Paradigm Shift of Interventional Strategies and Outcomes for Acute Limb Ischemia Post-Pandemic.

PURPOSE: We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). METHODS: Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. RESULTS: After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. CONCLUSION: Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. CLINICAL IMPACT: Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.

Sex-Related Disparities in Acute Limb Ischemia Treatment Outcomes.

BACKGROUND: Although a substantial impetus behind disparities research in healthcare exists, those that are sex-related within vascular surgery outcomes are largely unexplored. Consequently, published guidelines lack specificity when it comes to treating male and female patients with vascular disease. Disparities related to patients suffering from chronic limb-threatening ischemia have been broached, although no extensive studies assessing disparities in acute limb ischemia treatment outcomes have come to the forefront. In this study, our aim is to identify and quantify sex-related disparities as they pertain to interventions for acute limb ischemia. METHODS: Using the TriNetX global research network, we conducted a multicenter query across 48 healthcare organizations spanning 5 countries for patients treated for acute limb ischemia. We determined the number of male and female patients that received one of the following interventions: open revascularization, percutaneous mechanical thrombectomy, or catheter-directed thrombolysis and/or adjunctive endovascular procedures. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each sex, including reintervention, major amputation, and death. Risk of adverse outcomes was then compared between treatment groups of the same sex and between sexes. Type-I errors were reduced through utilization of the Holm-Bonferroni method to correct P values. RESULTS: Within our study, we noted several important findings. Females were more likely to receive catheter-directed thrombolysis and/or adjunctive endovascular procedures (P = 0.001) than males. There were no significant differences in the rates of open revascularization or percutaneous mechanical thrombectomy between males and females. Overall, females were more likely to die within 30 days (P < 0.0001) and greater number of males required reintervention within 30 days (P < 0.0001). Analyzing outcomes within individual treatment groups, females undergoing open revascularization or catheter-directed thrombolysis and/or adjunctive endovascular intervention demonstrated a profound increase in mortality within 30 days of intervention (P = 0.0072 and P = 0.0206, respectively), but these differences were not reflected in the percutaneous mechanical thrombectomy group. Limb salvage rates in females were higher than males overall although there were no significant sex differences within any treatment groups specifically. CONCLUSIONS: In conclusion, there was a significantly higher risk of death in females across all treatment groups in the studied timeframe. Limb salvage rates were higher for females in the open revascularization (OR) treatment group, while males were more likely to require a reintervention across all treatment groups. By evaluating these disparities, we can provide greater insight into personalized treatment for patients presenting with acute limb ischemia.

Controversies and evidence for cardiovascular disease in the diverse Hispanic population.

OBJECTIVE: Hispanics account for approximately 17% of the U.S. POPULATION: They are one of the fastest growing racial/ethnic groups, second only to Asians. This heterogeneous population has diverse socioeconomic conditions, making the prevention, diagnosis, and management of vascular disease difficult. This paper discusses the cultural, racial, and social aspects of the Hispanic community in the United States and assesses how they affect vascular disease within this population. Furthermore, it explores risk factors, medical and surgical treatments, and outcomes of vascular disease in the Hispanic population; generational evolution of these conditions; and the phenomenon called the Hispanic paradox. METHODS: A systematic search of the literature was performed to identify all English-language publications from 1991 to 2014 using PubMed, which draws from the National Institutes of Health and U.S. National Library of Medicine, with the words "cardiovascular disease," "prevalence," "vascular," and "Hispanic." An additional search was performed using "cardiovascular disease and Mexico," "cardiovascular disease and Cuba," "cardiovascular disease and Puerto Rico," and "cardiovascular disease and Latin America" as well as for complications, management, outcomes, surgery, vascular disease, and Hispanic paradox. The resulting publications were queried for generational data (spanning multiple well-defined age groups) regarding cardiovascular disease, and cross-references were obtained from their bibliographies. Results are segmented by country of origin. RESULTS: Compared with non-Hispanic whites, Hispanics face higher risks of cardiovascular diseases because of a high prevalence of high blood pressure, obesity, diabetes mellitus, and ischemic stroke. However, the incidence of peripheral arterial disease and carotid disease appears to be significantly lower than in whites. The Hispanic paradox (lower mortality in spite of higher cardiovascular risk factors) may relate to challenges in ascribing life expectancy and cause of death in this diverse population. Low socioeconomic status and high prevalence of concomitant diseases negatively influence the outcomes of all patients, independent of being Hispanic. CONCLUSIONS: Understanding the cultural diversity in Hispanics is important in terms of targeting preventive measures to modify cardiovascular risk factors, which affect development and outcomes of vascular disease. The available literature regarding vascular disease in the Hispanic population is limited, and further longitudinal study is warranted to improve health care delivery and outcomes in this group.

