Limited health literacy is common among vascular surgery patients

BACKGROUND

Health literacy is a crucial aspect of informed decision-making, and limited health literacy has been associated with worse health care outcomes. To date, health literacy has not been examined in vascular surgery patients. Therefore, we conducted a prospective observational study to determine the prevalence and factors associated with poor health literacy in vascular surgery patients.

METHODS

The Newest Vital Sign (Pfizer, New York, NY), a validated instrument, was used to appraise the health literacy of 150 patients who visited the outpatient vascular clinic at UF Health Shands Hospital between April 2022 and August 2022. Patients who scored a 4 (out of 6) or higher were classified as having adequate health literacy. Each study participant also completed a sociodemographic questionnaire.

RESULTS

In total, 82 out of the 150 (54%) patients we screened had limited health literacy. The prevalence of limited health literacy varied and was independently associated with increased age (odds ratio 1.06; 95% [1.02 to 1.10], P = .004), having not attended college (high school diploma versus college+ odds ratio 3.5; 95% [1.26 to 10.1], P = .018), and African American race (odds ratio 5.3; 95% [1.59 to 22.3], P = .012). A total of 83% of African American patients had limited health literacy, compared to 49% of Asian and White patients.

CONCLUSION

Most vascular surgery patients have limited health literacy. Increased age, fewer years of education, and African American race were associated with limited health literacy. Physicians caring for patients with lower health literacy should investigate and use communication strategies tailored to patients with limited health literacy.

Comparative outcomes of open mesenteric bypass after a failed endovascular or open mesenteric revascularization for chronic mesenteric ischemia

INTRODUCTION

Clinical practice guidelines have recommended an endovascular-first approach (ENDO) for the management of patients with chronic mesenteric ischemia (CMI), whereas an open mesenteric bypass (OMB) is proposed for subjects deemed to be poor ENDO candidates. However, the impact of a previous failed endovascular or open mesenteric reconstruction on a subsequent OMB is unknown. Accordingly, this study was designed to examine the results of a remedial OMB (R-OMB) after a failed ENDO or a primary OMB (P-OMB) for patients with recurrent CMI.

METHODS

All patients who underwent an OMB from 2002 to 2022 at the University of Florida were reviewed. Outcomes after an R-OMB (ie, history of a failed ENDO or P-OMB) and P-OMB were compared. The primary end point was 30-day mortality, whereas secondary outcomes included complications, reintervention, and survival. The Kaplan-Meier methodology was used to estimate freedom from reintervention and all-cause mortality, whereas multivariable Cox proportional hazards modeling identified predictors of death.

RESULTS

A total of 145 OMB procedures (R-OMB, n = 48 [33%]; P-OMB, n = 97 [67%]) were analyzed. A majority of R-OMB operations were performed for a failed stent (prior ENDO, n = 39 [81%]; prior OMB, n = 9 [19%]). R-OMB patients were generally younger (66 ± 9 years vs P-OMB, 69 ± 11 years; P = .09) and had lower incidence of smoking exposure (29% vs P-OMB, 48%; P = .07); however, there were no other differences in demographics or comorbidities. R-OMB was associated with less intraoperative transfusion (0.6 units vs P-OMB, 1.4 units; P = .01), but there were no differences in conduit choice or bypass configuration.The overall 30-day mortality and complication rates were 7% (n = 10/145) and 53% (n = 77/145), respectively, with no difference between the groups. Notably, R-OMB had decreased cardiac (6% vs P-OMB, 21%; P < .01) and bleeding complication rates (2% vs P-OMB, 15%; P = .01). The freedom from reintervention (1 and 5 years: R-OMB: 95% ± 4%, 83% ± 9% vs P-OMB: 97% ± 2%, 93% ± 5%, respectively; log-rank P = .21) and survival (1 and 5 years: R-OMB: 82% ± 6%, 68% ± 9% vs P-OMB: 84% ± 4%, 66% ± 7%; P = .91) were similar. Independent predictors of all-cause mortality included new postoperative hemodialysis requirement (hazard ratio [HR], 7.4, 95% confidence interval [CI], 3.1-17.3; P < .001), pulmonary (HR, 2.7, 95% CI, 1.4-5.3; P = .004) and cardiac (HR, 2.4, 95% CI, 1.1-5.1; P = .04) complications, and female sex (HR, 2.1, 95% CI, 1.03-4.8; P = .04). Notably, R-OMB was not a predictor of death.

CONCLUSIONS

The perioperative and longer-term outcomes for a remedial OMB after a failed intraluminal stent or previous open bypass appear to be comparable to a P-OMB. These findings support the recently updated clinical practice guideline recommendations for an endovascular-first approach to treating recurrent CMI due to the significant perioperative complication risk of OMB. However, among the subset of patients deemed ineligible for endoluminal reconstruction after failed mesenteric revascularization, R-OMB results appear to be acceptable and highlight the utility of this strategy in selected patients.

Presentation and Outcomes of Elective and Nonelective Complex Endovascular Repair for Thoracoabdominal and Juxtarenal Aortic Aneurysms

BACKGROUND

Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation.

METHODS

A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge.

RESULTS

Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71 ± 11 vs. 74 ± 7 years, P = 0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P = 0.02) and had a different race distribution compared to the elective cohort (P < 0.01). Thirty-day mortality was 4% (n = 6) in elective repairs and 7% (n = 3) in nonelective repairs. One-year mortality was 13% (n = 22) in elective repairs and 18% (n = 8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P = 0.40) or 1-year mortality (P = 0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P < 0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P < 0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P < 0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P > 0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P = 0.03).

CONCLUSIONS

Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.

National Institutes of Health funding among vascular surgeons is rare

BACKGROUND

The National Institutes of Health (NIH) is an essential source of funding for vascular surgeons conducting research. NIH funding is frequently used to benchmark institutional and individual research productivity, help determine eligibility for academic promotion, and as a measure of scientific quality. We sought to appraise the current scope of NIH funding to vascular surgeons by appraising the characteristics of NIH-funded investigators and projects. In addition, we also sought to determine whether funded grants addressed recent Society for Vascular Surgery (SVS) research priorities.

METHODS

In April 2022, we queried the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) database for active projects. We only included projects that had a vascular surgeon as a principal investigator. Grant characteristics were extracted from the NIH Research Portfolio Online Reporting Tools Expenditures and Results database. Principal investigator demographics and academic background information were identified by searching institution profiles.

RESULTS

There were 55 active NIH awards given to 41 vascular surgeons. Only 1% (41/4037) of all vascular surgeons in the United States receive NIH funding. Funded vascular surgeons are an average of 16.3 years out of training; 37% (n = 15) are women. The majority of awards (58%; n = 32) were R01 grants. Among the active NIH-funded projects, 75% (n = 41) are basic or translational research projects, and 25% (n = 14) are clinical or health services research projects. Abdominal aortic aneurysm and peripheral arterial disease are the most commonly funded disease areas and together accounted for 54% (n = 30) of projects. Three SVS research priorities are not addressed by any of the current NIH-funded projects.

