Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures.

BACKGROUND: Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. METHODS: One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. RESULTS: One-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. CONCLUSIONS: Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.

Outcome benefit of arterial duplex stent imaging after superficial femoral artery stent implantation.

OBJECTIVE: In-stent stenosis is a frequent complication of superficial femoral artery (SFA) endovascular intervention and can lead to stent occlusion or symptom recurrence. Arterial duplex stent imaging (ADSI) can be used in the surveillance for recurrent stenosis; however, its uniform application is controversial. In this study, we aimed to determine, in patients undergoing SFA stent implantation, whether surveillance with ADSI yielded a better outcome than in those with only ankle-brachial index (ABI) follow-up. METHODS: We performed a retrospective analysis of all patients undergoing SFA stent implantation for occlusive disease at a tertiary care referral center between 2009 and 2016. The patients were divided into those with ADSI and those with ABI follow-up only. Life-table analysis comparing stent patency, major adverse limb events (MALEs), limb salvage, and mortality between groups was performed. RESULTS: There were 248 patients with SFA stent implantation included, 160 in the ADSI group and 88 in the ABI group. Groups were homogeneous in clinical indications of claudication and critical limb-threatening ischemia (for ADSI, 39% and 61%; for ABI, 38% and 62%; P = .982) and TransAtlantic Inter-Society Consensus class A, B, C, and D lesions (for ADSI, 17%, 45%, 16%, and 22%; for ABI, 21%, 43%, 16%, and 20%; P = .874). Primary patency was similar between groups at 12, 36, and 56 months (ADSI, 65%, 43%, and 32%; ABI, 69%, 34%, and 34%; P = .770), whereas ADSI patients showed an improved assisted primary patency (84%, 68%, and 54%) vs ABI patients (76%, 38%, and 38%; P = .008) and secondary patency. There was greater freedom from MALEs in the ADSI group (91%, 76%, and 64%) vs the ABI group (79%, 46%, and 46%; P < .001) at 12, 36, and 56 months of follow-up. ADSI patients were more likely to undergo an endovascular procedure as their initial post-SFA stent implantation intervention (P = .001), whereas ABI patients were more likely to undergo an amputation (P < .001). CONCLUSIONS: In SFA stent implantation, patients with ADSI follow-up demonstrate an advantage in assisted primary patency and secondary patency and are more likely to undergo an endovascular reintervention. These factors are likely to have effected a decrease in MALEs, indicating the benefit of a more universal adoption of post-SFA stent implantation follow-up ADSI.

Contrast-induced nephropathy after peripheral vascular intervention: Long-term renal outcome and risk factors for progressive renal dysfunction.

OBJECTIVE: Contrast-induced nephropathy (CIN) is a frequently used quality outcome marker after peripheral vascular interventions (PVIs). Whereas the factors associated with CIN development have been well documented, the long-term renal effects of CIN after PVI are unknown. This study was undertaken to investigate the long-term (1-year) renal consequences of CIN after PVI and to identify factors associated with renal function deterioration at 1-year follow-up. METHODS: From 2008 to 2015, patients who had PVI at our institution (who were part of a statewide Vascular Interventions Collaborative) were queried for those who developed CIN. CIN was defined by the Collaborative as an increase in serum creatinine concentration of at least 0.5 mg/dL within 30 days after intervention. Preprocedural dialysis patients or patients without postprocedural creatinine values were excluded. Preprocedural, postprocedural, and 1-year serum creatinine values were abstracted and used to estimate glomerular filtration rate (GFR). ΔGFR was defined as preprocedural GFR minus 1-year GFR. Univariate and multivariate analyses for ΔGFR were performed to determine factors associated with renal deterioration at 1 year. RESULTS: From 2008 to 2015, there were 1323 PVIs performed; 881 patients met the inclusion criteria. Of these, 57 (6.5%) developed CIN; 47% were male, and 51% had baseline chronic kidney disease. CIN resolved by discharge in 30 patients (53%). Using multivariate linear regression, male sex (P = .027) and congestive heart failure (P = .048) were associated with 1-year GFR decline. Periprocedural variables related to 1-year GFR decline included percentage increase in 30-day postprocedural creatinine concentration (P = .025), whereas CIN resolution by discharge (mean, 13.1 days) was protective for renal function at 1 year (P = .02). A post hoc analysis was performed with 50 PVI patients (randomly selected) who did not develop CIN, comparing their late renal function with that of the CIN group stratified by the periprocedural 30-day variables. Patients with CIN resolution at discharge had similar 1-year renal outcomes to non-CIN patients, whereas the CIN-persistent (at discharge) patients had greater renal deterioration at 1 year compared with non-CIN patients (P = .016). CONCLUSIONS: Male sex and congestive heart failure are risk factors for further renal function decline in patients developing CIN after PVI. The magnitude and duration of increase in creatinine concentration (CIN persistence at discharge) correlated with late progressive renal dysfunction in CIN patients, suggesting that early-resolving CIN is relatively benign.

