DNA origami signposts for identifying proteins on cell membranes by electron cryotomography.

Electron cryotomography (cryoET), an electron cryomicroscopy (cryoEM) modality, has changed our understanding of biological function by revealing the native molecular details of membranes, viruses, and cells. However, identification of individual molecules within tomograms from cryoET is challenging because of sample crowding and low signal-to-noise ratios. Here, we present a tagging strategy for cryoET that precisely identifies individual protein complexes in tomograms without relying on metal clusters. Our method makes use of DNA origami to produce "molecular signposts" that target molecules of interest, here via fluorescent fusion proteins, providing a platform generally applicable to biological surfaces. We demonstrate the specificity of signpost origami tags (SPOTs) in vitro as well as their suitability for cryoET of membrane vesicles, enveloped viruses, and the exterior of intact mammalian cells.

Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair.

OBJECTIVE: Post implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. METHODS: Systematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. RESULTS: After screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. CONCLUSIONS: This systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.

Comparative Analysis of Outcomes of Unibody Endoprosthesis and Aortobifemoral Bypass for Aortoiliac Occlusive Disease.

BACKGROUND: Aortoiliac occlusive disease (AIOD) has traditionally been treated with aortobifemoral bypass (ABF). Unibody endograft (UBE) for AIOD, however, has been increasingly utilized in selected patients. We report outcomes of patients undergoing ABF or UBE for AIOD. METHODS: Patients (2016-2021) undergoing elective ABF or UBE with a unibody device for AIOD were identified at an academic institution. Chi-square and Kaplan-Meier analysis were used to evaluate outcomes by group. RESULTS: One hundred thirty-one patients undergoing UBE or ABF were screened, with 82 included. Twenty-one patients underwent UBE (25.6%) and 61 (74.4%) underwent ABF. UBE patients were older (63.8 vs. 58.2 years; P = 0.01), with a higher prevalence of diabetes (52.4 vs. 19.7%; P = 0.004). Significant differences were seen between UBE and ABF including a shorter surgery length (214 vs. 360 min; P = 0.0001), less blood loss (300 vs. 620 mls; P = 0.001), larger minimum aortic diameter (14.6 vs. 12.6; P = 0.0006), larger common iliac artery (9.5 vs. 7.9; P = 0.005) and lower postoperative ankle-brachial index (0.8 vs. 0.9; P = 0.04). There were no differences in TASC C/D iliac lesions in the UBE than ABF group (66.6% vs. 63.9%; P < 0.82) or Trans-Atlantic Inter-Society Consensus classification femoropopliteal lesions. Unadjusted analysis revealed no significant differences between UBE and ABF for 30-day mortality (0 vs. 1.6%; P = 1), stroke (0 vs. 3.3%; P = 1), or major adverse cardiac events (4.8 vs. 4.9%; P = 1). There were no significant differences in mid-term surgical outcomes over a mean follow-up period of 23.7 months between UBE and ABF groups; specifically endovascular (0 vs. 8.2%; P = 0.3) or open/hybrid reintervention (9.5 vs. 14.8%; P = 0.7) with similar limb occlusion (4.8 vs. 27.8; P = 0.12). Kaplan-Meier estimated primary, primary-assisted, and secondary patency at 36 months were similar with 94%, 100%, and 94% for UBE and 86%, 95%, and 86% for ABF, respectively. Estimated survival at 36 months was 95% for UBE and 97% for ABF (P = 0.8). CONCLUSIONS: Equivalent outcomes were seen between AIOD treated with UBE or ABF in similar patient populations. Mid-term outcomes such as reintervention and patency are similar for UBE and ABF. We still recommend ABF over UBE as a primary modality of treatment in surgically fit patients with greater complexity aortoiliac lesions and with smaller arterial diameters, especially women.

A New Architecture for DNA-Templated Synthesis in Which Abasic Sites Protect Reactants from Degradation.

