Association between cardiac conditions with venous leg ulcers in patients with chronic venous insufficiency.

INTRODUCTION: Venous leg ulcers (VLUs) are the final stage of chronic venous insufficiency. This study aims to characterize the association between cardiovascular diseases and VLU. METHODS: A multicentric case-control study analyzed 17,788 patients between 2015 and 2020. Cases were matched (1:2) by age and sex, and odds ratios (OR) were analyzed with conditional logistic regressions adjusted by risk factors. RESULTS: The prevalence of VLU was 15.2%. 2390 cases were analyzed. Diseases found to be associated with VLU were atrial fibrillation (OR, 1.21; 95% CI: 1.03-1.42), pulmonary hypertension (OR, 1.45; 95% CI: 1.06-2.00), right heart failure (OR, 1.27; 95% CI: 1.13-1.43), peripheral artery disease (OR, 2.21; 95% CI: 1.90-2.56), and history of pulmonary embolism (OR, 1.45; 95% CI: 1.06-2.00). CONCLUSIONS: Certain cardiovascular conditions showed an association with VLU. Further studies are warranted to evaluate the effect that treating concomitant cardiovascular diseases might exert on the natural history of venous leg ulcers.

Contemporary management and outcomes of peripheral venous aneurysms: A multi-institutional study.

OBJECTIVE: Extremity venous aneurysms result in the risk of pulmonary embolism (PE) and chronic venous insufficiency. At present, owing to the rarity of these aneurysms, no consensus for their treatment has been established. The purpose of the present study was to review the presentation, natural history, and contemporary management of extremity venous aneurysms. METHODS: We performed a retrospective, multi-institutional review of all patients with extremity venous aneurysms treated from 2008 to 2018. A venous aneurysm was defined as saccular or fusiform with an aneurysm/vein ratio of >1.5. RESULTS: A total of 66 extremity aneurysms from 11 institutions were analyzed, 40 of which were in a popliteal location, 14 iliofemoral, and 12 in an upper extremity or a jugular location. The median follow-up was 27 months (range, 0-120 months). Of the 40 popliteal venous aneurysms, 8 (20%) had presented with deep vein thrombosis (DVT) or PE, 13 (33%) had presented with pain, and 19 had been discovered incidentally. The mean size of the popliteal venous aneurysms presenting with DVT or PE was larger than that of those presenting without thromboembolism (3.8 cm vs 2.5 cm; P = .003). Saccular aneurysm morphology in the lower extremity was associated with thromboembolism (30% vs 9%; P = .046) and fusiform aneurysm morphology with a thrombus burden >25% (45% vs 3%). Patients presenting with thromboembolism were more likely to have had a thrombus burden >25% in their lower extremity venous aneurysm compared with those who had presented without thromboembolism (70% vs 9%). Approximately half of all the patients underwent immediate intervention, and half were managed with observation or antithrombotic regimen. In the non-operative cohort, three patients subsequently developed a DVT. Eight patients in the medically managed cohort went on to require surgical intervention. Of the 12 upper extremity venous aneurysms, none had presented with DVT or PE, and only 2 (17%) had presented with pain. Of the 66 patients in the entire cohort, 41 underwent surgical intervention. The most common indication was the absolute aneurysm size. Nine patients had undergone surgery because of a DVT or PE, and 11 for pain or extremity swelling. The most common surgery was aneurysmorrhaphy in 21 patients (53%), followed by excision and ligation in 14 patients (35%). Five patients (12%) had undergone interposition bypass grafting. A postoperative hematoma requiring reintervention was the most common complication, occurring in three popliteal vein repairs and one iliofemoral vein repair. None of the patients, treated either surgically or medically, had reported post-thrombotic complications during the follow-up period. CONCLUSIONS: Large lower extremity venous aneurysms and saccular aneurysms with thrombus >25% of the lumen are more likely to present with thromboembolic complications. Surgical intervention for lower extremity venous aneurysms is indicated to reduce the risk of venous thromboembolism (VTE) and the need for continued anticoagulation. Popliteal aneurysms >2.5 cm and all iliofemoral aneurysms should be considered for repair. Upper extremity aneurysms do not have a significant risk of VTE and warrant treatment primarily for symptoms other than VTE.

Initial experience and early outcomes of the management of acute pulmonary embolism using the FlowTriever mechanical thrombectomy device.