Survival after abdominal aortic aneurysm repair is affected by socioeconomic status.

OBJECTIVE: The association between socioeconomic status (SES) and outcome after abdominal aortic aneurysm (AAA) repair is largely unknown. This study aimed to determine the influence of SES on postoperative survival after AAA repair. METHODS: Patients undergoing surgical treatment of AAA at a tertiary referral center between January 1993 and July 2013 were retrospectively collected. Thirty-day postoperative mortality and long-term mortality were documented through medical record review and the Michigan Social Security Death Index. SES was quantified using the neighborhood deprivation index (NDI), which is a standardized and reproducible index used in research that summarizes eight domains of socioeconomic deprivation and is based on census tracts derived from patients' individual addresses. The association between SES and survival was studied by univariable and multivariable Cox regression analysis. RESULTS: A total of 767 patients were included. The mean age was 73 years; 80% were male, 77% were white, and 20% were African American. There was no difference in SES of patients who underwent open vs endovascular repair of AAA (P = .489). The average NDI was -0.18 (minimum, -1.47; maximum, 2.35). After adjusting for the variables that were significant on univariable analysis (age, medical comorbidities, length of stay, and year of surgery), the association between NDI and long-term mortality was significant (P = .021; hazard ratio, 1.21 [1.05-1.37]). CONCLUSIONS: Long-term mortality after AAA repair is associated with SES. Further studies are required to assess which risk factors (behavioral, psychosocial) are responsible for this decreased long-term survival in low SES patients after AAA repair.

Cryopreserved Allograft in the Management of Native and Prosthetic Aortic Infections.

BACKGROUND: The management of patients with aortic native and prosthetic infections is associated with significant morbidity and mortality. We describe a single-center experience with the use of cryopreserved allografts for the treatment of aortic infections, and compare outcomes with rifampin-soaked grafts and extra-anatomic bypass. METHODS: We retrospectively reviewed all patients who underwent an operative intervention for aortic infection at our tertiary care center from August 2007 to August 2017. Demographic data, preoperative work-up, procedural details, and outcomes were collected for each treatment modality. RESULTS: Thirty-two patients had aortic revascularization for aortic infection. Seventeen patients had cryopreserved allografts, 10 had rifampin-soaked grafts, and 5 had extra-anatomic bypass. Sixteen patients (50%) had native aortic infection and 16 patients (50%) had prosthetic aortic infection. Eighteen had involvement of the infrarenal abdominal aorta, 12 of the paravisceral aorta, and 2 of the descending thoracic aorta. Early mortality was 5.9% (1/17) for the cryopreserved group, 10% (1/10) for the rifampin-soaked group, and 40% (2/5) for the extra-anatomic bypass group. Early graft-related complications occurred in 1 patient (cryopreserved group). Mean follow-up was 34.8 months. Late death occurred in 4 patients with cryopreserved allografts, 2 with rifampin-soaked grafts and none with extra-anatomic bypass. Late graft-related complications occurred in 4 patients (cryopreserved group). Only 1 patient had recurrence of aortic infection (cryopreserved group) and 2 patients had limb loss (1 from the cryopreserved group and 1 from the rifampin-soaked group). At 1 month, 6 months, 1 year, and 3 years, estimated survival for patients with cryopreserved allografts was 94%, 82%, 75%, and 64%, respectively. CONCLUSIONS: The management of aortic infections is challenging. In patients who do not need immediate intervention, in situ aortic reconstruction with cryopreserved allografts is a viable treatment modality with relatively low morbidity and mortality.

Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms.

