Body Mass Index Impacts Indication But Not Outcomes of Thoracic Endovascular Aortic Repair.

BACKGROUND: There are limited studies looking at thoracic endovascular aortic repair (TEVAR) outcomes in obese and overweight patients. Our objective was to determine the rate of complications, reintervention, and short-term mortality in normal weight, overweight, and obese patients undergoing TEVAR. METHODS: Patients undergoing TEVAR at a large tertiary hospital from October 2007 to January 2020 were analyzed. Patients were stratified into 3 cohorts based on body mass index (BMI): normal (18.5-25 kg/m2), overweight (25-30 kg/m2), and obese (>30 kg/m2). Primary outcomes were 30-day and 1-year survival. Intraoperative, in-hospital, and postdischarge complications were assessed as secondary outcomes using the Clavian-Dindo classification system. In addition, reinterventions associated with the index TEVAR procedure as a secondary outcome. RESULTS: Among 204 patients fitting the study criteria, we identified 65 with normal BMI, 78 overweight, and 61 obese patients. Obese patients were younger than the overweight and normal BMI patients (mean age 62.2 vs. 66.7 vs. 70.7, respectively, P = 0.003). In terms of TEVAR indication, the obese cohort had the highest percentage of patients with type B aortic dissection (36.4%), while the normal BMI cohort had the higher proportion of patients undergoing TEVAR for isolated thoracic aortic aneurysm (63.9%). Intraoperative complications did not significantly differ between cohorts. Postoperatively, in-hospital complications, postdischarge complications and 30-day return to the operative room did not differ significantly between study cohorts. Odds of reintervention did not differ significantly between cohorts, both on univariate and multivariate analysis. Log-rank test of Kaplan Meier analysis revealed no difference in reintervention-free survival (P = 0.22). Thirty-day mortality and 1-year overall survival were similar across cohorts. Both univariate and multivariate logarithmic regression revealed no difference in likelihood of 30-day mortality between the obese and normal cohort. CONCLUSIONS: There were no measurable differences in complications, reinterventions, or mortality, suggesting that vascular surgeons can perform TEVAR across a spectrum of BMI without compromising outcomes.

Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair.

BACKGROUND: The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement. METHODS: A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS. RESULTS: A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7 years old. Patients undergoing SA were older with a mean age of 73.4 years versus 64.7 years for patients undergoing GA (P < 0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75 years old: 52.9% vs. 33.3%, P < 0.001; renal comorbidities: 20.6% vs. 10.6%, P = 0.03, and current smokers: 26.7% vs. 9.6%, P < 0.001). Length of stay (LOS) was decreased in the SA group (4.29 days vs. 9.70 days, P < 0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P = 0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P = 0.01), reintervention (19.2% vs. 26.8%, P = 0.02), and return to the operating room (6.8% vs. 12.7%, P = 0.02). Of the 19 patients that had SA + CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P = 0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA + CSFD patients versus SA + CSFD patients. Age >75 (P = 0.002), intraoperative complications (P < 0.001), and perioperative complications (P = 0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis. CONCLUSIONS: Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.

Feeding behavior and hormoligosis associated with imidacloprid resistance in Asian citrus psyllid, Diaphorina citri.

Imidacloprid is a neonicotinoid insecticide used for managing the Asian citrus psyllid, Diaphorina citri Kuwayama, which serves as vector of phytopathogens causing citrus greening. However, development of resistance to neonicotinoids among populations of D. citri has coincided with occasional control failures in the field. The objectives of this research were to (1) survey current levels of imidacloprid resistance in Florida citrus; (2) compare feeding behavior between imidacloprid-resistant and susceptible D. citri using electrical penetration graph recordings, and (3) investigate the possible amplification of insecticide hormoligosis associated with resistance. Field surveys confirmed that the susceptibility of D. citri populations to imidacloprid has decreased in commercial Florida citrus groves compared with a laboratory-susceptible population. Following 12 generations of selection, resistance to imidacloprid increased by 438 fold compared with the susceptible strain. Imidacloprid-susceptible D. citri feeding on citrus exhibited significantly more bouts associated with intercellular pathway (C), phloem penetration (D), phloem salivation (E1), and nonprobing (Np) activities than imidacloprid-resistant counterparts. However, there were no differences observed in the frequency or duration of phloem ingestion or xylem feeding between susceptible and resistant D. citri. There was no statistical difference in fecundity between resistant and susceptible strains. However, the fecundity of imidacloprid-susceptible female D. citri treated with a sublethal concentration of imidacloprid (LC25 ) increased significantly compared with controls, while such hormoligosis was less pronounced among imidacloprid-resistant psyllids. Our results suggest that imidacloprid-resistant psyllids may cease feeding sooner than susceptible counterparts following sublethal exposure to this insecticide, indicative of a behavioral resistance mechanism.