The synthesis of artificial sequence-defined polymers that match and extend the functionality of proteins is an important goal in materials science. One way of achieving this is to program a sequence of chemical reactions between precursor building blocks by means of attached oligonucleotide adapters. However, hydrolysis of the reactive building blocks has so far limited the length and yield of product that can be obtained using DNA-templated reactions. Here, we report an architecture for DNA-templated synthesis in which reactants are tethered at internal abasic sites on opposite strands of a DNA duplex. We show that an abasic site within a DNA duplex can protect a nearby thioester from degradation, significantly increasing the yield of a DNA-templated reaction. This protective effect has the potential to overcome the challenges associated with programmable, sequence-controlled synthesis of long non-natural polymers by extending the lifetime of the reactive building blocks.

Postoperative complications and their association with post-traumatic stress disorder in academic vascular surgeons.

OBJECTIVES: Postoperative complications are an inherent component of surgical practice. This study seeks to address their association with emotional responses of academic vascular surgeons. METHODS: An anonymous electronic survey was sent to all vascular surgery program directors in North America with a request to disseminate to their faculty. The survey captured data on demographics and practice type and used imbedded validated measures to determine emotional responses to postoperative complications and to assess coping mechanisms. Univariate analysis was performed to determine differences between those who reported at least partial symptoms of post-traumatic stress disorder (PTSD) following their worse major complication over the previous year and those who did not. Multivariable logistic regression analysis was performed for all covariates found significant on univariate analysis, and those deemed clinically relevant. RESULTS: The survey was distributed to 267 faculty at 128 institutions in the United States and 10 institutions in Canada and completed by 65 participants (response rate, 32%). Twenty of 65 (31%) identified as female, and the total group had a mean age of 47 ± 10.2 years. Most respondents (43/65; 66%) reported a major complication within 3 months of the survey, with the majority of respondents (45/65; 69%) reporting the outcome of patient mortality. Of respondents, 20 of 65 (31%) demonstrated at least partial symptoms of PTSD in response to the worst complication from the previous year, with 12 of 65 (19%) meeting the clinical diagnosis of PTSD. Respondents in the PTSD group were more likely to criticize/blame themselves following the complication (P = .0028); less likely to identify the complication as "expected" (P = .048) or to believe causes of their complications were due to others/external factors; and more likely to identify as a female (55% vs 20%; P = .008). Regarding support following major complications, most respondents (57/65; 88%) desired the ability to discuss details of the case with a respected peer. The most common external pressure influencing their emotional responses to complications was maintaining reputation and a sense of honor (66%). Gender differences persisted on multivariate analysis (P = .016). CONCLUSIONS: Emotional responses following major postoperative complications in vascular surgery are common and may pose a risk for PTSD. This may occur more commonly following complications that are unexpected or in cases in which the cause of the complication was due to a perceived or actual surgical mistake. The ubiquitous nature and severity of the emotional toll of major complications for vascular surgeons is poorly described and under-recognized. Gender-related differences may exist, and most surgeons desire a support network of respected peers with whom to discuss complications.

Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell's diverticulum.

OBJECTIVE: Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset. METHODS: Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak. RESULTS: Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms. CONCLUSIONS: Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate.

Characteristics Associated With Failure to Rescue After Open Abdominal Aortic Aneurysm Repair.

INTRODUCTION: Failure to Rescue (FTR), defined as mortality following a complication of care, is an important indicator of hospital care quality. Understanding risk factors associated with FTR in the elective Abdominal Aortic Aneurysm (AAA) population may help surgeons prevent operative mortality. METHODS: Elective open AAA repairs (2008-2018) were identified from Cerner's HealthFacts database using ICD-9 and ICD-10 diagnosis and procedure codes. Patient, hospital, and encounter characteristics were analyzed. Multivariate logistic regression models determined the relative contribution of patient and encounter characteristics leading to FTR. RESULTS: For 1761 patients who underwent open repair for nonruptured AAA, overall mortality was 6.1%. Of patients with one or more complications (40%), mortality was 9.6%, increasing to 21.5% for patients with ≥4 major complications. Complications of care most associated with death were myocardial infarction (MI), gastrointestinal (GI) bleeding, and pulmonary failure. After multivariable adjustment, FTR was associated with advanced age (odds ratio [OR] 1.19 for 5 y, 95% confidence interval [CI] 1.06-1.34); female sex (OR 1.74, 95% CI 1.12-2.70); congestive heart failure (OR 1.65, 95% CI 1.00-2.73); peptic ulcer disease (OR 3.99, 95% CI 1.18-13.5); diabetes (OR 4.90, 95% CI 1.90-12.6), and the number of complications of care. CONCLUSIONS: Complications of care were common following open elective AAA repair. The complications with the highest mortality included MI, GI bleeding, and respiratory failure. FTR was associated with female sex, comorbidities, and increasing numbers of complications of care. Often, the lowest occurring complications had the highest FTR. Adopting gender-specific assessment tools, a protocol-driven approach for perioperative GI prophylaxis, and preoperative MI risk mitigation may lead to reduced FTR.

