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Objective: The Society of Vascular Surgery (SVS) has made it a top priority to implement verification of vascular "centers of excellence". Our institutional aortic network was established in 2008 in order to standardize care of patients with suspected acute aortic pathology. The implementation and success of this program has been previously reported. We sought to use our experience as a benchmark for which to develop prognostic modeling to quantify clinical status upon admission and help predict outcomes. Our objective was to validate the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system using a cohort of aortic emergencies transferred by an organized transfer network. Method: This was a retrospective, single institution review of patients transferred through an institutional aortic network for acute aortic pathology from 2017-2018. Demographics, comorbidities, aortic diagnosis, APACHE II score, as well as 30-day mortality were recorded. Associations with 30-day mortality were evaluated using two-sample t -tests, ANOVA models, Pearson chi-square tests and Fisher exact tests. Receiver operating characteristic (ROC) curves were fit overall and by pathology to predict 30-day mortality by Apache II total score. Results: There were 395 consecutive transfers were identified. The mean age was 64.7 years. Diagnoses included Type A Dissection (n = 134), Type B (n = 81), Aortic Aneurysm (n = 122), and PAU/IMH (n = 27). Mean APACHE II score on arrival was 12. Overall there were 53 deaths (13.4%) in the cohort. Patients that died had significantly higher Apache II total scores (11.3 vs 16.5, P <.001). The area under the receiver operator characteristic (ROC) curve (AUC) was.66 for the full cohort, indicating a poor clinical prediction test. Conclusion: APACHE II score is a poor predictor of 30-day mortality in a large transfer network accepting all aortic emergencies. The authors believe further refining a prognostic model for diverse population will not only help in predicting outcomes but to objectively quantify illness severity in order to have a basis for comparison among institutions and verification of "centers of excellence". [ABSTRACT FROM AUTHOR]

Purpose: To examine the efficacy of a staged approach for the treatment of thoracoabdominal aneurysms, with open visceral revascularization followed by aortic endografting, in selected patients not considered candidates for conventional surgical repair. Methods: A retrospective review was conducted of 13 consecutive patients (8 women; mean age 64 years, range 33-77) who underwent visceral bypass followed by endovascular thoracoabdominal stent-graft implantation since 1999. Three patients presented with symptomatic aneurysms and 2 with rupture. Two patients had connective tissue disorders. All patients were deemed unfit for conventional thoracoabdominal repair due to comorbid conditions. The procedures were tailored to the pathology and specific patient anatomical situation: 5 aortic dissections with aneurysmal degeneration and 8 aneurysms (5 Crawford type II, 2 type III, and 1 type IV). Results: The patients underwent retrograde visceral bypass (11 iliovisceral and 2 infrarenal aortic to visceral artery) followed by endovascular aortic relining with Zenith TX2 devices (n=7), homemade endografts (n=5), or a Talent thoracic endograft (n=1). Six patients required either a proximal or distal direct aortic repair (2 infrarenal reconstructions, 3 arch elephant trunk grafts, and 1 ascending aortic repair), while 3 patients also underwent left carotid-subclavian bypass grafting. Two patients developed paraplegia (1 following a ruptured aneurysm), and 2 patients had transient paraparetic events. Two patients had acute renal failure requiring short-term dialysis. Three patients died within 30 days; 2 late aneurysm-related deaths were noted. Three patients developed endoleaks during follow-up. Mean lengths of stay were 13 days (7-30) for the visceral bypass and 12 (3-25) for the endovascular stent-graft. In addition, remaining procedures in 8 patients required a mean of 7 days (0-14) in hospital. Conclusion: Staged endovascular and open procedures are feasible for thoracoabdominal aneurysms in patients at prohibitive risk for open thoracoabdominal reconstruction. However, this approach still carries a significant risk of perioperative mortality and morbidity. The potential for less invasive alternatives should be investigated. [ABSTRACT FROM AUTHOR]

The stratifications of aortoiliac, femoropopliteal, and infrapopliteal lesions included in the original comprehensive report of the TransAtlantic Inter-Society Consensus (TASC I) have been commonly used to formally characterize clinical trial populations and to channel investigative discussion among clinicians, while the associated treatment recommendations have become outdated as compared to current clinical practice. The TASC II report is an abbreviated update focusing on key areas of diagnosis and management of peripheral artery disease, with revised stratifications of aortoiliac and femoropopliteal lesions but not infrapopliteal disease. The consensus document keeps new lesion stratifications linked to the same structure of recommendations for initial treatment: endovascular for type A, endovascular (with qualifications) for type B, open surgical (with qualifications) for type C, and open surgical for type D. In general, each TASC II lesion category includes more severe disease than in TASC I, but the TASC II report does not recommend specific endovascular modalities for infrainguinal occlusive disease. We discuss how the new TASC II femoropopliteal lesion categories reflect current research outcomes and clinical practice, including summarized results from some more recent studies that have demonstrated the ability to treat by endovascular means increasingly complex femoropopliteal lesions that would actually be classifiable as type C. Noting that TASC II does not include a separate stratification of infrapopliteal lesions, as did TASC I, we review evidence of recent endovascular treatment of infrapopliteal lesions and contend that TASC classifications in this anatomical area should be upgraded. [ABSTRACT FROM AUTHOR]

Endovascular therapy for disease of the superficial femoral artery (SFA) and the popliteal artery remains controversial. Percutaneous treatment of this arterial segment presents a particular technical challenge, as the extent of disease varies from short, focal, and stenotic to long, diffuse, and occluded lesions. Over the last 2 decades, multiple therapies have been evaluated, including simple balloon angioplasty, directional atherectomy, stenting (both balloon-expandable and self-expanding), and more recently, intra-arterial radiation, laser, and cryotherapy. Regardless of which modality is used, however, endovascular therapy as a revascularization strategy has the potential to improve symptoms and quality of life and, in selected patients, to avoid limb amputation. While percutaneous endovascular treatment has been historically associated with high procedural success and favorable short and intermediate-term patency rates, long-term clinical results have proven disappointing. Conventional balloon angioplasty is limited by elastic recoil, dissection, and restenosis. Balloon-expandable stents (particularly in the distal SFA) are associated with late stent deformation and mechanical compression, with resultant late clinical failure. Newer self-expanding stents have shown improved initial results but have been limited by late mechanical fatigue and associated restenosis. With the development of several newer endovascular techniques in recent years, the possibilities for treating this condition have increased dramatically. Currently, no long-term comparative data exist regarding the role of these alternative technologies. This article summarizes and compares important data about new endovascular options for intervention therapy in SFA and popliteal disease. In addition, based on this analysis, we propose a contemporary treatment strategy, integrating older and newer technologies into a real-world algorithm. [ABSTRACT FROM AUTHOR]