CONCLUSIONS

NIH funding of vascular surgeons is rare and predominantly consists of basic or translational science projects focused on abdominal aortic aneurysm and peripheral arterial disease research. Women are well-represented among funded vascular surgeons. Although the majority of SVS research priorities receive NIH funding, three SVS research priorities are yet to be addressed by NIH-funded projects. Future efforts should focus on increasing the number of vascular surgeons receiving NIH grants and ensuring all SVS research priorities receive NIH funding.

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.

Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair

OBJECTIVE

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center.

METHODS

Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent.

RESULTS

Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome.

CONCLUSIONS

Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.

Psoas Muscle Area as a Prognostic Factor for Survival in Patients Undergoing EVAR Conversion

OBJECTIVE

EVAR conversion(EVAR-c) is increasingly reported and known to be technically complex and physiologically demanding. It has been proposed that pragmatic anthropomorphic measures such as psoas muscle area(PMA) may reliably quantify levels of preoperative frailty and be used to inform point of care clinical decision making and patient discussions for a variety of complex operations. To date, there is mixed data supporting use of PMA as a prognostic factor in fenestrated endovascular and open AAA repairs; however, no literature exists evaluating the impact of preoperative PMA on EVAR-c results. Therefore, the purpose of this study was to review our EVAR-c experience and evaluate the association of PMA with perioperative and long-term mortality outcomes.

METHODS

A retrospective single-center review of all AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed(n=153). Cross-sectional PMA at the mid-body of the L3 vertebrae was measured. The lowest PMA tertile was used as a threshold value to designate patients as having "low" PMA(n=51) and this cohort was subsequently compared to subjects with "normal" PMA(n=102). Cox proportional hazards modeling was used to estimate covariate association with all-cause mortality.

RESULTS

Patients with low PMA were older(77 vs. 72 years;p=.002), more likely to be female(27% vs. 5%;p<.001), and had reduced BMI(26 vs. 29kg/m²;p=.002). Time to conversion, total number of EVAR reinterventions prior to conversion and elective EVAR-c presentation incidence were similar; however, patients with low PMA had larger aneurysms(8.3 vs. 7.5cm;p=.01) and increased post-EVAR sac growth(2.3 vs. 1cm;p=.005). Unadjusted inpatient mortality was significantly greater for low PMA patients(16% vs. normal PMA, 5%, p=.02). Similarly, the total number of complications was higher among low PMA subjects(1.5±1.9 vs. normal PMA, 0.9±1.5;p=.02). Although frequency of major adverse cardiovascular events and new onset inpatient hemodialysis were similar, low PMA patients had a more than four-fold increased likelihood of having persistent requirement of hemodialysis at discharge(18% vs. 4%,p=.01). The low PMA group had decreased survival at 1 and 5 years, respectively(77±5%, 65±6% vs. normal PMA, 86±3%, 82%±5%;log-rank p=.03). Low PMA was an independent predictor of mortality with every 100mm² increase in PMA being associated with a 15% reduction in mortality(HR 0.85,95% CI, .74-.97;p=.02).

CONCLUSION

Among EVAR-c patients, subjects with low preoperative PMA had higher rates of postoperative complications and worse overall survival. PMA assessments may be a useful adjunct to supplement traditional risk-stratification strategies when patients are being considered for EVAR-c.

Outcomes of EVAR Conversion in Octogenarians Treated at a High-Volume Aorta Center

INTRODUCTION

Endovascular aortic aneurysm repair(EVAR) is the dominant treatment strategy for infrarenal abdominal aortic aneurysms(AAA) but is especially preferred among octogenarian(age ≥80-years) patients due to concerns surrounding comorbidity severity and physiological frailty. Correspondingly, EVAR failure resulting in subsequent open conversion(EVAR-c) has been increasingly reported in older patients but there is a paucity of literature focusing on outcomes in this subgroup. The purpose of this analysis was to evaluate our experience with EVAR-c in octogenarians(≥80-years) compared to younger patients(age <80-years).

METHODS

A retrospective review of all non-mycotic EVAR-c procedures(2002-2020) at a single high-volume academic hospital with a dedicated aorta center(https://www.uf-health-aortic-disease-center) was performed. Patients(n=162) were categorized into octogenarian(age ≥80; n=43) and non-octogenarian(age<80; n=119) cohorts and subsequently compared. The primary end-point was 30-day mortality. Secondary end-points included complications, 90-day mortality, and overall survival. Cox regression determined effects of selected covariates on mortality risk. Kaplan-Meier methodology estimated survival.

RESULTS

No difference in pre-admission EVAR re-intervention rates was present(octogenerians-42% vs. non-octogenerians-43%;p=1) although time to first re-intervention was greater in octogenarians(41 vs. non-octogenarians, 15-months;p=.01). Concordantly, time to EVAR-c was significantly longer among octogenarian patients(61 vs. non-octogenarians, 39-months;p<.01). No difference in rupture presentation was evident(14% vs. 10%;p=.6); however, elective EVAR-c occurred less frequently(octogenerians-42% vs. non-octogenerians-59%;p=.07). AAA diameter was significantly larger for elective octogenarian EVAR-c(7.8±1.9cm vs. non-octogenarians, 7.0±1.5cm;p=.02) and type 1a endoleak was the most common indication overall(58%;n=91). Among all presentations, a trend in higher 30-day mortality was evident for octogenarian patients(16% vs. non-octogenarians, 7%;p=.06). Similarly 90-day mortality was greater among octogenarians(26% vs. non-octogenarians, 10%;p=.02). However, incidence of any complication(56% vs. 49%;p=.5), readmission(12% vs. 6%;p=.3), unplanned re-operation(10% vs. 5%;p=.5) and LOS(11 vs. 9 days;p=.3) was not significantly different. Age ≥80 was predictive of short-term mortality after non-elective but not elective cases; however, increasing comorbidity number, non-elective admission and renal/mesenteric revascularization had the strongest association with mortality risk. One- and three-year survival was not different between groups when comparing all patients after the first 90-days postoperatively.

CONCLUSION

Although higher unadjusted peri-operative mortality occurred among octogenarian patients, risk-adjusted elective outcomes were comparable to younger EVAR-c subjects when treated at a high-volume aortic surgery center. This underscores the importance of appropriate patient selection and modulation of operative complexity when feasible to achieve optimal results. Providers caring for octogenarian patients with EVAR failure should consider timely elective referral to high-volume aorta centers to reduce resource utilization and frequency of non-elective presentations.

Safety of Cerebrospinal Fluid Drainage for Spinal Cord Ischemia Prevention in Thoracic Endovascular Aortic Repair

Objective

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) is associated with permanent neurologic deficit and decreased survival. Prophylactic cerebrospinal fluid (CSF) drainage (CSFD) in TEVAR is controversial. We evaluated the usage of CSFD in TEVAR at our tertiary aortic center.

Methods

Our institutional TEVAR database was reviewed to determine the frequency of CSFD usage/complications. Complications were categorized as mild (headache/CSF leak not requiring intervention, urinary retention), moderate (headache/CSF leak requiring intervention, drain malfunction requiring replacement), or severe (intrathecal hemorrhage, CSFD-attributable neurologic deficit). The relationships between CSFD complications and patient/procedural characteristics, CSFD placement timing, and survival were analyzed.