Frailty Index (mFI-5) Predicts Resource Utilization after Nonruptured Endovascular Aneurysm Repair.

INTRODUCTION: The 5- factor frailty index (mFI-5) has reliably predicted outcomes after vascular surgeries. The purpose of this study was to determine the performance of this index in aortic endovascular surgery ( endovascular aneurysm repair [EVAR]) MATERIALS AND METHODS: The American College of Surgeons' National Surgical Quality Improvement Program Database (NSQIP) was retrospectively analyzed for patients undergoing nonruptured EVAR between 2015 and 2019. Outcomes were assessed using bivariate analysis (Mann Whitney U test, chi-squared test, and t-test) and multivariate logistic regression analysis. RESULTS: 10,450 patients were identified with a mean age of 73.59 (SD 8.93) y. 8222 (78.7%) were performed for large diameter with the remaining indications including dissection, symptomatic, and embolization/thrombosis. 30-d mortality was 1.3%. Univariate analysis showed that mFI-5≥0.6 was associated with higher rates of prolonged hospital stay (18.8% versus 5.7%, P < 0.001, reference mFI-5 = 0), readmission (12.3% versus 5.9%, P < 0.001), mortality (3.6 % versus 1.2%, P = 0.01), intensive care unit (ICU) length of stay more than 3 d (7.2% versus 2.7%, P < 0.001). Female gender higher age, indication for surgery, and mFI-5 were all associated with increased mortality. Multivariate logistic regression showed that mFI-5 remained as a significant predictor with mFI-5≥0.6 predicting a close to 3 times higher odds for 30-d mortality (odds ratio OR 2.83, P = 0.003), ICU length of stay >3 d (OR 2.48, P < 0.001), >7 d hospital stay (OR 3.94, P < 0.001), readmission (OR 2.16, P < 0.001), and pneumonia (OR 4.2, P < 0.001) CONCLUSIONS: The modified frailty index (mFI-5) is a good predictor for postoperative complications and hospital resource utilization after nonruptured EVAR.

A Systematic Review of Contemporary Outcomes from Aortic Arch In Situ Laser Fenestration During Thoracic Endovascular Aortic Repair.

BACKGROUND: In situ laser fenestrated endovascular aortic repair (L-FEVAR) is a novel and creative solution for complex aortic pathologies in the urgent and emergency setting. Outcomes of this technique, however, are poorly reported. We sought to evaluate the efficacy, safety, and outcomes of L-FEVAR in aortic arch pathologies. METHODS: A systematic literature review and analysis were conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses and Cochrane guidelines. A search was conducted using Google, PubMed, and Scopus to identify studies evaluating L-FEVAR. Two independent reviewers determined study inclusion. Case reports and series including < 10 patients were excluded. Reviewers also assessed the methodological quality and extracted data regarding outcomes. A meta-analysis of endoleak event rates was conducted using a fixed-effect model due to small sample size. RESULTS: Eight studies met inclusion criteria between 2013 and 2021. Most studies were retrospective (87.5%) with median follow-up duration of 12.5 months (range 10-42). There were 440 patients included (range 15-148), mostly men (64%). Mean age was 61 years (range 53-68). Included patients were all symptomatic with L-FEVAR being technically successful in 93.3% of cases. The main indication for aortic arch intervention was aortic dissection. Single fenestrations occurred most frequently (68%), followed by triple (22%) then double fenestrations (9%). Meta-analysis of 8 studies (n = 440) demonstrated an endoleak event rate of 0.06 (95% confidence interval 0.04-0.09, P < 0.001) with no observed statistically significant heterogeneity of effects (Q = 7.91, P = 0.34). The median operative time was 162 min (range 53-252) with median length of stay of 10 days (range 7-17). Primary branch patency was 96.6%. Secondary patency rate was 97%. Pooled complication rates such as endoleak occurred in 4.8%, stroke in 2.0%, spinal cord ischemia in 0.2%, retrograde dissection in 0.9%, and 30-day death in 2.0%. Access complications occurred in 0.4%. Antiplatelet regimen was poorly reported in the study cohort. CONCLUSIONS: In situ laser fenestration is a feasible, safe, and effective approach to treat aortic arch disease in patients who are unsuitable for open or custom-made endovascular means. High technical success and excellent short-term branch patency can be achieved. These single-institution series exhibit promising short-term outcomes. In a similar paradigm to investigational device exemptions studies for custom-made and physician modified endografts, these preliminary data make a persuasive argument for larger long-term multi-institutional prospective study of this promising technique.

