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Based on data supporting a volume-outcome relationship in elective aortic aneurysm repair, the Society of Vascular Surgery (SVS) guidelines recommend that endovascular aortic repair (EVAR) be localized to centers that perform ≥10 operations annually and have a perioperative mortality and conversion-to-open rate of ≤2% and that open aortic repair (OAR) be localized to centers that perform ≥10 open aortic operations annually and have a perioperative mortality ≤5%. However, the number and distribution of centers meeting the SVS criteria remains unclear. This study aimed to estimate the temporal trends and geographic distribution of Centers Meeting the SVS Aortic Guidelines (CMAG) in the United States. The SVS Vascular Quality Initiative was queried for all OAR, aortic bypasses, and EVAR from 2011 to 2019. Annual OAR and EVAR volume, 30-day elective operative mortality for OAR or EVAR, and EVAR conversion-to-open rate for all centers were calculated. The SVS guidelines for OAR and EVAR, individually and combined, were applied to each institution leading to a CMAG designation. The proportion of CMAGs by region (West, Midwest, South, and Northeast) were compared by year using a χ2 test. Temporal trends were estimated using a multivariable logistic regression for CMAG, adjusting by region. Overall, 67,865 patients (49,264 EVAR; 11,010 OAR; 7591 aortic bypasses) at 336 institutions were examined. The proportion of EVAR CMAGs increased nationally by 1.7% annually from 51.6% (n = 33/64) in 2011 to 67.1% (n = 190/283) in 2019 (β =.05; 95% confidence interval [CI], 0.01-0.09; P =.02). The proportion of EVAR CMAGs across regions ranged from 27.3% to 66.7% in 2011 to 63.9% to 72.9% in 2019. In contrast, the proportion of OAR CMAGs has decreased nationally by 1.8% annually from 32.8% (n = 21/64) in 2011 to 16.3% (n = 46/283) in 2019 (β = −.14; 95% CI, −0.19 to −0.10; P <.01). Combined EVAR and OAR CMAGs were even less frequent and decreased by 1.5% annually from 26.6% (n = 17/64) in 2011 to 13.1% (n = 37/283) in 2019 (β = −.12; 95% CI, −0.17 to −0.07; P <.01). In 2019, there was no significant difference in regional variation of the proportion of combined EVAR and OAR CMAGs (P =.82). Although an increasing proportion of institutions nationally meet the SVS guidelines for EVAR, a smaller proportion meet them for OAR, with a concerning downward trend. These data question whether we can safely offer OAR at most institutions, have important implications about sufficient OAR exposure for trainees, and support regionalization of OAR. [ABSTRACT FROM AUTHOR]

Guidelines recommend open revascularization (OR) over endovascular revascularization (ER) for the treatment of chronic mesenteric ischemia (CMI) for younger, healthier patients. However, little is known about the long-term costs of these recommendations with respect to patients' overall life expectancy. This study investigated whether 5-year value differs between these treatment modalities. Patient data were extracted from the Statewide Planning and Research Cooperative System, the New York statewide all-payor database containing demographics, diagnoses, treatments, and charges. The database was queried for patients with an International Classification of Diseases , ninth revision, code for CMI, with the specific exclusion of acute ischemia cases. A propensity score match was performed using the Charlson Comorbidity Index, age, sex, race, renal status, and pulmonary disease for the final cohort of patients. Multiple linear regression and mixed effects linear regression were used to determine factors associated with 5-year value, calculated as life-years/$100k in charges. Charges were gathered from the index admission and subsequent admissions for acute or CMI, mesenteric angiography, or follow-up reintervention. Kaplan-Meier estimation was performed for survival and reintervention-free survival. From 2000 to 2014, 875 patients underwent intervention for CMI. Of those meeting inclusion criteria, 209 (28.1%) underwent OR and 535 (71.9%) ER. After propensity score matching (n = 209 in each group), the ER group showed higher value at 5 years after the procedure (8.04 ± 11.42 life-years/$100k charges vs 4.89 ± 5.28 life-years/$100k charges; P <.01). More patients underwent reintervention in the ER group (37 patients vs 17 patients; P <.01), with 55 reinterventions in the ER group and 19 in the OR group (P <.01). Multiple linear regression analysis showed that age, congestive heart failure, dysrhythmia, cancer, and days spent in the intensive care unit were negatively associated with value at 5 years, whereas ER was positively associated. Survival was 59.6 ± 3.76% vs 62.3% ± 3.49% at 5 years (P =.91), and reintervention-free survival was 43.7 ± 3.86% vs 58.1 ± 3.53% (P =.04), for ER and OR respectively. Despite increased reinterventions and lower reintervention-free survival, the value for patients with CMI was higher in those who underwent ER in the largest propensity score-matched cohort to date looking at long-term value. Factors negatively associated with value were OR, age, days in intensive care, congestive heart failure, dysrhythmia, and cancer. In patients with amenable anatomy, ER is validated as the first-choice treatment for CMI based on the superior procedural value. [ABSTRACT FROM AUTHOR]