Early Season Monitoring of Tarnished Plant Bug, Lygus lineolaris, in Wild Hosts Using Pheromone Traps.

The tarnished plant bug, Lygus lineolaris (Hemiptera: Miridae), has a wide host range of over 700 plant species, including 130 crops of economic importance. During early spring, managing the field edges with weeds and other wild hosts is important in preventing early-season infestations of L. lineolaris in cotton to prevent damage to the squares and other fruiting structures. Scouting fields for L. lineolaris is time- and labor-intensive, and end-user variability associated with field sampling can lead to inaccuracies. Insect traps that combine visual cues and pheromones are more accurate, sustainable, and economically feasible in contrast to traditional insect detection methods. In this study, we investigated the application of red or white sticky cards baited with the female-produced sex pheromone to monitor overwintering L. lineolaris populations in early spring. Field experiments demonstrated that the red sticky cards baited with a pheromone blend containing hexyl butyrate, (E)-2-hexenyl butyrate, and (E)-4-oxo-2-hexenal in 4:10:7 ratio are highly effective in trapping L. lineolaris adults in early spring before the row crops are planted, and in monitoring their movement into a cotton crop. The monitoring of L. lineolaris should help growers to make judicious decisions on insecticide applications to control early pest infestations, thereby reducing economic damage to cotton.

Surgical External Iliac Artery Access for Transcatheter Aortic Valve Replacement Is a Safe, Suitable Alternative to Common Femoral Artery Access.

Background Many patients undergoing transcatheter aortic valve replacement (TAVR) have peripheral artery disease necessitating surgical access. This study reviews the preoperative risk factors, procedural characteristics, and outcomes in patients undergoing surgical common femoral artery (CFA) and external iliac artery (EIA) access through a retro-inguinal groin incision for TAVR. Methods A single-center TAVR database was retrospectively analyzed for patients undergoing surgical cutdown (January 1, 2016 - December 31, 2020). Access sites were evaluated on preoperative imaging. Data on demographics, imaging, procedural characteristics, and outcomes were collected. The vascular surgeon selected the cutdown site. Results A hundred and thirty TAVR patients had surgical cutdown. The choice of access site was either the common femoral artery (82 patients, 63%) or the iliac artery (48 patients, 37%). There was no difference in age, BMI, or medical risk factors. There was no difference in iliac diameter or circumferential iliac calcium. In the iliac group, there was a smaller mean CFA size and a higher incidence of circumferential CFA calcium. In the femoral group, there was: a lower mean sheath-to-CFA ratio, a trend toward increased unplanned endarterectomy, and a higher incidence of 30-day readmission. There was no difference in adjunct procedure use. Conclusion EIA surgical access had similar complication rates and length of stay with a reduced tendency for unplanned endarterectomy when compared to CFA access. The EIA is a suitable access site for TAVR in select patients.

Entomopathogenicity of Ascomycete Fungus Cordyceps militaris on the Cotton Bollworm, Helicoverpa zea (Boddie) (Lepidoptera: Noctuidae).