BACKGROUND: Submassive and massive pulmonary embolism is associated with a high risk of complications. We aimed to evaluate our initial experience with a mechanical thrombectomy device in the management of these patients. METHODS: A single-center, retrospective study was performed in patients with acute submassive and massive pulmonary embolism treated with the FlowTriever device (Inari Medical, Irvine, CA, USA) between June 2019 and November 2020. Clinical and technical parameters were analyzed during the hospitalization and at 30- and 180-days after the procedure. RESULTS: Fourteen patients were evaluated with a median (IQR) age of 60 (50-69) years and 64% were male. All had right heart strain as the main indication for thrombectomy. The procedure duration and fluoroscopic time was 52 (37-89) and 13 (9-24) minutes, respectively. There was 100% technical success, and the pulmonary arterial pressure went from 60 (48-65) mmHg to 40 (34-47) mmHg. Thrombolysis was used in two patients and nine patients required intensive care. 100% experienced improvement in symptoms at the time of discharge. There were no device-related complications, major bleeding events, myocardial infarctions, or deaths. Preprocedural hemoglobin was 13 (12-15) g/dL, and predischarge was 12 (10-13) g/dL. Overall postprocedural length of stay was three (2-6) days. All the patients were discharged with oral anticoagulation. There were no device-related complications or recurrence of embolism at 30 and 180 days. CONCLUSIONS: The mechanical thrombectomy device for submassive and massive pulmonary embolism is promising and appears a safe and effective procedure with 100% technical success, no complications, short intensive care requirement/stay, and good early clinical outcomes.

Association of Rideshare Use With Alcohol-Associated Motor Vehicle Crash Trauma.

Importance: Motor vehicle crashes (MVCs) are an important public health concern. Recent trends suggest that introducing rideshare services has decreased the incidence of MVCs. However, detailed analyses linking rideshare volume, convictions for impaired driving, and nonfatal MVC traumas remain inconclusive. Objective: To determine if there is an association between rideshare use and MVC traumas and convictions for impaired driving in Houston, Texas. Design, Setting, and Participants: This multicenter cohort study was conducted between January 2007 and November 2019 with hospital data from the Red Duke Trauma Institute within the Memorial Hermann Hospital-Texas Medical Center and Ben Taub General Hospital. Rideshare data from Uber and Google covered trips taken within Houston, Texas, from February 2014 (the date of deployment of Uber to Houston) to December 2018. Impaired driving convictions included all indictments made by the Harris County, Texas, District Attorney's office from January 2007 to December 2018. All adults with MVC traumas evaluated at both centers in the study population (individuals >16 years with a mechanism of injury classified under "motor vehicle collision") were included. Impaired driving incidents were included only if the final legal outcome was conviction. Main Outcomes and Measures: The primary study outcomes were the incident rate ratios for hourly MVC traumas and daily impaired driving convictions. Results: A total of 23 491 MVC traumas (involving patients with a mean [SD] age of 37.9 [17.8] years and 14 603 male individuals [62.1%]), 93 742 impaired driving convictions, and more than 24 million Uber rides were analyzed. Following the introduction of Uber in February 2014, MVC traumas decreased by 23.8% (from a mean [SD] of 0.26 [0.04] to 0.21 [0.06] trauma incidents per hour) during peak trauma periods (Friday and Saturday nights). The incident rate ratio of MVC traumas following Uber deployment was 0.33 (95% CI, 0.17-0.67) per 1000 indexed rides (P = .002). Furthermore, rideshare use was associated with a significant, geographically linked reduction in impaired driving convictions between January 2014 to December 2019 (incidence rate ratio, 0.76 [95% CI, 0.73-0.78]; P < .001). Conclusions and Relevance: In this study, introducing rideshare services in the Houston metropolitan area was associated with significant reductions in MVC traumas and impaired driving convictions. Increased use of rideshares may be an effective means of reducing impaired driving and decreasing rate of MVC traumas.

Percutaneous retrograde left external carotid artery coil embolization for management of hemorrhage from a persistent proatlantal intersegmental artery type 2.

Persistent fetal communications between the carotid and vertebrobasilar systems are rare and most often discovered incidentally. We present the case of a patient with oropharyngeal cancer status post chemotherapy, radiation therapy, and surgical resection who developed acute oropharyngeal hemorrhage on postoperative day 36, originating from branches of the ligated external carotid artery stump by retrograde flow through a proatlantal intersegmental artery type 2. This hemorrhage was successfully controlled with coil embolization through percutaneous access of the external carotid artery without recurrence at 1-year follow-up.

Coil embolization of a ruptured gastroduodenal artery pseudoaneurysm presenting with hemosuccus pancreaticus.