OBJECTIVE: It is not clear whether endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) results in an increase in renal insufficiency during the long term compared with open repair (OR). We reviewed our experience with AAA repair to determine whether there was a significant difference in postoperative and long-term renal outcomes between OR and EVAR. METHODS: A retrospective cohort study was conducted of all patients who underwent AAA repair between January 1993 and July 2013 at a tertiary referral hospital. Demographics, comorbidities, preoperative and postoperative laboratory values, morbidity, and mortality were collected. Patients with ruptured AAAs, preoperative hemodialysis, juxtarenal or suprarenal aneurysm origin, and no follow-up laboratory values were excluded. Preoperative, postoperative, 6-month, and yearly serum creatinine values were collected. Glomerular filtration rate (GFR) was calculated on the basis of the Chronic Kidney Disease Epidemiology Collaboration equation. Acute kidney injury (AKI) was classified using the Kidney Disease: Improving Global Outcomes guidelines. Change in GFR was defined as preoperative GFR minus the GFR at each follow-up interval. Comparison was made between EVAR and OR groups using multivariate logistics for categorical data and linear regression for continuous variables. RESULTS: During the study period, 763 infrarenal AAA repairs were performed at our institution; 675 repairs fit the inclusion criteria (317 ORs and 358 EVARs). Mean age was 73.9 years. Seventy-nine percent were male, 78% were hypertensive, 18% were diabetic, and 31% had preoperative renal dysfunction defined as GFR below 60 mL/min. Using a multivariate logistic model to control for all variables, OR was found to have a 1.6 times greater chance for development of immediate postoperative AKI compared with EVAR (P = .038). Hypertension and aneurysm size were independent risk factors for development of AKI (P = .012 and .022, respectively). Using a linear regression model to look at GFR decline during several years, there was a greater decline in GFR in the EVAR group. This became significant starting at postoperative year 4. AKI and preoperative renal dysfunction were independent risk factors for long-term decline in renal function. CONCLUSIONS: Although AKI is less likely to occur after EVAR, patients undergoing EVAR experience a significant but delayed decline in GFR over time compared with OR. This became apparent after postoperative year 4. Studies comparing EVAR and OR may need longer follow-up to detect clinically significant differences in renal function.

Cerebrovascular injuries found in acute type B aortic dissections are associated with blood pressure derangements and poor outcome.

OBJECTIVE: Cerebrovascular injury (CVI) is a recognized but underappreciated complication of acute type B aortic dissection (ATBAD). This study was performed to determine risk factors for CVI associated with ATBAD and, in particular, the possible contributory role of aggressive anti-impulse therapy. METHODS: A retrospective review of all patients presenting to a tertiary medical center with an ATBAD between January 2003 and October 2012 was conducted. All CVIs were adjudicated by a vascular neurologist and assigned a probable cause. The initial intensity of anti-impulse therapy was defined as the difference in mean arterial pressure (ΔMAP) from presentation to subsequent admission to the intensive care unit. RESULTS: A total of 112 patients were identified. The average age was 61 years; 64% were male, and 59% were African American. Twenty patients required operative intervention (14 thoracic endovascular aortic repairs and 6 open). CVI occurred in 13 patients (11.6%): 9 were hypoperfusion related (6 diffuse hypoxic brain injuries and 3 watershed infarcts), 2 were procedure related (both thoracic endovascular aortic repairs), 1 was an intracranial hemorrhage on presentation, and 1 was a probable embolic stroke on presentation. CVI patients had demographics and comorbidities comparable to those of the non-CVI patients. CVI was associated with operative intervention (54% vs 13%; P = .002). Thirty-day mortality was significantly higher in CVI patients (54% vs 6%; P < .001). Patients who suffered a hypoperfusion brain injury had a higher MAP on presentation to the emergency department (142 mm Hg vs 120 mm Hg; P = .034) and a significantly greater reduction in MAP (ΔMAP 49 mm Hg vs 15 mm Hg; P < .001) by the time they reached the intensive care unit compared with the non-CVI patients. CONCLUSIONS: In our series, CVI in ATBAD is more frequent than previously reported and is associated with increased mortality. The most common causes are related to cerebral hypoperfusion. Higher MAP on presentation and greater decline in MAP are associated risk factors for hypoperfusion-related CVI. A less aggressive approach to lowering MAP in ATBAD warrants further study in an attempt to reduce CVI in ATBAD.

Open aneurysmorrhaphy for repair of a massive iliac vein aneurysm and review of the recent literature.