We sought to quantify the percent calcification within carotid artery plaques and assess its impact on percent residual stenosis and rate of restenosis in patients undergoing transcarotid artery revascularization for symptomatic and asymptomatic carotid artery stenosis. A retrospective review of prospectively collected institutional Vascular Quality Initiative data was performed to identify all patients undergoing transcarotid artery revascularization from December 2015 to June 2021 (n = 210). Patient and lesion characteristics were extracted. Using a semiautomated workflow, preoperative computed tomography head and neck angiograms were analyzed to determine the calcified plaque volume in distal common carotid artery and internal carotid artery plaques. Intraoperative digital subtraction angiograms were reviewed to calculate the percent residual stenosis post-intervention according to North American Symptomatic Carotid Endarterectomy Trial criteria. Peak systolic velocity and end-diastolic velocity were extracted from outpatient carotid duplex ultrasound examinations. Univariate logistic regression was performed to analyze the relationship of calcium volume percent and Vascular Quality Initiative lesion calcification to percent residual stenosis in completion angiograms. Kaplan-Meier analysis examined the relationship between calcium volume percent and in-stent stenosis over 36 months. One hundred ninety-seven carotid arteries were preliminarily examined. Predilation was performed in 87.4% of cases with a mean balloon diameter of 5.1 ± 0.7 mm and a mean stent diameter was 8.8 ± 1.1 mm. The mean calcium volume percent was 11.9 ± 12.4% and the mean percent residual stenosis was 16.1 ± 15.6%. Univariate logistic regression demonstrated a statistically significant difference between calcium volume percent and percent residual stenosis (odds ratio [OR], 1.324; 95% confidence interval [CI], 1.005-1.746; P =.046). Stratified by quartile, only the top 25% of calcified plaques (>18.7% calcification) demonstrated a statistically significant association with higher percent residual stenosis (OR, 2.532; 95% CI, 1.049-6.115; P =.039). There was no statistical significance with lesion calcification (OR, 1.298; 95% C,: 0.980-1.718; P =.069). A Kaplan-Meier analysis demonstrated a statistically significant increase in the rate of in-stent stenosis during a 36-month follow-up for lesions containing >8.2% calcium volume (P =.0069). A calcium volume percent of >18.7% was associated with a higher percent residual stenosis, and a calcium volume percent of >8.2% was associated with higher in-stent stenosis at 36 months. There was one clinically diagnosed stroke during the follow-up period, demonstrating the overall safety of the procedure. [ABSTRACT FROM AUTHOR]