Hemosuccus pancreaticus is a rare form of upper gastrointestinal bleeding that accounts for roughly 1 in 1500 cases. It is characterized by hemorrhage from the ampulla of Vater secondary to rupture of a peripancreatic pseudoaneurysm or visceral artery pseudoaneurysm. Among the visceral artery pseudoaneurysms, gastroduodenal artery pseudoaneurysms are among the rarest. In this case report, we describe a successful coil embolization of a large ruptured gastroduodenal pseudoaneurysm in a patient with massive gastrointestinal bleeding.

Endovascular Repair of Ruptured Ascending Aorta Secondary to Embolized Transcatheter Aortic Valve.

Since its approval by the United States Food and Drug Administration in 2011, transcatheter aortic valve replacement has revolutionized the treatment of aortic valvular disease with a rapid increase in use. Potentially fatal aortic complications are rare, occurring in 0.2% to 1.1% of cases-all reported in the early perioperative period. We present a case of a late ascending aortic pseudoaneurysm with rupture secondary to erosion by an embolized transcatheter aortic valve occurring 6 years after implantation. The patient was successfully treated with a commercially available, off-the-shelf aortic endograft.

Thoracic branched endograft for traumatic aortic pseudoaneurysm.

Thoracic endovascular aortic repair is the standard treatment for blunt traumatic aortic injuries (BTAI). Approximately 40% of patients with BTAI require left subclavian artery (LSA) coverage for adequate proximal seal. Intentional LSA coverage is not benign; it is associated with complications including stroke, spinal cord ischemia, vertebrobasilar, and left arm ischemia. To avoid these devastating complications, LSA revascularization is recommended before elective zone II thoracic endovascular aortic repair, but is often omitted during emergent cases. We report two cases of aortic zone II traumatic grade III BTAI (aortic pseudoaneurysm) that we successfully treated with the GORE prior to TAG thoracic branch endoprosthesis.

Successful cerebral protection during removal of large right atrial thrombus with AngioVac in a patient with patent foramen ovale and recent embolic stroke.

Complications associated with central venous catheterization include deep venous thrombosis and atrial thrombi, among others. Large thrombi, including intracardiac thrombi, have classically been managed medically or with open surgery. However, recent reports detail the utility of the AngioVac system (AngioDynamics, Latham, NY), a vacuum-assisted suction thrombectomy system using a venous-venous extracorporeal circuit. Here, we present the case of a critically ill woman with large right atrial thrombus, patent foramen ovale, and recent embolic stroke who underwent successful vacuum-assisted suction thrombectomy with use of the Sentinel Cerebral Protection System (Boston Scientific, Marlborough, Mass) for stroke prevention.

Predictors of poor outcome in infrainguinal bypass for trauma.

BACKGROUND: Trauma remains a leading cause of morbidity and mortality worldwide. Vascular injuries are present in approximately 1% to 2% of trauma patients, with the majority of injuries occurring to the extremities. Trauma patients with vascular injuries have been shown to have increased morbidity and mortality as well as the need for increased resources compared with those without vascular injuries. This study aimed to determine predictors of poor outcomes in infrainguinal bypasses performed for traumatic arterial injury. METHODS: All patients admitted between September 1999 and July 2015 who underwent infrainguinal arterial bypass for trauma at a single level I trauma center were included for analysis. The primary outcome was a composite of thrombosis leading to graft abandonment, revision, amputation, or death. Data were analyzed by univariate descriptive and multiple logistic regression analyses. Long-term data were analyzed by Kaplan-Meier method. RESULTS: During the study period, 108 patients presented with and underwent infrainguinal arterial bypass for traumatic arterial injury. The cohort had a mean age of 35.8 years (16/108 female [15%]). The average Injury Severity Score was 15.2; admission glomerular filtration rate, 79.3 mL/min/1.73 m2; Mangled Extremity Severity Score (MESS), 6; and injury to operating room time, 5.1 hours. Of 108 patients, 37 (34%) had penetrating injury, 71 (66%) had blunt injury, 10 (9.3%) had diabetes mellitus, and 76 (70.4%) had a below-knee target for bypass. Univariate risk factors for poor outcome included age >40 years (odds ratio [OR], 3.27 [1.40-7.65]; P < .01), MESS ≥7 (OR, 5.19 [2.08-19.97]; P < .01), blunt mechanism (OR, 3.35 [1.24-9.07]; P = .02), popliteal artery injury (OR, 3.04 [1.22-7.6]; P = .02), and below-knee target vessel (OR, 4.32 [1.37-13.58]; P = .01). Concomitant orthopedic injuries (P = .08) were not associated with poor outcome. Baseline renal function, type of repair performed (end-to-side vs interposition bypass), injury to surgery time, surgeon's specialty, and associated venous injuries were not significantly predictive of poor outcome. MESS was strongly predictive of poor outcome, with probability rising as high as 95% when MESS reached 12. A score ≥7 (high MESS) was 73% sensitive and 70% specific to predict poor outcomes. Age (OR, 1.03/y; P < .05) and MESS ≥7 (OR, 3.6; P < .03) were persistent predictors of poor outcome in multivariable analysis. CONCLUSIONS: Poor outcomes in infrainguinal bypass for trauma are significantly predicted by the MESS, with poor outcomes occurring >50% of the time when MESS is ≥9 and >75% of the time when MESS is ≥11. Whereas amputation vs revascularization is a decision that also depends on nerve and soft tissue damage and other comorbidities, the MESS helps frame the data for the clinician and can aid in decision-making. Patients and family should understand that poor outcomes are more likely when MESS is ≥9. For patients with MESS ≥11, primary amputation can be considered.