Endovascular Aorto-Iliac Reconstruction vs. Aortobifemoral Bypass as First Choice for a Durable Revascularization for Aorto-Iliac Occlusive Disease.

INTRODUCTION: Aortoiliac occlusive disease (AIOD) is defined as atherosclerotic obstruction of the distal abdominal aorta and iliac arteries. Multiple options exist for management of AIOD including endovascular aortoiliac reconstruction and aortobifemoral bypass. As new technologies are developed, the best approach to manage this condition is evolving. METHODS: We performed a literature review to assess the current state of endovascular aortoiliac reconstruction and aortobifemoral bypass as options for revascularization of aortoiliac occlusive disease. CONCLUSION: Endovascular aortoiliac reconstruction and aortobifemoral bypass are both feasible and clinically effective options for management of aortoiliac occlusive disease. No randomized controlled trial has been performed to show one option to be more effective than the other. Recent literature demonstrates comparable long-term patency, limb salvage and survival among endovascular approaches to the treatment of AIOD with quicker recovery, lower costs and improved quality of life when compared to open aortobifemoral bypass (ABF) surgery. Selection of procedure should be tailored to the individual patient in order to develop an effective long-term successful strategy for management of aortoiliac occlusive disease. Further study is warranted to define durability of these endovascular approaches as well as patient specific characteristics that influence outcomes.

Managing False Lumen Patency in Chronic Thoracic Aortic Dissecting Aneurysms With Coil Embolization.

Thoracic endovascular aortic repair has become the preferred modality of treatment of complicated type B aortic dissections. However, persistent pressurization of the false lumen can lead to negative aortic remodeling with aneurysmal dilation. Described herein is the coil embolization technique that can be used to manage this complication and a review of the literature on the recent development of management options.

Time for radiation safety program guidelines for pregnant trainees and vascular surgeons.

OBJECTIVES: The evolution of endovascular surgery has increased the vascular surgeon's exposure to radiation, raising concern for female vascular trainees and staff of childbearing years. We developed surveys for female trainees, established vascular surgeons, and program directors in vascular surgery to determine current practices with respect to pregnancy and radiation exposure guidelines. METHODS: Two surveys were conducted to evaluate radiation exposure during pregnancy. A survey of the members of the Association of Program Directors in Vascular Surgery was conducted in an attempt to gather information about existing program and institutional radiation policies and assess the need for standard guidelines. A second survey was given to women in vascular surgery in an effort to obtain opinions among concerned groups regarding establishment of a policy from women who were exposed to radiation during and after completion of vascular training. RESULTS: Fifty-three of 181 female vascular surgeons (29% response rate) responded to the survey, with the majority (53% [28/53]) pregnant during training or practice. Though 68% of trainees and 82% of faculty performed endovascular procedures during pregnancy, only 42% of trainees and 50% of faculty wore a fetal badge. One trainee (3.7%) had complications during pregnancy that necessitated cessation of fluoroscopic procedures or limiting call. There were four practicing surgeons who had complications during their pregnancy. Of these, one was hospitalized with fetal decelerations secondary to excessive on-call obligations with double leading and heavy endovascular call coverage. The majority of women (>60%) felt supported by the program and that they were treated fairly. Over 90% of female trainees and faculty felt that establishment of guidelines for radiation safety for all vascular surgeons would be beneficial. Many (77%) felt that a policy would aid in the recruitment of talented women into the field. Thirty-two of 99 Association of Program Directors in Vascular Surgery program directors responded to the survey. Of the 32 program directors that responded (32% response rate), 75% would allow the pregnant trainee flexibility in rotation schedule. Finally, 75% of program directors support development of a national policy, and 81% would incorporate one into their program. CONCLUSIONS: There is compelling interest to establish radiation safety guidelines for the pregnant trainee or vascular surgeon. Consideration should be given at the Society leadership level to develop and support radiation safety guidelines for all vascular surgeons.

Endovascular revascularization of symptomatic infrapopliteal arteriosclerotic occlusive disease: comparison of atherectomy and angioplasty.

The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.

Management of mobile thrombus of the thoracic aorta.