It has been shown local or regional anesthetic techniques are a feasible alternative to general anesthesia for endovascular aortic aneurysm repair (EVAR). However, studies to date have shown controversial findings with respect to the benefit of locoregional anesthesia (LR) in the elective setting. The objective of this study is to compare postoperative outcomes between LR and general anesthesia (GA) in the setting of elective EVAR, using a large, multicenter database. Using the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed all patients who underwent elective EVAR from August 2003 to June 2021. Patients were grouped by anesthetic type based on the level of consciousness afforded by the anesthetic: local or regional anesthesia (LR) vs GA. Primary outcomes were total postoperative hospital length-of-stay (LOS) and intensive care unit (ICU) LOS. Propensity score matching was used for risk adjustment and to analyze the primary outcomes with confirmatory analysis using logistic or linear regression, as appropriate, in single and multilevel models. Secondary outcomes were 30-day mortality, 1-year mortality, postoperative outcomes, operative time, fluoroscopy time, and reoperation rate. These were analyzed following propensity score matching as well as using logistic regression and Cox proportional hazard regression in single and multilevel models, as appropriate. A total of 50,809 patients underwent elective EVAR from 2003 to 2021. Of these, 4302 repairs used LR (8.5%) and 46,507 (91.5%) were performed under GA. After employing propensity score matching, two groups of 3027 patients were produced. These showed no significant difference in 30-day mortality (odds ratio, 1.22; P =.53), 1-year mortality (hazard ratio, 1.06; P =.62), or any postoperative outcomes. LR was found to be significantly associated with shorter hospital stays (≤2 days) (12.5% vs 14.8%; P =.01), decreased ICU utilization (19.3% vs 30.6%; P <.001), decreased operative time (110.8 vs 117.3 minutes; P <.001), decreased fluoroscopy time (21.0 vs 22.7 minutes; P <.001), and a slight reduction in reoperation rate (1.2% vs 1.9%; P =.02), which all remained significant following single-level and multilevel multivariate analyses accounting for hospital and physician random effects. These data suggest that LR anesthesia is safe and may offer advantages in reducing resource utilization for patients undergoing elective EVAR, primarily based on associations with reduced ICU care and reduced hospital stay. Given these findings, LR may prove an advantageous technique in appropriately selected patient populations. [ABSTRACT FROM AUTHOR]

Vascular surgeons work long, unpredictable hours with repeated exposure to high-stress situations. Inspired by general surgery acute care surgery models, we sought to organize the care of vascular emergencies with the implementation of a vascular acute care surgery (VACS) model. Within this model, a surgeon is in-house without elective cases and assigned for consultations and urgent operative cases on a weekly basis. This study examined the impact of a VACS model on postoperative mortality and surgeon efficiency. This was a retrospective cohort analysis of institutional Vascular Quality Initiative data from July 2014 to July 2023. Patients undergoing lower extremity bypass, peripheral vascular intervention, or amputation were included. There was a washout period from January 2020 to January 2022 to account for COVID-19 pandemic practice abnormalities. Patients were separated into pre- or post-VACS groups. The primary clinical outcomes were 30-day and 2-year mortality. Secondary clinical outcomes included 30-day complications and 30-day and 1-year major adverse limb events (MALE). Separate analyses of operating room data from July 2017 to February 2024 and fiscal data from fiscal year 2019 to fiscal year 2024 were conducted. A washout period from January 2020 to January 2022 was applied. Efficiency outcomes included monthly relative value units (RVUs) per clinical fraction full-time equivalent (cFTE) and daytime (0730-1700, Monday-Friday) operating room minutes. Patient factors and operative efficiency were compared using appropriate statistical tests. Regression modeling was performed for the primary outcomes. There were 972 and 257 patients in the pre- and post-VACS groups, respectively. Pre-VACS patients were younger (66.8 ± 12.0 vs 68.7 ± 12.7 years; P =.03) with higher rates of coronary artery disease (34.6% vs 14.8%; P <.01), hypertension (88.4% vs 82.2%; P =.01), and tobacco history (84.4% vs 78.2%; P =.02). Thirty-day mortality (2.4% pre-vs 0.8% post-VACS; P =.18) and Kaplan-Meier estimation of 2-year mortality remained stable after VACS (P =.07). VACS implementation was not associated with 30-day mortality but was associated with lower 2-year mortality hazard on multivariable Cox regression (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.9; P =.01). Operative efficiency improved post-VACS (median, 850.0; interquartile range [IQR], 765.7-916.3 vs median, 918.0; IQR, 881.0-951.1 RVU/cFTE-month; P =.03). Daytime operating minutes increased (469.1 ± 287.5 vs 908.2 ± 386.2 minutes; P <.01), whereas non-daytime minutes (420.0; IQR, 266.0-654.0 vs 469.5; IQR, 242.0-738.3 minutes; P =.40) and weekend minutes (129.0; IQR, 0.0-298.0 vs 113.5; IQR, 0.0-279.5 minutes; P =.59) remained stable. A VACS model leads to improvement in surgeon operative efficiency while maintaining patient safety. The adoption of a vascular acute care model has a positive impact on the delivery of comprehensive vascular care. [ABSTRACT FROM AUTHOR]