International Multi-Institutional Experience with Presentation and Management of Aortic Arch Laterality in Aberrant Subclavian Artery and Kommerell's Diverticulum.

BACKGROUND: Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch. METHODS: Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions. RESULTS: 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change. CONCLUSIONS: In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.

Thrombosis or vasospasm: The utility of intraoperative neuromonitoring during TCAR.

OBJECTIVES: Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG). METHODS: We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images. RESULTS: TCAR was undertaken for a 58 year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10 months of follow-up. CONCLUSION: This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.

Opioid utilization after lower extremity amputation for peripheral vascular disease and discharge prescribing recommendations.

OBJECTIVES: Opioids are commonly used for pain control after lower extremity amputations (LEA)-below the knee amputations (BKA) and above the knee amputations (AKA). Well-defined benchmarks for prescription requirements after amputation are deficient. This analysis evaluated opioid utilization after amputation to identify high-risk patients and provide recommendations for post-hospitalization opioid prescriptions at discharge. METHODS: Patients undergoing LEA (2008-2016) with identified peripheral vascular disease were selected from Cerner's Health Facts® database using ICD-9 and 10 diagnosis and procedure codes. Patient demographics, disease severity, comorbidities, and hospital characteristics were evaluated. Post-operative opioid medications administered intravenously and orally during the hospital stay were identified from the data and converted to Morphine Milligram Equivalent per day (MME/d) for an evaluation and comparison during the index hospitalization. Descriptive statistics were used to report continuous and dichotomous variables. Dichotomous variables are reported as n (%) and continuous variables are reported as mean ± standard deviation (SD). Chi-square and T-tests were used as appropriate. RESULTS: 2399 patients who underwent AKA or BKA with peripheral vascular disease were evaluated. Sixty-three percent of the cohort was male, 67% Caucasian, and 42% married, and 58% had a Charlson index >3. The majority of patients had an average length of hospital stay of 5.7 days (M = 5.72, SD = 4.56). Patient groups that used significantly higher MME/d in the early postop period included: BKA (29.2 vs 20.7, p = 0.006), males (62.6 vs 54.0, p < 0.0001), Caucasians (64.3 vs 44.7, p < 0.0001), younger patients (69.6 vs 54.0, p < 0.0001), and those at non-training institutions (66.7 vs 56.7, p < 0.0001). Patients whose hospital stay was greater than 6 days were found to have increased opioid utilization likely secondary to index complications. For those discharged by post-operative day 7, the mean MME utilized on postop day 1 was 59.5 and decreased to a mean MME/d utilization prior to discharge of 17.6. CONCLUSIONS: This analysis demonstrates that younger patients, males, patients with BKAs, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay. At the time of discharge, patients utilized an average of 17.6 MME/d which equates to approximately three hydrocodone/acetaminophen 5/325 mg tablets per day. Based on these findings, vascular surgeons are likely over prescribing opioids at discharge and must be cognizant of appropriate dosing quantities. Prescriptions at discharge should reflect the daily utilization described from this analysis and tapered to avoid chronic utilization, overdose, and possible death.

Importance of the profunda femoris upon patency following aortoiliac procedures.