The role of ascending aortic size in outcomes of patients with uncomplicated acute type B aortic dissection.

OBJECTIVE: Recent studies demonstrate that uncomplicated acute type B aortic dissection (uATBAD) patients with enlarged descending thoracic aortic diameters are at high risk for development of complications. This study aimed to determine the association of maximum ascending aortic diameter and area and outcomes in patients with uATBAD. METHODS: All patients admitted with uATBAD from June 2000 to January 2015 were reviewed, and those with available imaging were included. All measurements were obtained by a specialized cardiovascular radiologist, including the maximum ascending aortic diameter and area. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analyses using SAS 9.4 software (SAS Institute, Cary, NC). RESULTS: During the study period, 298 patients with uATBAD were admitted, with 238 having available computed tomography and 131 having computed tomography angiography imaging and adequate follow-up available for analysis. The cohort had an average age of 60.96 ± 13.4 years (60% male, 53% white). Ascending aortic area >12.1 cm2 and ascending aortic diameter >40.8 mm were associated with subsequent arch and proximal progression necessitating open ascending aortic repair (P < .027 and P < .033, respectively). Ascending diameter >40.8 mm predicted lower intervention-free survival (P = .01). However, it failed to predict overall survival (P = .12). Ascending aortic area >12.1 cm2 predicted lower intervention-free survival (P = .005). However, this was not predictive of mortality (P = .08). Maximum aortic diameter along the length of the aorta >44 mm persisted as a risk factor for mortality (P < .001). Neither maximum ascending aortic diameter >40.8 mm (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.42-2.83; P = .85) nor area >12.1 cm2 (HR, 0.992; 95% CI, 0.38-2.61; P = .99) significantly predicted mortality when controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 7.34; 95% CI, 2.3-23.41; P < .001), diabetes mellitus (HR, 6.4; 95% CI, 2.17-18.93; P < .001), age (HR, 1.06/y; 95% CI, 1.03-1.10; P < .001), history of stroke (HR, 5.03; 95% CI, 1.52-16.63; P = .008), and syncope on admission (HR, 21.11; 95% CI, 2.3-193.84; P = .007). Ascending aortic diameter >40.8 mm (HR, 2.01; 95% CI, 1.03-3.95; P = .04) and maximum ascending aortic area >12.1 cm2 (HR, 1.988; 95% CI, 1.02-3.87; P = .04) on admission persisted as predictors of decreased intervention-free survival after controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 3.142; 95% CI, 1.47-6.83; P < .004), syncope on admission (HR, 26.3; 95% CI, 2.81-246; P < .004), and pleural effusion on admission (HR, 3.02; 95% CI, 1.58-5.77; P < .001). CONCLUSIONS: uATBAD patients with ascending aortic area >12.1 cm2 or maximum ascending aortic diameter >40.8 mm are at high risk for development of subsequent arch and proximal progression and may require closer follow-up or earlier intervention. Ascending aortic size (diameter and area) is predictive of decreased intervention-free survival in patients with uATBAD.

Stent Graft-Induced Pseudoaneurysms in a Patient With Vasculo-Behçet Disease.

Behçet disease (BD) is a rare condition that causes pathologic abnormalities in multiple systems, with vascular complications, termed vasculo-BD, occurring in 7% to 29% of individuals with the disease. Arterial complications portend the highest mortality in vasculo-BD. Here, we present a case of a young woman with active vasculo-BD in whom endovascular repair failed, with development of stent graft-induced pseudoaneurysms at the proximal and distal extents of the stent graft, necessitating open descending thoracic aortic repair.

Predictors of intervention and mortality in patients with uncomplicated acute type B aortic dissection.

