-2.8, p = .004), and age (OR 1.06/year, 95% CI 1.02-1.09, p = .002. CONCLUSION: The 30 day mortality was 4.6% for juxtarenal AAA, 9.5% for suprarenal AAA, and 14.7% for type IV TAAA. The open repair odds of 30 day mortality was nearly twice that of endovascular repair for cAAA. Independent associations with death included BMI <18.5, more severe CKD level, more proximally extending aneurysm, age, and history of advanced COPD.