OBJECTIVE: The importance of the profunda femoris for aortoiliac inflow procedure patency is well-recognized. We aim to quantify the characteristics of the profunda femoris and its relation to patency following aortoiliac inflow procedures. METHODS: Patients undergoing aortoiliac inflow procedures between 2009 and 2019 were identified. These were classified into aorto-bifemoral bypass (ABF), extra-anatomic bypass (EAB), femoral endarterectomy (FEA), and iliac stenting. Preoperative imaging characteristics of the profunda femoris were reviewed as well as outcomes. RESULTS: We performed 269 procedures in 202 patients. Of these, 162 were men (59.8%), with a mean age of 61 years (standard deviation, 11.45 years). A total of 123 patients (45.3%) presented with claudication, 69 (25.9%) with critical limb ischemia, and 30 (11.2%) with acute limb ischemia. Fifty patients (18.6%) underwent ABF, 44 (16.4%) underwent EAB, 57 (21.2%) underwent FEA, and 158 (58.7%) underwent iliac stenting. Fourteen patients (5.2%) underwent FEA plus iliac stenting. Fifty-two patients (19.2%) had an occluded superficial femoral artery. Twenty-four patients (8.9%) had additional outflow procedures performed during the index operation, including infrainguinal endovascular intervention in 10 patients (3.7%), infrainguinal bypass in 10 patients (3.7%), and femoropopliteal thrombectomy in 5 patients (1.9%). The mean follow-up was 17.5 months with overall 2-year primary patency (PP) of 79%. Two-year PP was 94.7% for FEA, 85.6% for ABF, 79.8% for iliac stents, and 62.5% for EAB. Unadjusted analysis revealed that loss of primary assisted patency was associated with active smoking (67.6% vs 48.6%; P = .035), lower creatinine (mean, 0.84 vs 1.06 mg/dL; P = .003), critical limb ischemia vs claudication (37.8% vs 21.4%; P = .037), and profunda femoris with fewer than five branches >2 mm in size (88.2% vs 68.5%; P = .011). Multivariate analysis confirmed that a profunda with five or more branches >2 mm in diameter was significantly associated with a lower risk of thrombosis (odds ratio, 0.30; P = .034). Size of the profunda greater than 6 mm approached statistical significance on univariate analysis (35% of the non-thrombosed vs 21% in the thrombosed; P = .073), but did not significantly affect risk of thrombosis on the multivariate analysis (odds ratio, 0.58; P = .25). The 2-year PP when all operations were considered was 76% compared with 72% for profunda with fewer than five branches > 2 mm. CONCLUSIONS: Anatomic characteristics of the profunda are associated with patency of inflow procedures. Care should be taken to assess the main profunda and branch diameters on preoperative imaging. A concomitant infrainguinal procedure should be considered in cases of profunda with inadequate large branches, to ensure long-term patency of the inflow operation.

Outcomes of elective abdominal aortic aneurysm repair in the setting of malignancy.

OBJECTIVE: Elective abdominal aortic aneurysm (AAA) repair for patients with a diagnosis of cancer has remained controversial. In the present study, we evaluated the in-hospital outcomes for patients who had undergone AAA repair in the setting of a cancer diagnosis. METHODS: Inpatients (2008-2018) who had undergone elective AAA repair were selected from the Cerner Health Facts database using International Classification of Diseases, ninth and tenth revision, procedure codes. We used χ2 analysis and logistic regression models to evaluate the association of patient characteristics with the medical and vascular outcomes. RESULTS: A total of 8663 patients who had undergone AAA repair were identified (270 with a cancer diagnosis and 8393 without a cancer diagnosis). No significant demographic differences were found between the two groups, except that more patients with a cancer diagnosis had undergone endovascular aneurysm repair (EVAR) than open aneurysm repair (88.2% vs 82.1%; P = .01). Male reproductive organ (24.8%) and lung (24.4%) cancer were the most common cancer diagnoses in the cohort. The unadjusted analysis revealed that patients with a cancer diagnosis were more likely to require remedial EVAR (relative risk, 3.47; 95% confidence interval [CI], 1.18-10.2) or reoperation for bleeding, infection, or thrombosis (relative risk, 1.59; 95% CI, 1.09-2.32). Multivariable analysis demonstrated that, overall, patients with a cancer diagnosis were more likely to require a prolonged length of stay (odds ratio [OR], 2.2; 95% CI, 1.5-3.3) and to have developed respiratory failure (OR, 2.1; 95% CI, 1.3-3.4) or infection (OR, 1.7; 95% CI, 1.2-2.4). Similar point estimates were found for men with and without a cancer diagnosis. However, women with a cancer diagnosis had a greater odds of a prolonged length of stay compared with women without a cancer diagnosis (OR, 2.6; 95% CI, 1.2-5.6). EVAR in the presence of a cancer diagnosis was also significantly associated with poor outcomes. CONCLUSIONS: Elective AAA repair for patients with a cancer diagnosis was associated with a prolonged length of stay and the development of infection, respiratory failure, and vascular-specific complications during the inpatient hospitalization. Given that differences in outcomes stratified by gender and treatment modality have been shown for patients with a cancer diagnosis, careful patient selection is important and reinforces the finding that cancer exerts negative systemic postoperative effects even when treated or quiescent.