Results

Nine hundred thirty-six TEVAR procedures were performed in 869 patients from 2011 to 2020. Three hundred ninety CSFD drains were placed in 373 (41.7%) TEVAR patients. Most CSFD drains (89.5%) were pre-TEVAR. Most post-TEVAR drains were placed for new SCI symptoms (n = 21). Twenty-five patients (6.4%) suffered 32 CSFD complications. Most (n = 17) were mild in severity. Severe CSFD complications occurred in 5/432 (1.1% CSF drains) patients. No patient/procedural characteristics were predictive of CSFD complications. Post implant CSFD placement for new SCI symptoms conferred an increased risk of CSFD complication (odds ratio, 6.9; 95% CI, 2.42-19.6; P < .01). The long-term survival of the CSFD complication cohort did not differ from the overall population.

Conclusions

Post-TEVAR CSFD placement for new SCI symptoms was associated with substantially greater risk of CSFD complications. Avoidance of post-implant therapeutic drain placement might be the key to prevention of CSFD complications, favoring a strategy of selective pre-implant drain placement in patients at higher risk for SCI.

EVAR Conversion is an Increasingly Common Indication for Open AAA Repair

OBJECTIVE

Although EVAR re-intervention is common, conversion to open repair(EVAR-c) occurs less frequently but can be associated with significant technical complexity and perioperative risk. There is a paucity of data highlighting the evolution of peri-procedural results surrounding EVAR-c and change in practice patterns, especially for referral centers that increasingly manage EVAR failures. The purpose of this analysis was to perform a temporal analysis of our EVAR-c experience and describe changes in patient selection, operative details and outcomes.

METHODS

A retrospective single center review of all open AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed. EVAR-c patients(n=184) were categorized into two different eras(2002-2009, n=21; 2010-2019, n=163) for comparison. Logistic regression and Cox proportional hazards modeling were used for risk-adjusted comparisons.

RESULTS

A significant increase in EVAR-c as an indication for any type of open aneurysm repair was detected(9%→27%;p<.001). Among EVAR-c patients, no change in age or individual comorbidities was evident[mean age: 71±9 years]; however, the proportion of female subjects(p=.01) and ASA classification >3 declined(p=.05). There was no difference in prevalence[50% vs. 43%;p=.6] or number[median-1.5(0, 5)] of pre-admission EVAR re-interventions; however, time to re-intervention decreased(median: 23[6,34] vs. 0[0,22] months;p=.005). In contrast, time to EVAR-c significantly increased(median: 16[9,39]vs. 48[20,83]-months;p=.008). No difference in frequency of non-elective presentation[mean-52%;p=.9] or indication was identified but a trend toward increasing mycotic EVAR-c was observed(5% vs. 15%;p=.09). Use of retroperitoneal exposure(14% vs. 77%;p<.0001), suprarenal cross-clamp application[6286%;p=.04] and visceral-ischemia time(median: 0[0,11] vs. 5[0,20]min;p=.05) all increased. In contrast, estimated blood loss(P-trend=.03) and procedure-time(p=.008) decreased. The unadjusted elective 30-day mortality rate improved but did not reach statistical significance[elective: 10% vs. 5%;p=.5] with no change for non-elective operations[18% vs. 16%;p=.9]. However, a significantly decreased risk of complications was evident(OR 0.88, 95%CI .8-.9;p=.01). One and 3-year survival was similar over time.

CONCLUSION

EVAR-c is now a common indication for open AAA repair. Patients frequently present non-electively and at increasingly later intervals after their index EVAR. Despite increasing technical complexity, decreased complication risk and comparable survival can be anticipated when patients are managed at a high-volume aortic referral center.

Improved perioperative mortality after secondary aorto-enteric fistula repair and lessons learned from a 20-year experience

BACKGROUND

Secondary aorto-enteric fistulas (SAEFs) are rare but represent one of the most challenging and devastating problems for vascular surgeons. Several issues surrounding SAEF treatment remain unresolved, including optimal surgical reconstruction and conduit choice. We performed an audit of our experience with SAEFs and highlight aspects of care that have affected outcomes over time with the intent to identify factors associated with best outcomes.

METHODS

We performed a single center, retrospective review of all consecutive SAEF repairs (1999-2019), defined as presence of a false communication between an enteric structure and pre-existing aortic graft. The primary endpoint was 30-day mortality. Secondary endpoints included incidence of complications and overall survival. Time-dependent outcome comparison was performed. Cox proportional hazards modeling and life-table analysis estimated risk and freedom from endpoints.

RESULTS

A total of 57 patients (63% male; n = 36) presented with SAEF (median age, 69 years; interquartile range [IQR], 61-74 years). Median follow-up time was 10 months (interquartile range, 3-21 months. The most common presenting symptoms were gastrointestinal bleeding (60%; n = 34) and abdominal pain (56%; n= 3 2). For the overall cohort, 30% (n = 17) underwent extra-anatomic bypass with aortic ligation, 30% (n = 17) rifampin-soaked Dacron graft, 26% (n = 15) femoral vein (eg, neoaortoiliac system), and 14% (n = 8) cryopreserved aortic allograft. The enteric communication involved the duodenum in 85% (n = 48), and a double-layer hand-sewn primary repair was most commonly employed (61%; n = 35). Thirty-day mortality was 35% (n = 20) with no significant difference between 90 days (39%; n = 22) and 180 days (42%; n = 24). Morbidity was 70% (n = 40), with gastrointestinal (30%; n = 17; leak [9%]), pulmonary (25%; n = 14), and renal (21%) complications being most common. Incidence of reoperation for any vascular and/or gastrointestinal-related complication was 56% (n = 32). One-year and 3-year survival was 54% ± 6% and 48% ± 8%, respectively. Over time, 30- and 90-day mortality improved (odds ratio, 0.1; 95% confidence interval, 0.4-0.5; P = .002) despite no change in patient factors, operative strategy, conduit choice, or morbidity rate. Prehospital history of gastrointestinal bleeding was associated with worse survival (hazard ratio, 2.0; 95% confidence interval, 1.0-3.9; P = .06); however, reconstruction strategy (in-situ vs extra-anatomic bypass), postoperative gastrointestinal and/or vascular complication, omental flap use, and preoperative endovascular aneurysm repair history were not associated with outcome.

CONCLUSIONS

In conclusion, we observed improved short-term mortality despite no significant change in patient presentation or postoperative complications. This highlights increasing institutional experience in selecting the optimal surgical strategy and improved ability to rescue patients experiencing adverse postoperative events. An individualized approach to reconstruction and conduit choice can lead to best outcomes after SAEF management when patients are treated at a high-volume aortic surgery center.

Effect of ischemia-reperfusion on outcomes after open mesenteric bypass for chronic mesenteric ischemia

OBJECTIVE

Significant physiologic perturbations can occur in patients with chronic mesenteric ischemia (CMI) undergoing open mesenteric bypass (OMB). These events have frequently been attributed to ischemia-reperfusion events and have been directly implicated in the occurrence of multiple organ dysfunction (MOD). Scoring systems (MOD score [MODS] and sequential organ failure assessment [SOFA]) have been derived within the critical care field to provide a composite metric for these pathophysiologic changes. The purpose of the present study was to describe the early pathophysiologic changes that occur after OMB for CMI and determine whether these are predictive of the outcomes.