This study investigated the exposure of the cotton bollworm, Helicoverpa zea (Boddie) (Lepidoptera: Noctuidae) to a novel pathogenic fungal agent historically associated with human medicinal value, a commercial strain of Cordyceps militaris ((L.) Fr.) Vuill. (Hypocreales). A series of comparative studies were conducted to evaluate the efficacy of two different exposure methods using four concentrations (n × 109, n × 108, n × 107, n × 106) of C. militaris, where n × 109 provided a concentration of approximately 420 ± 37 spores per mm2 with 398 ± 28 viable spores. Survival of cotton bollworms of all stages was not affected by C. militaris at any concentration 1 d post-exposure. The greatest reduction in survival and highest sporulation rates were observed primarily on or after 7 d post-exposure for early instars (first and second). Significant declines in the survival of early instars were observed for all concentrations at 7 d, and 95% mortality by 10 d, with the exception of the fifth instars that experienced a less severe reduction in survival (35%) when exposed to any concentrations used in the study. Survival of late instars (third to fifth) ranged from 44% to 68% on day 10, while adult survival was near 99% across the duration of the experiment. The relatively narrow range observed for both the lethal concentration and sporulation of second, third, and fifth instar cotton bollworms exposed to the C. militaris strain may demonstrate potential field application for control of larval populations of cotton bollworms.

The Venous Thrombectomy Armamentarium: An Expanding World.

Acute deep venous thrombosis (DVT) is a common and important public health problem. It affects more than 350,000 people in the United States annually and has a substantial economic impact. Without adequate treatment, there is significant risk of development of post-thrombotic syndrome (PTS) resulting in patient morbidity, worse quality of life, and costly long-term medical care. Over the past decade, the treatment algorithm for patients with acute DVT has significantly changed. Prior to 2008, the treatment recommendation for patients with acute DVT was limited to anticoagulation and conservative management. In 2008, national clinical practice guidelines were updated to include interventional strategies such as surgical- and catheter-based techniques for the treatment of acute DVT. Early strategies for debulking of extensive acute DVT primarily consisted of open surgical thrombectomy and administration of thrombolytics. In the intervening period, a plethora of advanced endovascular techniques and technologies have been developed which reduced the morbidity of operative intervention and risks of hemorrhage associated with thrombolysis. This review will focus on the novel technologies commercially available for management of acute DVT, denoting unique features inherent to each device. This expanded armamentarium gives vascular surgeons and proceduralists the opportunity to individualize their treatment approach to the specific patient's anatomy, lesion, and history.

Resilience, endogenous policy responses to COVID-19, and their impacts on farm performance.

Policy measures aimed at containing the spread of the COVID-19 pandemic had unintended consequences on economic activities globally. In this study, we isolate and investigate the short-term partial impacts of six such measures on the farm and nonfarm incomes of agricultural households and examine the related resilience factors. Using Nigeria as a case study, we find that the COVID containment measures had mixed effects on farm and non-farm incomes in the short run. These varying effects are due to households' resilience and vulnerability factors, including land size, wealth, income diversification, involvement in processing activities, and reliance on hired labor. Our findings highlight the need for more targeted health crisis containment measures which consider the uniqueness, diversity, and regional heterogeneity of agriculture, especially the potential implications for farm viability.

Combining visual cues and pheromone blends for monitoring and management of the tarnished plant bug Lygus lineolaris (Hemiptera: Miridae).

BACKGROUND: The tarnished plant bug Lygus lineolaris (Palisot de Beauvois) is considered the most damaging pest of cotton (Gossypium hirsutum L.) in the mid-southern United States. Previous studies have reported the role of different ratios of volatile metathoracic gland components such as hexyl butyrate, (E)-2-hexenyl butyrate and (E)-4-oxo-2-hexenal in eliciting low-level attraction of L. lineolaris. In this study, we tested different visual cues (colored sticky cards) in combination with olfactory cues (pheromone blends) to optimize the attraction and capture of L. lineolaris in the field. RESULTS: Red-colored sticky cards were more attractive to L. lineolaris adults than white, blue or yellow cards. Red sticky cards combined with blends of three potential pheromone components attracted significantly more L. lineolaris adults than sticky cards without a blend added. Traps baited with a blend of hexyl butyrate, (E)-2-hexenyl butyrate and (E)-4-oxo-2-hexenal in 4:10:7 ratio, respectively, caught a significantly higher number of L. lineolaris than those baited with 10:4:2 or 7:10:4 blends or an unbaited control in the first week of the experiment. CONCLUSIONS: Combining visual cues (red color) with olfactory cues (pheromone blends) significantly increased the capture of L. lineolaris in the field. This device or a future iteration could contribute towards sustainable and environmentally appropriate early-season monitoring and management of L. lineolaris in the field. © 2023 The Authors. Pest Management Science published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Withholding methotrexate after vaccination with ChAdOx1 nCov19 in patients with rheumatoid or psoriatic arthritis in India (MIVAC I and II): results of two, parallel, assessor-masked, randomised controlled trials.