Surfactant Protein A, a Novel Regulator for Smooth Muscle Phenotypic Modulation and Vascular Remodeling-Brief Report.

OBJECTIVE: The objective of this study is to determine the role of SPA (surfactant protein A) in vascular smooth muscle cell (SMC) phenotypic modulation and vascular remodeling. Approach and Results: PDGF-BB (Platelet-derived growth factor-BB) and serum induced SPA expression while downregulating SMC marker gene expression in SMCs. SPA deficiency increased the contractile protein expression. Mechanistically, SPA deficiency enhanced the expression of myocardin and TGF (transforming growth factor)-ß, the key regulators for contractile SMC phenotype. In vivo, SPA was induced in medial and neointimal SMCs following mechanical injury in both rat and mouse carotid arteries. SPA knockout in mice dramatically attenuated the wire injury-induced intimal hyperplasia while restoring SMC contractile protein expression in medial SMCs. These data indicate that SPA plays an important role in SMC phenotype modulation and vascular remodeling in vivo. CONCLUSIONS: SPA is a novel protein factor modulating SMC phenotype. Blocking the abnormal elevation of SPA may be a potential strategy to inhibit the development of proliferative vascular diseases.

30-Day Readmission and Outcomes after Fenestrated Versus Traditional Endovascular Aortic Aneurysm Repair.

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) has emerged as a minimally invasive alternative for repairing complex abdominal aortic aneurysms (AAA). Comparisons of outcomes for FEVAR and traditional endovascular aneurysm repair (EVAR) are limited. We evaluated outcomes following elective endovascular AAA repair with FEVAR or EVAR. METHODS: Hospitalizations for elective nonruptured AAA repair from 2014 to 2016 were selected from the Nationwide Readmissions Database (NRD) using ICD-9 and ICD-10 procedure and diagnosis codes. In-hospital mortality, length of stay (LOS), complications, 30-day readmission, and charges were evaluated. Multivariable logistic regression was used to control for confounding between groups. RESULTS: We identified 23,262 EVAR and 2,373 FEVAR with nonruptured elective procedures. In-hospital mortality was 0.14% for both groups (P = 0.99). Of those at risk for readmission (21,152 EVAR, 1,915 FEVAR), index LOS was greater for FEVAR compared to EVAR, 1.8 days versus 1.7 days (P = 0.028). There was no difference in procedure type based on hospital location (P = 0.37), teaching status (P = 0.17) or hospital size (P = 0.26). During the index hospitalization, pneumonia, renal, and respiratory complications were similar between groups (all P > 0.05). FEVAR patients were more likely to experience cardiac complications (P = 0.0098) or hemorrhage (P = 0.029). Total charges for the index stay were greater for FEVAR compared to EVAR ($125,381 vs. $113,513, P < 0.0001). All-cause 30-day readmission was similar between groups (7.0% EVAR vs. 8.0% FEVAR, P = 0.37), as were time to readmission (11.9 vs. 13.3 days, P = 0.16) and readmission charges ($53,967 vs. $56,617, P = 0.75). Renal failure was the most common readmission stay complication, with similar rates for EVAR and FEVAR patients (P = 0.22). Pneumonia was a more common complication during the readmission stay for EVAR patients (P = 0.004). Renal disease and chronic pulmonary disease were the most common comorbidities in the readmission stay for both groups. CONCLUSIONS: For patients with nonruptured elective AAA, FEVAR was not associated with increased mortality, length of stay, readmission, or most complications compared to traditional EVAR. Despite the increased technical complexity of cannulating and stenting visceral arteries with FEVAR, these data demonstrate that FEVAR carries a similar risk of renal, respiratory, and infectious complications compared to traditional EVAR. FEVAR patients were more likely to experience hemorrhagic and cardiac complications during the index hospitalization. EVAR patients were more likely to have pneumonia during readmission. The overall risk for readmission after an endovascular aortic repair was associated with female sex, greater age, chronic pulmonary disease, malignancy, and loss of function. Further investigations into the causes and prevention of 30-day readmissions are needed for both procedures.