OBJECTIVE: Patients with uncomplicated acute type B aortic dissection (uATBAD) have historically been managed with medical therapy. Recent studies suggest that high-risk patients with uATBAD may benefit from thoracic endovascular aortic repair. This study aims to determine the predictors of intervention and mortality in patients with uATBAD. METHODS: All patients admitted with uATBAD from 2000 to 2014 were reviewed, and those with computed tomographic angiography imaging were included. Multiplanar reconstruction was used to obtain double orthogonal oblique measurements. All measurements were obtained by a specialized cardiovascular radiologist (D.O.). The maximum aortic diameter, proximal descending thoracic aorta false lumen (FL) diameter, and area were recorded. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analysis using SAS v 9.4 (SAS Institute, Cary, NC). RESULTS: During the study period, 294 patients with uATBAD were admitted with 156 having admission computed tomographic angiography imaging available for analysis. The cohort had an average age of 60.6 years (±13.6 years); 60% were males. The average follow-up time was 3.7 years (interquartile range, 2.1-6.9). A stratified analysis demonstrated the most sensitive cutoff for mortality was aortic diameter >44 mm (P < .01), and it appeared to be a threshold effect with minimal additional information added by finer size stratification. FL diameter did not predict mortality in our series (P = .36). Intervention-free survival, alternatively, appeared to decrease over the range of diameters from 35 to 44 mm (P < .01). An FL diameter >22 mm was associated with decreased intervention-free survival (P < .04). Age >60 years on admission also demonstrated decreased survival compared with those ≤60 years of age (P < .01). Diameter >44 mm persisted as a risk factor for mortality (hazard ratio, 8.6; P < .01) after adjustment for diabetes (6.7; P < .01), age (1.06/y; P < .01), history of stroke (5.4; P < .01), connective tissue disorder (2.3; P < .01), and syncope on admission (9.5; P < .04). The 1-, 5-, and 10-year intervention rate for patients with admission aortic diameter >44 mm was 18.8%, 29.5%, and 50.3%, respectively, compared with 4.8%, 13.3%, and 13.3% in the ≤44 mm group (P < .01). CONCLUSIONS: Aortic diameter >44 mm is a predictor of mortality after adjustment for other significant risk factors. Age >60 years on admission is a predictor of mortality. An FL diameter >22 mm as well as those with maximum aortic diameter >44 mm on admission were associated with decreased intervention-free survival. Patients with these high-risk criteria may benefit from thoracic endovascular aortic repair. Further studies are needed to further define those patients at highest risk and, thus, most likely to benefit from early intervention.

Outcomes of endovascular repair for patients with blunt traumatic aortic injury.

BACKGROUND: Traumatic aortic injury (TAI) remains a leading cause of death after blunt force. Thoracic endovascular aortic repair (TEVAR) has been widely adopted as an alternative to open repair for the treatment of TAI. Although significant short-term benefits have been demonstrated for patients undergoing TEVAR, longer-term follow-up data are lacking. METHODS: Trauma registry data were analyzed. Follow-up data were gathered from a combination of medical records, imaging, telephone interviews, and Social Security Death Index. Primary outcomes were in-hospital mortality, stroke, and paraplegia. Secondary outcomes included device-related adverse events (rupture, migration, or endoleak), secondary procedures, open conversion, and all-cause mortality. RESULTS: Between September 2005 and July 2012, 82 consecutive patients (57 males, mean [SD] age, 39.5 [20] years; mean [SD] Injury Severity Score [ISS], 34 [9.5]) underwent TEVAR for TAI. A total of 87 devices were implanted: TAG (n = 36), CTAG (n = 12) (WL Gore, Flagstaff, AZ); Talent (n = 29), Valiant (n = 5) (Medtronic, Santa Rosa, CA); TX2 (n = 2) (Cook, Bloomington, IN); and other (n = 3). Left subclavian artery coverage was required in 32 patients (39%). Technical success rate was 100%. Rates of in-hospital mortality, stroke, and paraplegia were 5.0%, 2.4%, and 0%, respectively.Median follow-up time was 2.3 years (range, 0-7 years). The availability of follow-up data was as follows: Social Security Death Index (100%), telephone interview (68%), clinic visit (61%), and imaging (82%). The incidence of device-related adverse events was 2.4%. There were four secondary procedures: two patients underwent a carotid-subclavian bypass, and two had an open conversion for device-related complications. Survival was 95% at 30 days, 88% at 1 year, 87% at 2 years, and 82% at 5 years. CONCLUSION: At midterm follow-up, TEVAR is an effective and durable option for the treatment of TAI in properly selected patients. Device-related adverse events, secondary procedures, and open conversion are rare. Follow-up remains a challenge. LEVEL OF EVIDENCE: Therapeutic study, level V.