METHODS

Patients with CMI who had undergone elective OMB from 2002 to 2018 at a single institution were reviewed. Changes in the hemodynamic, pulmonary, hepatic, renal, and hematologic parameters in the first 96 hours postoperatively were analyzed. The MODSs and SOFA scores were calculated. Cox regression was used to determine the association of the MODSs and SOFA scores with the outcomes.

RESULTS

The use of OMB was analyzed for 72 patients (age, 66 ± 11 years; 68% women; body mass index, 23.8 ± 6 kg/m²; 48 ± 34-lb weight loss in 59%). Previous mesenteric stent placement or bypass had been performed in 39% [stenting in 21; bypass in 8; (one patient had both)]. An antegrade configuration (93%) was most common (retrograde configuration, 7%), with revascularization of the superior mesenteric artery/celiac vessels in 85% (superior mesenteric artery only in 15%). Postoperative pathophysiologic and metabolic changes were common, and the mean MODSs and SOFA scores were 3.6 ± 2.4 (range, 1-10) and 4.0 ± 2.7 (range, 1-13), respectively. The median length of stay was 14 days (interquartile range, 9-21). The 30-day mortality was 4% (n = 3) and in-hospital morbidity was 53% (n = 38; gastrointestinal, 25%; infectious, 22%; cardiac, 18%; pulmonary, 18%; renal, 11%). The clinical follow-up period was 16 ± 20 months. The MODSs and SOFA scores correlated linearly with overall mortality (MODS: odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.7; P < .01; SOFA score: OR, 1.4; 95% CI, 1.2-1.7; P < .01 per unit), with a score of ≥5 the inflection point most predictive of mortality (MODS: OR, 3.9; 95% CI, 1.6-9.9; P ≤ .01; SOFA score: OR, 2.8; 95% CI, 1.2-6.6; P = .02). The 1- and 3-year primary bypass patency and freedom from reintervention was 91% ± 5% and 83% ± 7%, respectively, with no association with the MODSs or SOFA scores. The 1- and 3-year survival was 86% ± 4% and 71% ± 6% with significantly worse outcomes for patients with higher MODSs and/or SOFA scores.

CONCLUSIONS

Most CMI patients undergoing OMB will experience significant metabolic derangements resulting from sequelae of the ischemia-reperfusion phenomenon postoperatively. These can be objectively assessed in the early postoperative period using simply applied scoring systems to reliably predict the early and long-term outcomes. A derivation of the MODS and/or SOFA score after OMB for CMI can identify the most vulnerable patients at the greatest risk of mortality. (J Vasc Surg 2021;XX:XX-X.).

Complicated acute type B aortic dissection: update on management and results

BACKGROUND

The role of thoracic endovascular aortic repair (TEVAR) has evolved and is now firmly established as a mainstay of therapy for acute complicated type B aortic dissection (acTBAD). However, several important issues remain unresolved including the optimal timing, sizing, graft selection, coverage length and utilization of adjunctive therapies to address false lumen perfusion. Therefore, the purpose of this study was to provide a contemporary perspective on the management and results for TEVAR of acTBAD.

METHODS

All TEVAR patients (N.=159) with acTBAD from a single high-volume, academic medical center were analyzed. Comparative results across time-dependent cohorts (2005-2009 [N.=43] vs. 2010-2014 [N.=56] vs. 2015-2020 [N.=60]) are presented.

RESULTS

30-day mortality was 13%(N.=21) with a trend towards improvement over time (2005-2009, 18% vs. 2010-2020, 12%; P=0.1). Similarly, incidence of postoperative complications also declined: 2005-2009, 70% vs. 2010-2020, 36%(P-trend=0.08). One and 2-year freedom from aorta-related reintervention was 78±7% and 73±9% and did not differ across cohorts (log-rank P=0.5). Respective one and 5-year survival was 75±3% and 64±7%, but significantly improved with time (log-rank P<0.001). The corresponding one and five-year freedom from aorta-related mortality was 82±4% and 78±7% but did not change during the study interval (log-rank P=0.3).

CONCLUSIONS

Outcomes for TEVAR of acTBAD continue to improve over time. This time-dependent analysis delineates how results have changed due to increasing experience, technologic evolution, and maturation of the peer reviewed evidence. These results along with the evidence-based review provided herein, provide an update on the management and results of TEVAR of acTBAD while highlighting specific controversies unique to the management of this challenging clinical problem.

Remodeling, Reintervention, and Survival After Endovascular Repair of Chronic Type B Dissection

BACKGROUND

The efficacy of thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection (cTBAD) is controversial. Only limited evidence describes temporal anatomic changes after TEVAR for cTBAD and their relationship to outcomes. We sought to investigate early aortic remodeling events after TEVAR for cTBAD with thoracic aneurysm and determine the association with reintervention and survival.

METHODS

Records from 95 cTBAD patients undergoing TEVAR from 2005 to 2017 were reviewed. Using 3-dimensional centerline analysis, anatomic phenotyping of the thoracoabdominal aorta was performed. Reverse aortic remodeling (RAR) was defined by a ≥5-mm reduction in maximal thoracic aortic diameter. Kaplan-Meier analysis estimated freedom from reintervention and survival.

RESULTS

Visceral segment dissection involvement was present in 89% of patients (n = 85), and the mean preoperative thoracic diameter was 63 mm (SD, 10). Complete thoracic false lumen thrombosis occurred in 71% of patients (n = 67), whereas abdominal false lumen thrombosis was documented in 60% (n = 57) by 6 months. RAR occurred in 41%. Aortic reintervention rate was 39% (n = 37). The 1- and 3-year freedom from reintervention was significantly higher in subjects experiencing early RAR (log-rank P = .02), but reintervention did not impact overall survival (log-rank P = .9). Similarly, overall survival was similar between patients with or without RAR (log-rank P = .4).

CONCLUSIONS

Early RAR is associated with decreased rates of reintervention; however, overall survival is not impacted by these changes. TEVAR for cTBAD results in a high rate of reintervention, which mandates vigilant surveillance protocols.

Surgical Treatment of True Superior Mesenteric Artery Aneurysms

BACKGROUND

Superior mesenteric artery aneurysms (SMAAs) are a rare clinical problem that can be associated with significant morbidity and mortality. The optimal surgical approach for both mycotic and degenerative SMAAs remains poorly defined. The study was designed to review our institutional experience and develop a treatment algorithm.

METHODS

A single-institution, retrospective review was performed to document presentation, treatment, and outcomes of patients undergoing surgical repair of SMAAs from 2003 to 2020. The primary end-point was 30-day mortality, and secondary end-points included complications, patency, freedom from reinfection, freedom from reintervention, and survival.