Vascular surgeons have one of the highest rates of burnout among surgical specialties, often attributed to high patient acuity and clinical workload. Acute Care Surgery models are a potential solution used among general and trauma surgeons. This is a retrospective analysis of prospectively collected Accreditation Council for Graduate Medical Education survey results from faculty and residents before and after implementation of a vascular Acute Care Surgery (VACS) model. The VACS model assigns a weekly rotation of an attending surgeon with no elective cases or clinic responsibilities and a monthly rotating resident team. Residents and attendings are in-house to cover all urgent and emergent vascular daytime consultations and procedures, whereas nights and weekend coverage remain a typical rotating schedule. Survey question results were binned into domains consistent with the Maslach Burnout Inventory. Both residents and faculty reported an increase in median scores in Maslach Burnout Inventory domains of emotional exhaustion (Faculty: 2.9 vs 3.4; P <.001; Residents: 3.1 vs 3.6; P <.001) and faculty reported higher personal accomplishment scores (Faculty: 3.3 vs 3.8; P =.005) after the VACS model implementation. A VACS model is a tangible practice change that can address a major problem for current vascular surgeons, as it is associated with decreased burnout for faculty and residents through improvement in both emotional exhaustion and personal accomplishment. Improved longitudinal assessment of resident and faculty burnout is needed and future work should identify specific practice patterns related to decreased burnout. [ABSTRACT FROM AUTHOR]

The annual number of open abdominal aortic aneurysm (AAA) repairs has decreased dramatically over the last decade, making the search for physician case volume thresholds more important. The purpose of this study was to identify a minimum threshold for annual surgeon case volume in open AAA repair. The New York Statewide Planning and Research Cooperative System inpatient database was used to identify all patients undergoing open repair of an intact AAA between 2000 and 2008. Thirty-day survival was calculated using New York State vital records, which contain all New York State death certificates. The annual case volume for each surgeon was defined as the number of open AAA repairs performed in the year of the index procedure. The Contal and O'Quigley method was used to identify a minimum volume threshold. A total of 11,086 patients were included in the analysis. The selected cutpoint was six or more cases per year based on maximization of the Contal and O'Quigley test statistic. The high-volume group had comparable rates of cardiovascular comorbidities, but significantly improved 30-day and 5-year survival rates as well as shorter lengths of stay in the hospital. This study identifies an ideal threshold for minimum annual surgeon case volume for open AAA repair. Over the study period, perioperative mortality would not have occurred in up to 150 patients if all procedures had been done by high-volume surgeons performing at least six repairs per year. However, even a minimum annual threshold of at least two repairs per year provided a mortality benefit. Ideal minimum volume thresholds should be developed using rigorous statistical analysis as well as local information about practice patterns. [ABSTRACT FROM AUTHOR]