Background: There is a necessity for an optimal COVID-19 vaccination strategy for vulnerable population groups, including people with autoimmune inflammatory arthritis on immunosuppressants such as methotrexate, which inhibit vaccine-induced immunity against SARS-CoV-2. Thus, we aimed to assess the effects of withholding methotrexate for 2 weeks after each dose of ChAdOx1 nCov-19 (Oxford-AstraZeneca) vaccine (MIVAC I) or only after the second dose of vaccine (MIVAC II) compared with continuation of methotrexate, in terms of post-vaccination antibody titres and disease flare rates. Methods: MIVAC I and II were two parallel, independent, assessor-masked, randomised trials. The trials were done at a single centre (Dr Shenoy's Centre for Arthritis and Rheumatism Excellence; Kochi, India) in people with either rheumatoid arthritis or psoriatic arthritis with stable disease activity, who had been on a fixed dose of methotrexate for the preceding 6 weeks. Those with previous COVID-19 or who were positive for anti-SARS-CoV-2 nucleocapsid antibodies were excluded from the trials. People on high-dose corticosteroids and rituximab were also excluded, whereas other disease-modifying antirheumatic drugs were allowed. In MIVAC I, participants were randomly assigned (1:1) to stop methotrexate treatment for 2 weeks after each vaccine dose or to continue methotrexate treatment. In MIVAC II, participants who had continued methotrexate during the first dose of vaccine were randomly assigned (1:1) to withhold methotrexate for 2 weeks after the second dose of vaccine or to continue to take methotrexate. The treating physician was masked to the group assignments. The primary outcome for both MIVAC I and MIVAC II was the titre (absolute value) of anti-receptor binding domain (RBD) antibody measured 4 weeks after the second dose of vaccine. All analyses were done per protocol. The trials were registered with the Clinical Trials Registry- India, number CTRI/2021/07/034639 (MIVAC I) and CTRI/2021/07/035307 (MIVAC II). Findings: Between July 6 and Dec 15, 2021, participants were recruited to the trials. In MIVAC I, 250 participants were randomly assigned and 158 completed the study as per the protocol (80 in the methotrexate hold group and 78 in the control group; 148 [94%] were women and 10 [6%] were men). The median post-vaccination antibody titres in the methotrexate hold group were significantly higher compared with the control group (2484·0 IU/mL, IQR 1050·0-4388·8 vs 1147·5 IU/mL, 433·5-2360·3; p=0·0014). In MIVAC II, 178 participants were randomly assigned and 157 completed the study per protocol (76 in the methotrexate hold group and 81 in the control group; 135 [86%] were women and 22 [14%] were men). The methotrexate hold group had higher post-vaccination antibody titres compared with the control group (2553·5 IU/ml, IQR 1792·5-4823·8 vs 990·5, 356·1-2252·5; p<0·0001). There were no reports of any serious adverse events during the trial period. Interpretation: Withholding methotrexate after both ChAdOx1 nCov-19 vaccine doses and after only the second dose led to higher anti-RBD antibody titres compared with continuation of methotrexate. However, withholding methotrexate only after the second vaccine dose resulted in a similar humoral response to holding methotrexate after both vaccine doses, without an increased risk of arthritis flares. Hence, interruption of methotrexate during the second dose of ChAdOx1 nCov-19 vaccine appears to be a safe and effective strategy to improve the antibody response in patients with rheumatoid or psoriatic arthritis. Funding: Indian Rheumatology Association.

Susceptibility of Different Life Stages of Kudzu Bug Megacopta cribraria (F.) (Hemiptera: Plataspidae) to Two Different Native Strains of Beauveria bassiana.