RESULTS

Eighteen patients (mean age: 46 ± 16 yrs; 50% male; mean diameter 2.4 ± 2.0 cm) underwent treatment of mycotic (50%) or degenerative (50%) SMAAs. Abdominal pain (66%) was the most common presenting symptom, and the diagnosis was confirmed with CT arteriography. Endocarditis secondary to intravenous drug abuse was responsible for most (88%) of the mycotic SMAAs, with a majority (66%) having positive cultures and Streptococcus being the most common organism. The majority (61%) of patients underwent urgent or emergent repair with aneurysmectomy and interposition saphenous vein bypass being the most common treatment of mycotic SMAAs while aneurysmectomy and prosthetic bypass were used most frequently for degenerative aneurysms. The operative mortality rate was 6% with a major complication rate of 17% (n = 3 patients: respiratory failure/reintubation-1, pulmonary embolism-1, necrotizing pancreatitis/graft disruption and death-1). The single death occurred in a patient with a degenerative aneurysm that developed postoperative pancreatitis and multiple organ dysfunction. The mean clinical follow-up time was 25 ± 48 (95% CI 1-48) months. The estimated primary patency, freedom from reinfection, and freedom from reintervention were 93 ± 7 %, 94 ± 5%, and 94 ± 5%, respectively, at 1 year. The overall mean survival was 55 ± 51 (95% CI 30-80) months with an estimated survival at 3 years of 77 ± 10%.

CONCLUSIONS

SMAAs associated with both degenerative and mycotic etiologies can be treated using a variety of surgical approaches with acceptable morbidity and mortality. Mycotic SMAAs should likely be repaired, regardless of size, while the indications for asymptomatic, degenerative aneurysms remain to be defined by further natural history studies.

Contemporary management and outcomes of complex vascular surgical groin wound infections

OBJECTIVE

Vascular surgical groin wound infection (VS-GWI) has multiple causes and frequently is manifested as a limb- or life-threatening problem, resulting in significant morbidity and mortality. For patients undergoing operative extirpation, in situ repair, extra-anatomic bypass, or ligation can be used; however, limited data exist describing comparative results of the different operative choices or conduit subtypes. Therefore, we sought to describe our experience with management of VS-GWI and to detail outcomes of the different strategies.

METHODS

Patients (2003-2017) undergoing surgical treatment of VS-GWI (Szilagyi grade III) secondary to primary infectious arteritis or infected pseudoaneurysm after percutaneous intervention as well as previous prosthetic graft placement were reviewed. The primary end point was major adverse limb events (MALEs; major amputation, graft occlusion, or unplanned reintervention). Secondary end points included 30-day mortality, wound healing, amputation-free survival (AFS), and all-cause mortality. Cox proportional hazards modeling was used to determine relative risk of end points; Kaplan-Meier methodology was employed to estimate freedom from outcomes.

RESULTS

There were 149 patients (age, 65 ± 11 years; body mass index, 27 ± 6 kg/m²; 70% male; 32% diabetes) identified, of whom 120 (81%) had unilateral and 29 (19%) had bilateral VS-GWI. Indications included infected prosthetic bypass (88% [n = 131]; infrainguinal, 107; suprainguinal, 24) and primary infectious femoral artery complications (12% [n = 18]). A majority underwent single-stage operations (87% [n = 129]). In situ reconstruction occurred in 87% (n = 129); 9% (n = 13) underwent ligation, and 6% (n = 7) received extra-anatomic revascularization. Autogenous conduit was used most commonly (68% [n = 101/149]; 88% single stage), of which 81% (n = 80) were femoral vein. The remaining patients received cadaveric (15% [n = 23]; 87% single stage) or prosthetic (8% [n=12]; 67% single stage) grafts. Adjunctive myocutaneous flap was used in 37% (n = 54). Length of stay was 19 ± 15 days and 30-day mortality was 7% (n = 10), with no difference between conduit repair types. All femoral wounds healed (mean follow-up, 17 ± 11 months); however, 33% (n = 49) underwent reoperation (unplanned graft reintervention, 33%; graft occlusion, 16%; wound débridement, 15%; major amputation, 11%). Reinfection occurred in 17% (n = 27), with no difference between groups. MALE rate was 22% (n = 33; most were arterial reinterventions, 19%), with no difference in single-stage vs multistage, in situ vs extra-anatomic, or autogenous vs nonautogenous conduit strategies Predictors of MALE included younger age (hazard ratio [HR], 1.6 per decade; 95% confidence interval [CI], 1.1-2.5; P = .02) and lower body mass index (<25 kg/m²; HR, 1.6 per BMI category; 95% CI, 1.1-2.5; P = .02). Overall, 1- and 3-year freedom from MALE, AFS, and survival were as follows: MALE, 74% ± 5% and 63% ± 6%; AFS, 68% ± 4% and 58% ± 5%; survival, 78% ± 3% and 70% ± 4%. Autogenous conduit use was associated with better survival (HR, 0.5; 95% CI, 0.3-0.8; 1-year: 83% ± 4% vs nonautogenous, 78% ± 4%; 3-year: 68% ± 8% vs 53% ± 9%; log-rank, P = .006).

CONCLUSIONS

An individualized approach to operative strategy and conduit choice leads to comparable outcomes in this challenging group of patients. VS-GWI can be safely managed with in situ, autogenous reconstruction in a majority of patients with acceptable mortality, excellent wound healing rates, and improved overall survival. However, a significant proportion of patients experience reinfection and MALEs, the preponderance of which are arterial reintervention, mandating need for close follow-up and graft surveillance.

Safety and efficacy of a hybrid approach for repair of complicated aberrant subclavian arteries

OBJECTIVE

Aberrant subclavian artery (ASA), a well-described aortic arch anomaly, is frequently associated with dysphagia and development of Kommerell diverticulum (KD) with aneurysmal degeneration. Historically, open repair has been performed, which can be associated with significant morbidity. More recently, hybrid approaches using different arch vessel revascularization techniques in combination with thoracic endovascular aortic repair (hybrid TEVAR) have been described, but there is a paucity of literature describing outcomes. The objective of this analysis was to describe our experience with management of complicated ASAs using hybrid TEVAR, further adding to the literature describing approaches to and outcomes of hybrid ASA repair.

METHODS

A retrospective, single-institution review was performed of all patients treated for ASA complications using hybrid TEVAR (2002-2018). The primary end point was technical success, defined as absence of type I or type III endoleak intraoperatively and within 30 days postoperatively. Secondary end points included complications, reintervention, and survival. Centerline measurement of KD diameters (maximum diameter = opposing aortic outer wall to diverticulum apex) was employed. Kaplan-Meier methodology was used to estimate secondary end points.

RESULTS

Eighteen patients (1.4% of 1240 total TEVAR procedures; male, 67%; age, 59 ± 13 years) were identified (left-sided arch and right ASA, 94% [n = 17]; right-sided arch and left ASA, n = 1 [6%]; retroesophageal location and associated KD, 100%); median preoperative KD diameter was 60 mm (interquartile range [IQR], 37-108 mm). Operative indications included diverticulum diameter (61%), dysphagia (17%), rupture (11%), rapid expansion (6%), and endoleak after TEVAR (6%). All procedures used some combination of supraclavicular revascularization and TEVAR (staged, 50% [n = 9]), whereas partial open arch reconstruction was used in 17% (n = 3). There were no perioperative deaths or spinal cord ischemic events. Major complications occurred in 22% (n = 4): nondisabling stroke, one; arm ischemia, one; upper extremity neuropathy, one; and iatrogenic descending thoracic aortic dissection, one. Technical success was 83%, but 44% (n = 8) had an endoleak (type I, n = 3; type II, n = 5 [intercostal, n = 2; aneurysmal subclavian artery origin, n = 3]) during follow-up (median, 4 months; IQR, 1-15 months). Two endoleaks resolved spontaneously, three were treated, and three were observed (1-year freedom from reintervention, 75% ± 10%). Median KD diameter decreased by 7 mm (IQR, 1-12 mm), and 78% (n = 14) experienced diameter reduction or stability in follow-up. The 1- and 3-year survival was 93% ± 6% and 84% ± 10%, respectively.