Abstract Background An anatomic severity grade (ASG) score to categorize and to define anatomic factors for abdominal aortic aneurysm (AAA) repair was proposed. Other studies have previously reported that aortic anatomic complexity is a marker of survival and resource utilization after repair, although it remains unclear whether individual components of the ASG score independently contribute to survival. This study analyzed and validated an aortic and iliac artery calcium scoring system that can potentially predict survival after AAA repair. Methods Patients who underwent infrarenal AAA repairs from July 2007 to May 2012 were analyzed using complete 5-year records. Those who died ≤30 days of surgery were excluded. Calcium score (CS) was defined using the ASG scoring system for its basis by preoperative imaging <6 months before surgery. A CS for any patient was 0 to 5 points, the sum of the points assigned to aortic neck (2 points total) and iliac artery (3 points total) calcification. A receiver operating characteristic curve was used to determine a CS threshold for mortality. The 5-year survivors and deaths were compared in regard to comorbidities, pharmacology, and CS at or above the defined threshold. Each variable with a P value <.1 between the groups was then placed into a Cox proportional hazards model, with statistical significance of P <.05. Results There were 356 patients who underwent AAA repair with complete 5-year follow-up data; 26% died within 5 years of surgery. Of these, 13% had CS of 0 with 15% mortality, 28% had CS of 1 with 21% mortality, 24% had CS of 2 with 24% mortality, 23% had CS of 3 with 35% mortality, 10% had CS of 4 with 40% mortality, and 2% had CS of 5 with 17% mortality. The receiver operating characteristic curve demonstrated an appropriate threshold of CS 3. Of these patients, 65% had a CS <3, whereas 35% had a CS ≥3. Patients with a CS ≥3 had a lower 5-year survival probability (P =.003). Comparing 5-year survivors and deaths in a Cox proportional hazards analysis, CS ≥3 was associated with a hazard ratio of 1.579 (95% confidence interval, 1.038-2.402; P =.0328). Conclusions A CS ≥3 is linked to a lower 5-year survival after AAA repair in our population. This system potentially can be another measure for risk stratification and serve as a means to predict midterm mortality in AAA repairs. Future study will be needed for further validation to predict midterm mortality and to better guide surgical decision-making. [ABSTRACT FROM AUTHOR]

Background Potential cost effectiveness of endovascular aneurysm repair (EVAR) compared with open aortic repair (OAR) is offset by the use of intraoperative adjuncts (components) or late reinterventions. Anatomic severity grade (ASG) can be used preoperatively to assess abdominal aortic aneurysms, and provide a quantitative measure of anatomic complexity. The hypothesis of this study is that ASG is directly related to the use of intraoperative adjuncts and cost of aortic repair. Methods Patients who undergo elective OAR and EVAR for abdominal aortic aneurysms were identified over a consecutive 3-year period. ASG scores were calculated manually using three-dimensional reconstruction software by two blinded reviewers. Statistical analysis of cost data was performed using a log transformation. Regression analyses, with a continuous or dichotomous outcome, used a generalized estimating equations approach with the sandwich estimator, being robust with respect to deviations from model assumptions. Results One hundred forty patients were identified for analysis, n = 33 OAR and n = 107 EVAR. The mean total cost (± standard deviation) for OAR was per thousand (k) $38.3 ± 49.3, length of stay (LOS) 13.5 ± 14.2 days, ASG score 18.13 ± 3.78; for EVAR, mean total cost was k $24.7 ± 13.0 ( P = .016), LOS 3.0 ± 4.4 days ( P = .012), ASG score 15.9 ± 4.13 ( P = .010). In patients who underwent EVAR, 25.2% required intraoperative adjuncts, and analysis of this group revealed a mean total cost of k $31.5 ± 15.9, ASG score 18.48 ± 3.72, and LOS 3.9 ± 4.5, which were significantly greater compared with cases without adjunctive procedures. An ASG score of ≥15 correlated with an increased propensity for requirement of intraoperative adjuncts; odds ratio, 5.75 (95% confidence interval, 1.82-18.19). ASG >15 was also associated with chronic kidney disease, end stage renal disease, hypertension, female sex, increased cost, and use of adjunctive procedures. Conclusions Complex aneurysm anatomy correlates with increased total cost and need for adjunctive procedures during EVAR. Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource use. Patient comorbid factors are associated with anatomic complexity defined according to ASG. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts toward value-based reimbursement. [ABSTRACT FROM AUTHOR]