Mobile thrombus of the nonaneurysmal, nonatherosclerotic aorta is a rare condition but presents with catastrophic embolic events. We describe two cases that demonstrate differences in presentation and treatment strategies. We review the literature to discuss initial management as well as surgical options. However, due to the limited number of cases, no definitive guidelines for management exist.

Predictive value of reactive hyperemia for cardiovascular events in patients with peripheral arterial disease undergoing vascular surgery.

OBJECTIVE: Reactive hyperemia is the compensatory increase in blood flow that occurs after a period of tissue ischemia, and this response is blunted in patients with cardiovascular risk factors. The predictive value of reactive hyperemia for cardiovascular events in patients with atherosclerosis and the relative importance of reactive hyperemia compared with other measures of vascular function have not been previously studied. METHODS AND RESULTS: We prospectively measured reactive hyperemia and brachial artery flow-mediated dilation by ultrasound in 267 patients with peripheral arterial disease referred for vascular surgery (age 66+/-11 years, 26% female). Median follow-up was 309 days (range 1 to 730 days). Fifty patients (19%) had an event, including cardiac death (15), myocardial infarction (18), unstable angina (8), congestive heart failure (6), and nonhemorrhagic stroke (3). Patients with an event were older and had lower hyperemic flow velocity (75+/-39 versus 95+/-50 cm/s, P=0.009). Patients with an event also had lower flow-mediated dilation (4.5+/-3.0 versus 6.9+/-4.6%, P<0.001), and when these 2 measures of vascular function were included in the same Cox proportional hazards model, lower hyperemic flow (OR 2.7, 95% CI 1.2 to 5.9, P=0.018) and lower flow-mediated dilation (OR 4.2, 95% CI: 1.8 to 9.8, P=0.001) both predicted cardiovascular events while adjusting for other risk factors. CONCLUSIONS: Thus, lower reactive hyperemia is associated with increased cardiovascular risk in patients with peripheral arterial disease. Furthermore, flow-mediated dilation and reactive hyperemia incrementally relate to cardiovascular risk, although impaired flow-mediated dilation was the stronger predictor in this population. These findings further support the clinical relevance of vascular function measured in the microvasculature and conduit arteries in the upper extremity.

Open direct carotid artery access for coiling of an intracranial aneurysm under conscious sedation.

We describe the case of a 61-year-old patient with significant medical co-morbidities and tortuous vascular anatomy presenting with a large middle cerebral artery aneurysm. To avoid the risks of general anesthesia and circumvent a majority of the tortuous vessels, the aneurysm was accessed by direct open exposure of the common carotid artery under conscious sedation and local anesthesia. We were able to achieve complete endovascular occlusion of the aneurysm and the patient tolerated the procedure well with no intra- or post-operative complications. Use of conscious sedation is possible and safe for direct open common carotid artery access in patients with significant vascular tortuosity that makes the standard trans-femoral approach difficult or impossible.

Diabetic vascular disease: characteristics of vascular disease unique to the diabetic patient.

Diabetes is a cardiovascular disease affecting almost every arterial vascular bed with significant consequences. Vascular disease is one part of a triopathy of complications that singularly but most commonly in combination makes the diabetic patient uniquely susceptible to lower extremity complications. The other two conditions are neuropathy and an altered response to infection. Diabetic peripheral arterial disease has a predilection for the smaller below knee tibial/peroneal arteries and there is no microvascular occlusive arterial disease affecting the diabetic foot. Microvascular dysfunction is not an occlusive phenomenon and supports an aggressive approach to treating existing macrovascular atherogenic occlusive disease complicating diabetic wounds of all extremities. Individualized, patient-centered treatment utilizing all available endovascular and open revascularization options best ensures the highest quality outcomes at a cost our healthcare system can afford.

Limb outcome and mortality in lower and upper extremity arterial injury: a comparison using the National Trauma Data Bank.

OBJECTIVE: To examine the outcomes of lower extremity (LE) and upper extremity (UE) arterial trauma. METHODS: Retrospective review of 2008 version of National Trauma Databank. Adult patient with LE and UE arterial trauma was identified and outcomes were compared. RESULTS: There were 8311 cases of extremity arterial trauma and 37% involved the LE. The LE cohort had higher blunt injury (56.2% vs 37.4%; P < .0001). The LE cohort was more likely to require fasciotomy (23.6% vs 6.7%; P < .0001) and amputation (7.8% vs 1.3%; P < .0001). Complication (18.8% vs 5.1%; P < .0001) and mortality rate (7.7% vs 2.2%, P < .0001) were higher in the LE cohort. Regardless of extremity, blunt trauma was associated with higher mortality (4.8% vs 3.8%; P = .03) and amputation (6.7% vs 1.3%; P < .0001). In multivariable analysis, LE arterial trauma was associated with increased mortality (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.7-2.9; P < .0001) and amputation (OR 4.3, 95% CI 3.2-5.8; P < .0001). CONCLUSIONS: Lower and upper extremity arterial injuries have different modes of presentation and outcomes. Lower extremity arterial trauma is more commonly caused by blunt injury and associated with worse outcomes despite more intensive intervention.