CONCLUSIONS

Hybrid open brachiocephalic artery revascularization with TEVAR appears to be safe and reasonably effective in management of ASA complications as evidenced by a low perioperative complication risk and reasonable positive aortic remodeling. However, endoleak rates raise significant concerns about durability. Therefore, if this technique is employed, the mandatory need for surveillance and high rate of reintervention should be emphasized preoperatively. This analysis represents a relatively large series of a hybrid TEVAR technique to treat ASA complications, but greater patient numbers and longer follow-up are needed to further establish the role of this procedure.

Impact of secondary interventions on mortality after fenestrated branched endovascular aortic aneurysm repair

BACKGROUND

Fenestrated and branched endovascular aortic repair (F/BEVAR) is increasingly used to manage pararenal and thoracoabdominal aortic disease (TAAA). Device-related reintervention after F/BEVAR is common, but little is known about its impact on postoperative mortality. The purpose of this analysis was to describe secondary intervention (SI) after F/BEVAR and determine the impact of these procedures on patient survival.

METHODS

A single-center review was done on all consecutive F/BEVARs performed from 2010 to 2016. Primary end points were incidence of secondary aortic, branch, and/or access vessel‒related SI, and survival. SI was categorized as minor endovascular (branch restenting, access vessel treatment, or percutaneous coil embolization), major endovascular (new aortic graft placement), or open (bleeding, access vessel, and/or aortic). Kaplan-Meier methodology was used to estimate freedom from SI and survival. Multivariable analysis was used to identify predictors of SI.

RESULTS

A total of 308 F/BEVAR procedures were performed (75% physician-modified, 18% custom, 7% Zfen), with 1022 vessels revascularized (celiac, 228; superior mesenteric artery [SMA], 263; renal, 525). There were 117 (39%) extent I-III TAAA, 132 (44%) extent IV TAAA/4-vessel pararenal, and 54 (18%) <4-vessel pararenal repairs performed. Any type of SI occurred in 24% (74) of patients during the mean follow-up of 20 ± 21 months. The majority of reinterventions were endovascular (minor, 53% [n = 39]; major, 32% [n = 24]), whereas 12% (n = 9) were open and 3% (n = 2) hybrid. Primary indication for SI included: 22 (29%) with branch-related endoleaks (1C or III); 15 (22%) with proximal or distal aortic degeneration; 8 (12%) with branch vessel thrombosis/stenosis; 10 (11%) with aortic device type III endoleak/loss of overlap; 4 (6%) with postoperative mesenteric or renal bleeding events; 5 (5%) with type II endoleak; 3 (5%) with access vessel complication; and 2 (3%) with graft infection. Most SIs were elective (65%; n = 48) with the remainder occurring emergently (24%; n = 18) or for symptoms/urgently (11%; n = 8). Compared with endovascular remediation, open SI was more likely to be emergent (89%, 8 of 9; P = .001). Freedom from SI was 80 ± 3% and 64 ± 4% at 1 and 3 years, respectively. One- and 5-year survival with or without SI was: 1 year, 88 ± 4% vs 81 ± 3%; 5 years, 76 ± 5% vs 59 ± 4% (log rank test, P = .06). There was no survival difference based on type of SI (log rank test, P = .3). Extent I-III TAAA (HR, 1.6; 95% CI, 0.98-3.3; P = .06) and history of cerebrovascular disease (HR, 1.8; 95% CI, 0.97-2.6; P = .07) were predictive of SI.

CONCLUSIONS

SIs after F/BEVAR most frequently involve branch vessel or aortic device remediation procedures; however, they do not negatively impact out-of-hospital survival. These results further highlight the crucial role of imaging surveillance after F/BEVAR to maintain durability. Discussions with patients, periprocedural planning, and the next generation of device design must focus on issues surrounding the risk of device-related SI events.

Contemporary outcomes of thoracofemoral bypass

OBJECTIVE

Thoracofemoral bypass (TFB) is an alternative to aortofemoral bypass (AFB) or extra-anatomic bypass for severe aortoiliac occlusive disease (AIOD). TFB may be particularly useful in select patients with concurrent visceral aortic branch vessel disease, infrarenal aortic occlusions, or after failed AFB. However, there are few contemporary series describing the indications and outcomes for TFB. Therefore, the purpose of this analysis was to review our experience with TFB.

METHODS

All patients undergoing TFB for occlusive disease from 2002 to 2017 were reviewed. All patients underwent left thoracoretroperitoneal exposure of the supraceliac aorta with division of the diaphragmatic crus and supraceliac cross-clamping. An end-to-side aortic anastomosis was created and each graft limb was tunneled in the retroperitoneum to the femoral bifurcation. Adjunctive visceral/infrainguinal revascularization was performed selectively based on symptoms, end-organ function, and/or preoperative imaging. The primary end points were major complications and 30-day mortality. Secondary end points included limb patency, freedom from major adverse limb events, and survival. Kaplan-Meier methodology was used to characterize the end points.

RESULTS

Forty-one patients (age 61 ± 9 years; 54% female; 7% in a hypercoaguable state) underwent TFB. The mean preoperative ankle-brachial index was 0.4 bilaterally. Indications included critical limb ischemia (56%), claudication (30%), acute limb ischemia (7%), and combined AIOD and mesenteric ischemia (7%). Seven patients (17%) had previously undergone AFB and 15 (38%) had previously undergone any prior aortic operation. Adjunctive visceral bypass occurred in 8 patients (20%; N = 14 grafts, n = 6 renal, n = 5 superior mesenteric artery, and n = 3 celiac). The postoperative duration of stay was 11 days (interquartile range [IQR], 7-16 days) and the 30-day mortality was 5% (n = 2). Major complications occurred in 34% of patients (N = 14; pulmonary, 15%; cardiac, 12%; bleeding, 7%; accidental splenectomy, 5%; renal, 5%; wound, 2%). The mean postoperative ankle-brachial index was 0.9 bilaterally. At a median follow-up of 7 months (IQR, 1-17 months), 5 patients (12%) underwent some form of reintervention (graft/limb related, n = 4 [n = 2 graft thrombosis, n = 2 graft infection], n = 1 mesenteric bypass revision). The estimated 3-year primary limb patency and freedom from major adverse limb events were 80 ± 10%, and 70 ± 10%, respectively. The estimated 5-year survival was 93 ± 5% (median, 27.3; IQR, 14.5-35.2; 95% confidence interval, 17.9-32.8).

CONCLUSIONS

This experience represents one of the largest and most current series of retroperitoneal TFB. We demonstrate that TFB can be performed with good outcomes for patients with severe AIOD, especially if concomitant visceral/infrainguinal reconstruction is warranted. These results support a continued role for TFB in select patients.

Management of Aortoiliac Aneurysms with Atypical Renal Artery Anatomy

BACKGROUND

Renal artery anomalies occur at a rate of 1-2% and present a challenge to vascular surgeons performing aortic surgery. We describe adjuncts used to manage such anatomic variants.