An iliac vein aneurysm is a rare vascular anomaly, scarcely reported in the vascular literature. We present the case of a 72-year-old man with a history of a remote heart transplant complicated by severe tricuspid regurgitation and traumatic abdominal injury, who was incidentally found to have a 10-cm right common iliac vein aneurysm. Because of the size and risk of rupture, we elected to treat him with surgical iliac vein aneurysmorrhaphy. His iliac venous diameter and flow continued to be stable at subsequent follow-up.

Rate of Ipsilateral Chronic Limb-Threatening Ischemia (CLTI) After Kidney Transplantation: A Retrospective Single-Center Study.

OBJECTIVE: To analyze whether the rate of lower extremity (LE) ischemia is higher on the ipsilateral side after kidney transplantation. METHODS: Our institutional transplant database was retrospectively queried for all patients who received a kidney transplant and underwent subsequent LE revascularization or major limb amputations between January 2004 and July 2020. The one-sample binomial test was used to test whether the LE ipsilateral to the transplanted kidney was at higher risk of peripheral arterial disease (PAD) complications necessitating intervention (major amputation or revascularization). RESULTS: There were 1,964 patients who received a kidney transplant during the study period. Of these, 51 patients (3%) had subsequent LE arterial revascularizations or major amputations. The mean age was 58 ± 10 years, and 37 patients (73%) were male. A total of 33 patients had ipsilateral LE vascular interventions (26 major amputations and seven revascularizations) while 18 patients had contralateral vascular interventions (14 major amputations and four revascularizations) (P = 0.049). The average interval between transplantation and subsequent vascular intervention was 52 months for the ipsilateral intervention group and 41 months for the contralateral intervention group (P = 0.33). CONCLUSIONS: In patients who received kidney transplantation and required subsequent LE surgical intervention, we observed an association between the side of transplantation and the risk of future ipsilateral LE arterial insufficiency. Further studies are needed to determine the etiology of this association.

Progressive stenosis of a popliteal artery stent graft by laminated thrombus.

We present a case of failed popliteal artery aneurysm repair using a Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) due to laminated thrombus formation. A 75-year-old man presented with a symptomatic popliteal artery aneurysm. He was treated with a Viabahn stent graft. On follow-up, the patient complained of lower extremity claudication, and duplex ultrasound examination showed a focal intrastent stenosis. A computed tomography scan showed a significant stenosis within the stent graft, at the level of the knee joint creases. The patient underwent superficial femoral artery to distal popliteal surgery. This case report aims to expand on the mechanism of stent graft failure in popliteal aneurysms.

COVID-19 Pandemic Significantly Decreases Acute Surgical Complaints.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic significantly reduced elective surgery in the United States, but the impact of COVID-19 on acute surgical complaints and acute care surgery is unknown. STUDY DESIGN: A retrospective review was performed of all surgical consults at the Hospital of the University of Pennsylvania in the 30 days prior to and 30 days following confirmation of the first COVID-19 patient at the institution. Consults to all divisions within general surgery were included. RESULTS: Total surgical consult volume decreased by 43% in the post-COVID-19 period, with a significant reduction in the median daily consult volume from 14 to 8 (P < .0001). Changes in consult volume by patient location, chief complaint, and surgical division were variable, in aggregate reflecting a disproportionate decrease among less acute surgical complaints. The percentage of consults resulting in surgical intervention remained equal in the 2 periods (31% vs 28%, odds ratio 0.85, 95% CI 0.61-1.21, P = .38) with most but not all operation types decreasing in frequency. The rise in the COVID-19 inpatient census led to increased consultation for vascular access, accommodated at our center by the creation of a new surgical procedures team. CONCLUSION: The COVID-19 pandemic significantly altered the landscape of acute surgical complaints at our large academic hospital. An appreciation of these trends may be helpful to other Departments of Surgery around the country as they deploy staff and allocate resources in the COVID-19 era.

Early clinical experience using telemedicine for the management of patients with varicose vein disease.