Surgical removal of self-expanding stents from the carotid artery: does the type of stent make a difference?

PURPOSE: To evaluate the degree of difficulty in surgically removing 2 different stent models placed in the canine carotid artery. METHODS: In 5 dogs, each carotid artery was stented with a braided Elgiloy self-expanding stent (BESES) on one side and a surface-spanning micro stent (SSMS) on the other. After 4 weeks, an arteriogram was obtained, and the stents were removed via direct surgical exposure. The minimum lengths of the skin incisions and arteriotomies, the ease of stent removal, and the presence of a distal intimal flap were recorded. RESULTS: Stent deployment and removal were successful in each animal, but there was a substantial difference in the ease of removal. The BESES could be removed in a strand-by-strand fashion via a more proximal, smaller arteriotomy compared to the SSMS (8.8+/-1.3 versus 37.2+/-4.7 mm, p<0.01). Furthermore, a smaller skin incision (3.85+/-0.9 versus 9.75+/-0.5 cm, p<0.01) was required for the BESES. There was no distal flap formation following BESES removal, whereas SSMS removal produced a large distal flap in each artery (p<0.01). CONCLUSIONS: Although rare, restenosis after stenting occurs, and surgical repair may become necessary in some patients. Each stent has inherent advantages and disadvantages, but the braided Elgiloy self-expanding stent lends itself to easier surgical removal, which may have important clinical implications, especially when used in the carotid artery.

Open aneurysm repair at an endovascular center: value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms.

OBJECTIVE: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. METHODS: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P =.04-.001) in the retroperitoneal group. All factors were correlated with outcome. RESULTS: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P >.2). CONCLUSION: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.

Nonoperative management with selective delayed surgery for large abdominal aortic aneurysms in patients at high risk.

OBJECTIVE: An accepted fact is that abdominal aortic aneurysms (AAAs) larger than 5.5 cm should undergo elective repair. However, subsets of these patients have serious comorbid conditions, which greatly increase operative risk. This study evaluated the outcomes of periods of protracted nonoperative observational management with selective delayed surgery in patients at high risk with large infrarenal and pararenal AAAs. METHODS: Among 226 patients with AAAs more than 5.5 cm, we selected 72 with AAAs from 5.6 to 12.0 cm (mean, 7.0 cm) for periods of nonoperative management because of their prohibitive surgical risks. Comorbid factors included a low ejection fraction of 15% to 34% (mean, 22%) in 18 patients, 1 second forced expiratory volume less than 50% (mean, 38%) in 25, prior laparotomy in 10, and morbid obesity in 22. Follow-up examination was complete in the 72 patients for the 6 to 76 months (mean, 23 months) that they underwent nonoperative treatment. Fifty-three patients ultimately underwent operation because of AAA enlargement or onset of symptoms after 6 to 72 months (mean, 19 months) of nonoperative treatment. RESULTS: Of the 72 selected patients, 54 (75%) are living and 18 (25%) are dead. Seven patients who underwent only nonoperative treatment presently survive after 28 to 76 months (mean, 48 months). Of the 18 deaths, AAA rupture occurred in only three patients (4%) who were observed for 12, 31, and 72 months before rupture. Nine other deaths (13%) occurred after 6 to 72 months from comorbidities unrelated to the AAA. Six of the 53 patients who underwent delayed operation died within 30 days of operation (11% mortality rate). The mortality rate for the 154 good-risk patients with an AAA who underwent prompt open or endovascular repair was 2.2%. CONCLUSION: These data indicate that some patients with large AAAs and serious comorbidities are acceptably managed for long periods (6 to 76 months) with nonoperative means. Substantial delays of 12 to 76 months resulted in an AAA rupture rate of only 4%, and 13% of these patients (nine of 72) died of comorbidities unrelated to AAA rupture or surgery. Mortality rate in this group of patients, when operated, was 11% (six of 53). These findings support the selective use of nonoperative management in some patients with large AAAs and serious comorbidities.