METHODS

A single surgeon registry of all abdominal aortic aneurysms repaired in an academic center was retrospectively reviewed. Patients with prior renal transplants, congenital pelvic kidneys, or horseshoe kidneys were included. Open repair was reserved for patients with no endovascular or hybrid repair options.

RESULTS

Over an 8-year period, 18 patients were identified (renal transplant n = 9, horseshoe kidney n = 3, congenital pelvic kidney n = 6). All transplant patients were treated with endovascular repair. Four required cross-femoral bypasses, 1 for retrograde allograft perfusion after aorto-uni-iliac (AUI) procedure to the contralateral external iliac artery and 3 for contralateral limb perfusion after endograft extension into iliac artery ipsilateral to allograft. Three transplant patients required carotid access due to severe iliofemoral occlusive disease or allograft origin off the internal iliac artery. Two horseshoe kidney patients underwent open repair with direct reimplantation of accessory renal arteries, whereas 1 underwent endovascular repair with exclusion of an isthmus branch. Of the congenital single/pelvic kidney cohort, 2 underwent open repair with renal reimplantation, 2 underwent endovascular aneurysm repair, 1 was treated with AUI and cross-femoral bypass, and one was treated with a staged iliorenal bypass and subsequent fenestrated endovascular repair. Intravascular ultrasound was used to minimize contrast use in patients with chronic renal insufficiency (Cr > 1.5 mg/dL, n = 6). Over a mean follow-up of 31 months (range, 1-110), there were no aortic deaths or reintervention, no decline in renal function (measured by serum creatinine and glomerular filtration rate), and 100% patency of the preserved renal arteries.

CONCLUSIONS

Atypical renal anatomy should not preclude repair of aortic aneurysms. Repair of such aneurysms is safe and achieves good long-term outcomes with the use of the described techniques.

Impact of Postoperative Duplex Surveillance after Radiofrequency Ablation of the Greater Saphenous Vein

Purpose

Radiofrequency ablation (RFA) is an effective therapeutic option for the treatment of greater saphenous vein (GSV) insufficiency; however, recent reports have begun to document an associated incidence of postprocedural deep venous thrombosis (DVT) of up to 16%. We evaluated our incidence of DVT after RFA and the role of venous duplex ultrasonography (VUS) in the assessment and treatment of GSV reflux.

Methods

During a 17-month period, 62 lower extremities with symptomatic GSV reflux were evaluated by VUS in 51 patients (74% women; mean age 51 years, range 25–83 yrs). Clinical history and examination focusing on risk factors for venous insufficiency and DVT were obtained along with a complete preoperative bilateral lower-extremity VUS in all patients. All procedures were completed by performing an intraoperative VUS to confirm patency of the GSV and common femoral veins before and after RFA. All patients received outpatient complete lower-extremity VUS within 5 days of the procedure to assess technical success of the procedure and superficial and deep venous patency.

Results

Fifty (98%) of patients completed RFA, with one patient undergoing high ligation of the GSV because of our inability to pass a guidewire and catheter into the proximal GSV. Duplex ultrasound confirmed successful RFA of the GSV in all limbs treated. Stab phlebectomy was performed in 33 (53%) limbs for associated clusters of large varicose veins. Two postoperative DVTs occurred (2/62,3.2%), both of which were identified as a floating thrombus in the common femoral vein and which subsequently were treated with percutaneous catheter-directed suction thrombectomy without the need for extended anticoagulation therapy.

Conclusion

Duplex venous scanning is an important component in the diagnosis and treatment of GSV insufficiency. VUS not only is necessary to direct the success of these catheter-based ablative procedures but is mandatory to confirm the absence of extended DVT after the procedure is completed. Our series has recorded a relatively low incidence of DVT and demonstrates that early recognition and aggressive treatment of nonocclusive common femoral DVT after RFA can obviate the need for long-term anticoagulation and potentially the sequelae of deep venous thrombosis.

Configuration affects parallel stent grafting results

OBJECTIVE

A number of adjunctive "off-the-shelf" procedures have been described to treat complex aortic diseases. Our goal was to evaluate parallel stent graft configurations and to determine an optimal formula for these procedures.

METHODS

This is a retrospective review of all patients at a single medical center treated with parallel stent grafts from January 2010 to September 2015. Outcomes were evaluated on the basis of parallel graft orientation, type, and main body device. Primary end points included parallel stent graft compromise and overall endovascular aneurysm repair (EVAR) compromise.

RESULTS

There were 78 patients treated with a total of 144 parallel stents for a variety of pathologic processes. There was a significant correlation between main body oversizing and snorkel compromise (P = .0195) and overall procedural complication (P = .0019) but not with endoleak rates. Patients were organized into the following oversizing groups for further analysis: 0% to 10%, 10% to 20%, and >20%. Those oversized into the 0% to 10% group had the highest rate of overall EVAR complication (73%; P = .0003). There were no significant correlations between any one particular configuration and overall procedural complication. There was also no significant correlation between total number of parallel stents employed and overall complication. Composite EVAR configuration had no significant correlation with individual snorkel compromise, endoleak, or overall EVAR or procedural complication. The configuration most prone to individual snorkel compromise and overall EVAR complication was a four-stent configuration with two stents in an antegrade position and two stents in a retrograde position (60% complication rate). The configuration most prone to endoleak was one or two stents in retrograde position (33% endoleak rate), followed by three stents in an all-antegrade position (25%). There was a significant correlation between individual stent configuration and stent compromise (P = .0385), with 31.25% of retrograde stents having any complication.

CONCLUSIONS

Parallel stent grafting offers an off-the-shelf option to treat a variety of aortic diseases. There is an increased risk of parallel stent and overall EVAR compromise with <10% main body oversizing. Thirty-day mortality is increased when more than one parallel stent is placed. Antegrade configurations are preferred to any retrograde configuration, with optimal oversizing >20%.

Intraoperative Gutter Leaks That Merit Our Attention

INTRODUCTION

The natural history and potential morbidity of gutter endoleaks are unclear. We present our experience with intraoperative gutter endoleaks and strategies to determine which of these require intervention.

METHODS

This is a retrospective review of all patients treated with parallel stent grafts from January 2010 to September 2015. We reviewed all operative records and intraoperative angiograms as well as all postoperative imaging and secondary interventions. All gutter leaks were classified as low-flow/nonsac-enhancing gutter endoleaks or high-flow/sac-enhancing gutter endoleaks. Adjunctive interventions to manage the gutter leaks were noted, as were all subsequent interventions for gutter leak and endoleak management.

RESULTS

Seventy-eight patients had 144 parallel stents placed over a 5-year period with an average of 1.8 stents per patient. Twenty-eight patients (36%) had gutter endoleaks diagnosed intraoperatively. Seventeen patients had adjunctive procedures to reduce gutter leaks prior to leaving the operating room (OR). Patients selected for treatment had gutters filling early during completion angiography and/or contrast enhancement of the aneurysm sac. Twenty-two patients (28%) left the OR with low-flow/delayed/nonsac-enhancing gutter endoleaks. At 30 days, a total of 6 persistent gutter endoleaks were diagnosed on computed tomographic angiography. This gives a 73% rate of resolution for low-flow/nonaneurysm sac-enhancing endoleaks. There were 2 de novo endoleaks not detected at the index procedure diagnosed at 6-month follow-up. Of the 8 total postoperative endoleaks, 5 required additional intervention with a 100% success rate. Multivariate analysis revealed that the only significant predictor of having a postoperative endoleak is leaving the OR with an endoleak.