INTRODUCTION: The use of telemedicine services may be effective in the perioperative management of patients with varicose veins. METHODS: Over a seven-month period, patients with varicose veins were evaluated in the virtual clinic via two-way secure videoconferencing or the traditional clinic by the same physician provider. Data sources included institutional Vascular Quality Initiative registry and patient satisfaction surveys. RESULTS: Among a total of 121 patients with varicose veins who underwent endovenous catheter ablation of the saphenous vein, 20 patients (16.5%) chose the telemedicine clinic (Group A) and 101 patients (83.5%) chose the traditional clinic (Group B) for their perioperative management. Comparing Group A and Group B, the mean age was 59.2 ± 12.1 versus 59.6 ± 13.0, respectively ( p = 0.944); women were 75% versus 73.3%, respectively ( p = 0.872); African Americans comprised 5% versus 22.8%, while Caucasians comprised 95% versus 63%, respectively ( p = 0.049). Half of the telemedicine patients had multiple virtual visits for a total of 31 virtual encounters. Among telemedicine patients using SurveyMonkey®, 29 telemedicine encounters (93.5%) reported that their virtual visit is "Yes, definitely" or "Yes, somewhat" more convenient over traditional methods. All patients answered that they were able to communicate clearly with the provider, able to have their questions answered, and able to clearly hear and see the provider via telemedicine methods. DISCUSSION: Telemedicine services enable another means to deliver high-quality care for patients with venous disease in a safe and coordinated manner. Patients with varicose veins are highly satisfied with the use of telehealth services over the traditional healthcare delivery model.

Post-anastomotic venous stenosis after Optiflow deployment: An unexpected outcome.

Arteriovenous fistula failure represents a major cause of hospitalization and a significant economic burden for end-stage renal disease patients on hemodialysis. The Optiflow (Bioconnect Systems Inc., Ambler, PA) is a new device developed to improve arteriovenous fistula outcomes and decrease failure rates by reducing the risk of stenosis and improving maturation rates. This case report describes a 50-year-old male with hypertensive nephropathy on dialysis who had multiple arteriovenous fistula failures in the past. He was scheduled to undergo brachiocephalic fistula construction using the Optiflow device. After 8 months of use, the new fistula developed a peri-anastomotic venous stenosis, just distal to the Optiflow device. To our knowledge, this is the first time such a complication has been reported.

Compression of endograft limb after translumbar embolization of a type II endoleak using n-butyl cyanoacrylate.

Cyanoacrylate "glue" has been used in a variety of surgical disciplines. In vascular surgery, it has been used to seal type II endoleaks after endovascular aneurysm repair. In this case, we report a rare complication after translumbar injection of n-butyl cyanoacrylate to occlude a persistent type II endoleak. The cyanoacrylate resulted in significant compression of the right iliac graft limb with reduced distal perfusion.

Men present with higher clinical class of chronic venous disease before endovenous catheter ablation.

BACKGROUND: Risk factors for chronic venous disease (CVD) have been widely reported in population health management. However, predisposing factors associated with patients treated for advanced stages of CVD have yet to be established. We examined the demographics and risk factors associated with advanced clinical presentation of CVD for patients referred for vein ablation. METHODS: Retrospective analysis of our institutional Vascular Quality Initiative Varicose Vein Registry included endovenous laser treatment and radiofrequency ablation procedures at our tertiary institution, community hospital, and outpatient vein clinic between January 2015 and December 2016. All incompetent truncal veins were divided into two groups based on the Clinical, Etiology, Anatomy, and Pathophysiology clinical class of CVD: mild-moderate (C1-C3) and severe (C4-C6). The two groups were compared in terms of their demographics and medical comorbidities using univariate and multivariate analysis. Data analysis was conducted on SPSS 22.0 (IBM Corp, Armonk, NY). RESULTS: During the study period, a total of 650 incompetent truncal veins were ablated. The mean age of patients was 58 years, and 73% were female. Severe CVD composed 21% of the cohort. Male sex was a risk for advanced CVD (odds ratio, 2.6; P < .001). Older age was also associated with severe CVD; the average age was 63 years for patients with advanced stage CVD vs 56 years for mild to moderate CVD (P < .001). Race, diabetes, body mass index, number of pregnancies, congestive heart failure, history of venous thromboembolism, current anticoagulation, and history of smoking or current smoking status did not affect the severity of CVD. CONCLUSIONS: Among patients treated with vein ablation for superficial venous insufficiency, older age and male sex were associated with increased severity of advanced CVD. Despite the higher incidence of varicose veins among women, men are more likely to have clinically advanced CVD when they present for truncal vein ablation.