Outcomes of Endovascular Aneurysm Repair with Adjunctive Stenting.

BACKGROUND: Endovascular aneurysm repair is the standard of care for abdominal aortic aneurysm repair, however data regarding adjunctive stenting at the time of endovascular aneurysm repair (EVAR) are limited. The study aims to evaluate outcomes of patients undergoing EVAR with and without adjunctive stenting. METHODS: Patients undergoing EVAR with stenting (EVAR-S) and without stenting (EVAR) (2008 - 2017) were selected from Cerner HealthFacts database using ICD-9 diagnosis and procedure codes. Chi-square analysis and multivariable logistic regression were used to evaluate the association of patient characteristics with medical and vascular outcomes. RESULTS: 4,957 patients undergoing EVAR procedures were identified (3,816 EVAR and 1,141 EVAR-S). Demographic analysis revealed that patients who underwent EVAR-S had higher Charlson comorbidity scores (2.35 vs. 2.13, P = 0.0001). EVAR-S was associated with a greater frequency of vascular complications such as thrombolysis/percutaneous thrombectomy (0.9% vs. 0.2%; P < 0.0004). There were no differences seen in access complications between EVAR and EVAR-S. Multivariable analysis revealed that EVAR-S was associated with prolonged length of stay (OR 1.37, 95% CI 1.03-1.82), readmission < 30 days (OR 1.36, 95% CI 1.11-1.68), major adverse cardiac events (OR 1.59, 95% CI 1.09-2.32), respiratory complications (OR 1.47, 95% CI 1.16-1.88) and renal failure (OR 1.57, 95% CI 1.16-2.11). CONCLUSION: Endovascular aneurysm repair with adjunctive stenting (EVAR-S) was associated with vascular complications requiring reintervention, although the overall rate was very low. As well, readmission within 30 days, cardiac complications, respiratory problems and renal failure were more likely when compared to standard EVAR. The need for adjunctive stenting acts as a marker for an overall sicker and more complex population, not just in terms of vascular complications but across all medical complications as well. Staging the procedure may be helpful in terms of spreading out the operative risk into smaller portions. Furthermore, consideration of a non-operative strategy should be discussed with the patient if the risk of the procedure outweighs the risk of aneurysm rupture in high-risk groups.

Balloon-Assisted Endovascular Thrombectomy for Tibial Thromboembolism.

We present a novel approach to endovascular thrombectomy using the Penumbra Indigo® Aspiration System with balloon assistance for a thromboembolic occlusion to the tibioperoneal trunk and tibial arteries causing acute limb ischemia. This technique allows for effective suction thrombectomy of distal vessels into a shorter, large-diameter aspiration catheter, thereby overcoming the limitations of the longer but smaller aspiration catheters.

Preoperative HbA1c and Outcomes following Lower Extremity Vascular Procedures.