CONCLUSIONS

Intraoperative treatment of gutter endoleaks has an acceptable rate of resolution. It does have a high rate of converting high-flow endoleaks to low-flow endoleaks. Low-flow/nonsac-enhancing gutter endoleaks have a high rate of spontaneous resolution. Intraoperative gutter endoleaks are not predictive of future aneurysm sac growth.

Critical Appraisal of Cardiac Risk Stratification Before Elective Vascular Surgery

This study was undertaken to evaluate the efficacy of the cardiac risk stratification protocol proposed by the American College of Cardiology/American Heart Association (ACC/AHA) in predicting cardiac morbidity and mortality associated with elective, major arterial surgery. Cardiac risk stratification using ACC/AHA guidelines was done on 425 consecutive patients before 481 elective cerebrovascular (n=146), aortic/inflow (n=166), or infrainguinal (n=169) procedures at an academic Veterans Affairs Medical Center. Cardiac risk was stratified as low, intermediate, or high based on clinical risk factors, such as, Eagle criteria, history of cardiac intervention, patient functional status, results of noninvasive cardiac stress testing, and coronary angiography with coronary revascularization performed when appropriate. Outcomes (myocardial infarction, unstable angina, congestive heart failure, ventricular arrhythmia, cardiac death, and mortality) within 30 days of surgery were compared between the various risk stratification groups. Univariate and multivariate analyses were used to identify clinically useful prognostic variables from the preoperative cardiac evaluation algorithm. Overall mortality (1.7%), cardiac death (0.4%), and adverse cardiac event (4.8%) rates were low, but cardiac death and morbidity were increased (p<0.05) in high-risk stratified patients (3.4%, 11.9%) compared to intermediate (0%, 2.8%) and low (0%, 4.0%) cardiac risk groups. The presence of 3-vessel angiographic coronary artery occlusive disease was an independent predictor of cardiac morbidity, while inducible ischemia by cardiac stress imaging was not. Previous coronary revascularization was associated with increased mortality as was the development of a non-cardiac complication. Cardiac risk assessment identified 78 (18%) patients with indications for coronary angiography. Angiographic findings resulted in coronary artery intervention (9-angioplasty; 4-bypass grafting) in 13 (3%) patients who experienced no adverse cardiac events after the planned vascular surgery (15 procedures). Cardiac risk stratification using ACC/AHA guidelines can predict adverse cardiac events associated with elective vascular surgery; however, protocol modification by increased reliance on Eagle criteria and less use of cardiac stress testing can improve identification of the “highest risk” patients who may benefit from prophylactic coronary intervention.

Intravascular Ultrasound Guidance for Peripheral Vascular Interventions

Intravascular ultrasound (IVUS) imaging during peripheral endovascular interventions adds important information regarding the distribution of disease by providing controlled measurements of the cross-sectional area of the vessel lumen and wall prior to and following procedures. IVUS is useful in determining the mechanism and efficacy of balloon angioplasty, in guiding atherectomy devices, and in assuring appropriate placement of intravascular stents. The incorporation of an IVUS element into catheter-based interventional devices may improve the immediate and long-term results of endovascular interventions by decreasing complications from dissection and perforation of the arterial wall. Combined IVUS-stent prototype catheters are being developed to enable imaging and deployment simultaneously. Similar devices are being explored to enhance expedient, precise delivery of endoluminal grafts. Future studies of endovascular techniques should include IVUS, when possible, to accurately quantitate the initial efficacy of devices and to determine the nature and distribution of recurrent lesions.

Outcomes after inferior vena cava thrombectomy and reconstruction for advanced renal cell carcinoma with tumor thrombus

BACKGROUND

This report details the experience of a multidisciplinary surgical team in the management of stage III and stage IV renal cell carcinoma (RCC) with concomitant inferior vena cava (IVC) tumor thrombus.

METHODS

A retrospective inquiry of our vascular database from 2003 to 2012 identified 55 surgical cases of stage III (n = 40) and stage IV (n = 15) RCC presenting with IVC tumor thrombus. Tumor characteristics and IVC tumor thrombus were evaluated by clinical staging and postoperative pathology staging. Patient demographics and surgical reconstruction are detailed. Cancer-specific outcomes consisted of oncologic surveillance with computed tomography or magnetic resonance imaging. A Clavien-Dindo classification of early (<30 days) complications and mortality was recorded, including a review of secondary surgical interventions.

RESULTS

According to the Novick classification of IVC tumor thrombus, there were 10 supradiaphragmatic (level IV), 20 intrahepatic (level III), and 25 infrahepatic (level II or I) tumor thrombi. Vena cava reconstruction was completed in 54 patients (98%), with one patient deemed unresectable. Vena cava control required cardiac bypass (n = 10), venovenous bypass (n = 4), or infrahepatic IVC control (n = 40). Reconstruction of the IVC was completed with two prosthetic interposition grafts for one stage IV thrombus and one stage III thrombus; two patch repairs were done for stage III thrombus, and there were 50 primary IVC repairs. All other IVC reconstructions were patent at a mean follow-up of 23 months. A single asymptomatic patient with primary IVC repair had estimated 30% IVC narrowing but no other measurable stenosis as detected by postoperative imaging. Three patients required reoperation (two for surgical site bleeding, one for small bowel fistula). Early surgical complications included Clavien-Dindo grades I (n = 3), II (n = 6), IIIa (n = 2), IIIb (n = 3), and V (n = 2). Regional retroperitoneal or distant recurrent RCC occurred in 26 patients (48%); a single patient demonstrating recurrent IVC tumor thrombus at 8 months required secondary IVC thrombectomy. All patients with tumor invasion of the IVC wall developed recurrent RCC, and no patient survived beyond 5 years. Early mortality was 3.6% (n = 2), with 27 patients (49%) dying within 24 months, resulting in an overall mortality for the cohort of 80% (n = 44) as established on routine regular postoperative surveillance.

CONCLUSIONS

A multidisciplinary approach for the management of advanced RCC and IVC tumor thrombus helps optimize outcomes. Primary IVC repairs are possible in most patients, and IVC patency is good. Recurrent tumor thrombus rates are low; however, RCC tumor recurrence and mortality are high, especially among patients with advanced cancer with IVC wall invasion.

Evolving Microbiology and Treatment of Extracavitary Prosthetic Graft Infections

The authors report the microbiology and outcomes following an individualized treatment algorithm for extracavitary (EC) prosthetic graft infection, including the use of graft preservation and in situ graft replacement techniques. A retrospective 8-year review of 87 patients treated for EC prosthetic graft infections was carried out. The treatment algorithm included culture-specific antibiotic therapy, surgical site debridement with antibiotic bead placement, selected graft preservation with muscle flap coverage, or graft excision with in situ conduit replacement. Outcomes measured included death, limb loss, and recurrent infection. It was found that present-day management of EC prosthetic graft infections is associated with lower mortality and morbidity despite changes in microbiology and the increased application of graft preservation and in situ grafting treatments.