Objective The molecular mechanisms leading to the development of abdominal aortic aneurysms (AAAs) remain poorly understood. The aim of this study was to determine the expression of Sonic Hedgehog (SHh), transforming growth factor β (TGF-β), and Notch signaling components in human aneurysmal and nonaneurysmal aorta in vivo. Methods Paired tissue samples were obtained from aneurysmal and nonaneurysmal (control) segments of the aortic wall of eight patients with suitable anatomy undergoing open repair of infrarenal AAAs. Protein and messenger RNA (mRNA) expression levels were determined by Western blot and quantitative real-time polymerase chain reaction analysis. Results Aneurysm development resulted in a significant reduction in vascular smooth muscle (vSMC) differentiation genes α-actin and SMC22α at both mRNA and protein levels. In parallel experiments, an 80.0% ± 15% reduction in SHh protein expression was observed in aneurysmal tissue compared with control. SHh and Ptc-1 mRNA levels were also significantly decreased, by 82.0% ± 10% and 75.0% ± 5%, respectively, in aneurysmal tissue compared with nonaneurysmal control tissue. Similarly, there was a 50.0% ± 9% and 60.0% ± 4% reduction in Notch receptor 1 intracellular domain and Hrt-2 protein expression, respectively, in addition to significant reductions in Notch 1, Notch ligand Delta like 4, and Hrt-2 mRNA expression in aneurysmal tissue compared with nonaneurysmal tissue. There was no change in Hrt-1 expression observed in aneurysmal tissue compared with control. In parallel experiments, we found a 2.2 ± 0.2-fold and a 5.6 ± 2.2-fold increase in TGF-β mRNA and protein expression, respectively, in aneurysmal tissue compared with nonaneurysmal tissue. In vitro, Hedgehog signaling inhibition with cyclopamine in human aortic SMCs resulted in decreased Hedgehog/Notch signaling component and vSMC differentiation gene expression. Moreover, cyclopamine significantly increased TGF-β1 mRNA expression by 2.6 ± 0.9-fold. Conclusions These results suggest that SHh/Notch and TGF-β signaling are differentially regulated in aneurysmal tissue compared with nonaneurysmal tissue. Changes in these signaling pathways and the resulting changes in vSMC content may play a causative role in the development of AAAs. [ABSTRACT FROM AUTHOR]

Objective: The single puncture intravascular ultrasound (IVUS)-guided bedside placement of inferior vena cava (IVC) filters has been shown to be an effective technique. The major disadvantage of this procedure is a steep learning curve that can lead to an increased risk of filter malposition. In an effort to increase the safety and efficacy of IVUS-guided bedside IVC filter placement, we proposed that preoperative planning could reduce the incidence of IVUS-guided filter malpositions. As a first step, we examined the correlation between preoperative abdominal computed tomography (CT) scan measurements and intraprocedural IVUS derived measurements of vena cava anatomy and its surrounding structures. As a second step, we attempted to determine the safety of this protocol by assessing the incidence of malposition. Methods: A retrospective review of prospectively collected data was performed on all patients receiving bedside IVUS-guided filters from July 1, 2010 to August 31, 2011. Measurements of the IVC length from the atrial-IVC junction to the midportion of the crossing right renal artery, the lowest renal vein, and iliac vein confluence were obtained prior to IVC filter placement by both CT-based measurement, as well as intraprocedural IVUS pullback lengths. Regression analysis (significant for P < .05) was used to determine the correlation between these imaging modalities. Results: Forty-six patients had adequate CT scans available to perform the analysis and were candidates for bedside IVUS-guided IVC filter placement. All IVUS-guided filters were placed using a single puncture technique with the Cook Celect Filter. This study found there was a close correlation between IVUS and CT derived measurements of the right atrium to right renal artery distance, lowest renal vein distance, and iliac confluence distance. In addition, we found that the IVUS distances from the atrial-IVC junction to the right renal artery and lowest renal vein were statistically similar. Nine patients had 10 vascular anatomic variations, all identified by both IVUS and CT. There were no complications or malpositions of IVC filters using this protocol. Conclusions: These data suggest that IVUS pullback measurements from the right atrium used in combination with preprocedure CT derived measurements of the distance from the right atrium to the lowest renal vein and iliac vein confluence provide an accurate roadmap for the placement of bedside IVC filters under IVUS guidance. We provide a method for organizing this information in a preplanning document to aid this procedure. We suggest this easily employed technique be more fully utilized to help decrease the incidence of malpositioned filters using single puncture IVUS guidance. [Copyright &y& Elsevier]