BACKGROUND: Limited data exist evaluating preoperative hemoglobin A1c (HbA1c) in patients undergoing vascular procedures for peripheral arterial disease (PAD). This study evaluated the relationship of preoperative HbA1c on outcomes after open and endovascular lower extremity (LE) vascular procedures for PAD. METHODS: We selected patients with PAD admitted for elective LE procedures between September 2008 and December 2015 from the Cerner Health Facts® database using International Classification of Disease, Ninth Edition, Clinical Modification diagnosis and procedure codes. Bivariable analysis and multivariable logistic models examined the association of patient characteristics, procedure type, and preoperative HbA1c (normal < 6.5%, high ≥ 6.5%) with postsurgical outcomes that included infection, renal failure, respiratory or cardiac complications, length of stay, in-hospital mortality, and readmission. RESULTS: Of 4087 patients who underwent a LE vascular procedure for PAD, 2462 (60.2%) had a preoperative HbA1c recorded. The cohort was mostly male (60%), white (73%), and underwent endovascular intervention (77%). Patients with high HbA1c levels were more likely of black race (P < 0.02) and had significantly higher comorbidities (P < 0.0001). Elevated HbA1c was associated with diabetes (P < 0.0001) and cellulitis (P = 0.05) on unadjusted analysis. Multivariable logistic regression (adjusting for patient, hospital, comorbidity and procedural characteristics) revealed that elevated HbA1c was significantly associated with 30-day readmission (OR = 1.06, 95% confidence interval = 1.00-1.12), but was not associated with the other outcomes. An independent diagnosis of diabetes was not predictive of complications or readmission. CONCLUSIONS: Historic glucose control, as evidenced by a high preoperative HbA1c level, is not associated with adverse outcome, other than readmission, in patients undergoing LE procedures for PAD. Given the known association of high perioperative glucose levels with poor outcome following vascular procedures, this is suggestive of a more important effect of perioperative, as opposed to chronic, glucose control upon outcome. Thus, we suggest focusing efforts on creating standardized goal-directed guidelines for glucose control in the perioperative period for LE vascular procedures to potentially mitigate complications.

Chimney endovascular aneurysm repair (ChEVAR) for hostile neck complex aneurysm.

OBJECTIVE: Recent guidelines recognize the role of chimney endovascular aneurysm repair (ChEVAR) in the treatment of complex aortic disorders. The optimal configuration and number of visceral vessels that can be incorporated is still controversial. We aim to review outcomes from a multi-institutional decade-long experience with ChEVAR. METHODS: Patients undergoing ChEVAR with multiple (≥2) chimney branches were selected from a prospectively maintained database at the two academic university hospitals. All patients were poorly suited for fenestrated or branched endograft repair (F/BEVAR) and deemed poor-risk for open surgery. RESULTS: Forty-nine multiple ChEVAR were performed in 44 men and 5 women, with complete outcome data at a mean follow-up of 18 months. Overall, 2 patients died during follow-up (4%) with no aneurysm-related mortality and two ruptures after ChEVAR (4.1%) due to a type Ib endoleak from iliac limb pullout and persistent gutter-flow, both repaired with endovascular means. No stroke or spinal cord ischemia was noted during the follow-up period. Reintervention was undertaken in eight patients (16.3%) with five reinterventions for persistent gutter-flow and four chimney graft-associated. Three-vessel ChEVAR was performed in 16 patients, with two-vessel ChEVAR in 33 patients for a total of 114 chimney branches (mean 2.3 chimneys per patient). There were 21 superior mesenteric artery (SMA), 45 right renal, 46 left renal artery (LRA), and two accessory LRA chimneys placed. Antegrade configuration of chimney branches was chosen in 43 patients (88%). There were no significant differences between three-vessel and two-vessel ChEVAR upon univariate analysis in aneurysm size (65.6 vs 60.5 mm; p = 0.059), iliac diameter (7.3 vs 7.1 mm; p = 0.85), or endograft oversizing (30 vs 32.5%; p = 0.43). Three-vessel ChEVAR was associated with a larger aneurysm neck diameter (28.4 vs 25.0 mm; p = 0.021), shorter native infrarenal neck (0.5 vs 3.37 mm; p = 0.002) as well as longer seal zone (36.33 vs 22.67 mm; p = 0.005) compared with two-vessel ChEVAR. At follow-up, there were no significant differences in gutter area between three-vessel and two-vessel ChEVAR (18.9 vs 15.7 mm3; p = 0.73) nor the rate of persistent gutter-flow (12.5 vs 9.1%; p = 0.71). CONCLUSION: Reintervention to multiple chimney grafts and for persistent gutter-flow is higher compared to single chimneys and demands close surveillance. However, based upon this combined transantlantic experience, we believe multiple ChEVAR provides a reasonable and safe option for complex aortic aneurysm repair when open or custom endografts are not available or indicated based on their Instructions For use, even when triple chimney grafts are required. The optimal configuration for multiple ChEVAR still warrants further study, although theoretical preliminary advantages may exist for a combination of antegrade and retrograde chimneys.