This is the first study that examined and compared the survival, LC50, and RR50 estimates of Megacopta cribraria F. (Hemiptera: Plataspidae) nymphs and adults that were exposed to two native Beauveria bassiana isolates (Previously codified as NI8 and KUDSC strains) at four concentrations. The greatest reduction in survival and mortality was observed primarily on or after 10 d post-exposure to B. bassiana isolates. Survival of early instars (2nd, 3rd) were not affected by either strains or concentration at 3 d and 5 d post-exposure. Survival of later instars (5th) and adults was significantly reduced when exposed to the KUDSC strain at all concentrations. Comparison of dose−mortality values (LC50) using resistance ratios (RR50) were significantly different between life stages of the kudzu bug for both strains of B. bassiana. The LC50 values showed that kudzu bug adults are more susceptible than any other life stage when exposed to either strain. The KUDSC strain was more pathogenic than NI8 10 d after exposure, but NI8 exhibited significantly higher pathogenicity than KUDSC 20 d after exposure. Our results suggest potential field application of B. bassiana for kudzu bug control and their integration into pest management strategies to suppress them before they cause economic damage to soybean crops.

Higher surgeon volume is associated with lower odds of complication following thoracic endovascular aortic repair for aortic dissections.

OBJECTIVE: This study aimed to understand the impact of surgeon volume on outcomes of thoracic endovascular aortic repair (TEVAR) in patients being treated for aortic dissection. METHODS: Patients undergoing TEVAR from January 2014 to March 2021 in the Vascular Quality Initiative database were analyzed. Patients with aortic dissection who underwent TEVAR were divided into quartiles based on the annual TEVAR volume of their vascular surgeon. The highest quartile, middle two quartiles, and lowest quartile were deemed high volume (HV), moderate volume (MV), and low volume (LV), respectively. Multivariable logistic regressions were performed to compare cohort outcomes in terms any postoperative complication, stroke, spinal cord ischemia, reintervention, and 30-day mortality. A Cox proportional hazard model was used to assess the hazard of overall postoperative mortality. RESULTS: Among 1217 patients undergoing TEVAR, 321, 621, and 275 were performed by HV, MV, and LV surgeons, respectively. HV surgeons performed >19 annual TEVARs, MV surgeons between five and 18, and LV surgeons four or less. Adjusted odds of any postoperative complication revealed that HV and MV surgeons had lower odds of overall postoperative complications (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.30-0.85; P = .011 and OR, 0.60; 95% CI, 0.38-0.87; P = .008, respectively) when compared with patients of LV surgeons. Patients of HV surgeons had lower odds of respiratory complications than those of LV surgeons (OR, 0.42; 95% CI, 0.17-0.93; P = .039). Adjusted analysis of outcomes including spinal cord ischemia, stroke, myocardial infarction, 30-day mortality, and overall mortality did not reveal statistically significant differences between cohorts. CONCLUSIONS: Surgeon volume does not to impact 30-day mortality or long-term mortality after TEVAR for aortic dissection, but the odds of overall postoperative complications were lower for HV and MV surgeons when compared with LV surgeons.

Collapsed endograft and lower limb ischemia from type B dissection repaired with thoracic endovascular aortic graft and iliac stenting: A case report and review of the literature.

The collapse of an abdominal aortic endograft is a rare event. We present the case of a 60-year-old man with an abdominal endograft who came to the emergency department with chest, back, abdominal, and lower extremity pain in addition to a cool left foot. On imaging, he was found to have a type B aortic dissection and a collapsed abdominal endograft. Subsequently, the patient was taken to the operating room and treated with a thoracic endovascular aortic repair, abdominal aortic cuff, and an iliac stent. Our study details this case and thoroughly reviews similar cases in the literature.

The Feasibility and Applicability of Percutaneous Deep Vein Arterialization in Peripheral Artery Disease.