Within the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm. Retrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm. There were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P =.001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P =.056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P =.023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P =.016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P =.461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants. These data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm. [ABSTRACT FROM AUTHOR]

Objective: The use of cross-sectional area (CSA) measurements obtained from computed tomographic angiography (CTA) for the calculation of carotid artery stenosis has been suggested but not yet validated in a large population. The objective of this study was to determine whether CTA-derived CSA measurements were able to predict carotid stenosis with a level of confidence similar to CTA-derived diameter measurements, using Strandness criteria applied to carotid duplex ultrasound (CDUS) as a surrogate for true stenosis. Methods: A retrospective review was conducted to identify patients who underwent both CDUS and CTA between 2000 and 2009. Percent stenosis was calculated using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) formula with diameter measurements and again with CSA measurements. A nonparametric correlation coefficient was calculated to detect correlation between the two groups. Two-dimensional receiver-operating characteristic curves with corresponding area under the curve (AUC) statistics were generated for >50% stenosis and >80% stenosis. Three-dimensional receiver-operating characteristic plots with corresponding volume under the surface (VUS) statistics were generated to measure the comparative accuracy of diameter-based and CSA-based stenosis for <50%, 50%-79%, and >80% stenosis. Results: A total of 575 vessels in 313 patients were included in the study. Spearman's correlation coefficient between diameter and CSA-derived stenosis was ρ = 0.938 (95% confidence interval [CI], 0.927-0.947; P < .0001). For diameter-derived stenosis, AUC was 0.905 (95% CI, 0.878-0.932; P < .0001) for >50% stenosis and 0.950 (95% CI, 0.928-0.972; P < .0001) for 80%-99% stenosis. For CSA-derived percent stenosis, the AUC was 0.908 (95% CI, 0.882-0.935; P < .0001) for >50% stenosis and 0.935 (95% CI, 0.908-0.961; P < .0001) for 80%-99%. The nonparametric estimate for VUS in the diameter-based stenosis group was 0.761, whereas in the CSA-based group, the VUS was 0.735. The difference between VUS was 0.026 (95% CI, –0.022 and 0.077; P = .318). Conclusions: These data support the use of CTA as an accurate method of calculating carotid artery stenosis based on agreement with Strandness criteria applied to CDUS velocities. When additional imaging beyond CDUS is necessary, we report no significant difference between diameter and CSA measurements obtained from CTA for preoperative evaluation of carotid disease. [Copyright &y& Elsevier]

Venous thoracic outlet syndrome progressing to the point of axilosubclavian vein thrombosis, variously referred to as Paget-Schroetter syndrome or effort thrombosis, is a classic example of an entity which if treated correctly has minimal long-term sequelae but if ignored is associated with significant long-term morbidity. The subclavian vein is highly vulnerable to injury as it passes by the junction of the first rib and clavicle in the anterior-most part of the thoracic outlet. In addition to extrinsic compression, repetitive forces in this area frequently lead to fixed intrinsic damage and extrinsic scar tissue formation. Once primary thrombosis is recognized, catheter-directed thrombolytic therapy is usually successful if initiated within ten to 14 days of clot formation, but often unmasks an underlying lesion. The vast majority of investigators believe that decompression of the venous thoracic outlet, usually by means of first rib excision, partial anterior scalenectomy, resection of the costoclavicular ligament, and thorough external venolysis, is necessary, although opinion is less uniform as to the need for and method of treatment of the venous lesion itself. Using this algorithm, long-term success rates of 95 to 100% have been reported by many investigators. This review, in addition to discussing the overall treatment algorithm in more detail, attempts to point out controversies that still exist and research directions, both clinical and basic, that need to be pursued. Prospective randomized trials addressing this entity are surprisingly lacking, and although there is consensus based on experience, it may be necessary to step back and rigorously explore several aspects of this entity. [Copyright &y& Elsevier]