Peripheral artery disease (PAD) can often present with chronic limb threatening ischemia (CLTI), including ischemic rest pain and severe tissue loss. Progression of PAD can lead to "no option" or end-stage disease in which there are no traditional open or endovascular interventions available for revascularization. This cohort of patients have a poor prognosis, with a major amputation rate of 40% and mortality of up to 20% at six months. For this patient population, surgical deep vein arterialization (DVA) is offered as an attempt to provide blood flow to the distal preserved venous bed and reverse the ischemic process. Surgical DVA has traditionally been offered as an option and was pioneered by Herb Dardik. The evolution of endovascular technology has allowed for percutaneous DVA (pDVA). Using ultrasound and fluoroscopic guidance, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts to increase distal limb perfusion with the goals of improving wound healing and amputation-free survival. Lysis of venous valves with a valvulotome also aids with reversal of flow into the distal venous system. Investigations of percutaneous deep vein arterialization are underway with one device, the LimFlow System (LimFlow SA, Paris, France), which is undergoing feasibility trials. Here we present the current clinical indications, feasibility, results, and our institutional experience with the use of percutaneous deep vein arterialization.

Management of Innominate Artery Occlusion With Severe Left Common Carotid Artery Stenosis.

Innominate artery occlusion is a rare entity, particularly when coupled with severe left common carotid artery stenosis. Innominate artery disease may present with varying degrees of symptomatology and can place patients at risk for both posterior fossa and hemispheric ischemic events. We present a symptomatic case of innominate artery occlusion with severe left common carotid disease. We reviewed the literature and current options for the treatment of innominate artery disease. The patient underwent successful hybrid repair with left carotid artery retrograde stenting and left carotid artery to right carotid artery bypass. She has been symptom and re-intervention free during her one-year follow-up. We describe a successful hybrid repair of symptomatic innominate artery occlusion with concomitant severe left carotid artery stenosis in a patient with a prohibitive open thoracic surgical risk.

Large-bore Aspiration Thrombectomy for Acute Venous Thromboembolism.

Pulmonary embolism can occur following dislodgement of deep venous thrombosis into the pulmonary artery circulation, which results in obstruction of the pulmonary artery system and can be fatal. The consequences of pulmonary embolism include hypotension, right heart strain, and hypoxia. In the long term, pulmonary embolism may lead to Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Patients who develop hypotensive massive and submassive pulmonary embolism can be treated with large-bore aspiration thrombectomy. In the acute setting, this improves short-term outcomes by decreasing the ICU stay. It can also reduce the risk of CTEPH. Options for large-bore aspiration thrombectomy include the FlowTriever™ system (Inari Medical, Irvine, CA) and the Lightning 12 vascular thrombectomy system (Penumbra Inc., Alameda, CA). This review discusses the pathophysiology of pulmonary embolism, management, and options for large-bore aspiration thrombectomy.

Transcarotid Artery Revascularization and Advances in Vascular Surgery for Carotid Artery Disease.

Carotid artery atherosclerotic disease impacts over 2 million Americans annually. Since the advent of the carotid endarterectomy by Debakey in 1953, the surgical management of carotid artery stenosis has prevented cerebrovascular accidents. The technology utilized to manage carotid artery stenosis continued to evolve with the utilization of carotid artery stenting in 1989 and more recently transcarotid artery revascularization (TCAR). This review discusses the modern management of carotid artery stenosis with an emphasis on transcarotid artery revascularization (TCAR) and reversal of flow for reversal of flow for embolic protection.

Intravascular Lithotripsy in the Treatment of Lower Extremity Peripheral Arterial Disease.

Endovascular intervention has become first-line treatment for the majority of atherosclerotic lesions associated with peripheral artery disease. Traditionally, treatment modalities have included various types of balloon angioplasty and stenting. However, recent technological advancements have introduced the concept of endovascular lithotripsy as a novel alternative to angioplasty and stenting. This new addition to the armamentarium of surgeons and interventionalists has the potential to alter the treatment paradigm for patients with complex peripheral artery disease.

Double-barrel stenting for endovascular repair of a superior mesenteric artery dissecting aneurysm.

The patient was a 58-year-old man with a history of hypertension who had incidentally been found to have a 2.7-cm dissecting fusiform superior mesenteric artery aneurysm involving a long segment of a proximal to distal superior mesenteric artery. Double-lumen anatomy was present, with the true lumen perfusing the proximal and mid-small bowel and the false lumen perfusing the distal small bowel and the ileocolic artery. The patient elected to undergo endovascular repair using double-barrel stenting with self-expanding and balloon-expandable covered stents, as described. Computed tomography angiography after 1 year demonstrated patent stents.