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Objective: As it remains unclear whether there are sex-based differences in clinical outcomes after thoracic endovascular aortic repair (TEVAR), this meta-analysis aimed to evaluate differences in early outcomes and overall survival between female and male patients who underwent TEVAR., Methods: The PubMed, Embase, Web of Science, and Cochrane Central databases were searched for eligible studies published through June 10, 2023, that reported sex-based differences in clinical outcomes after TEVAR. The primary outcome was operative mortality; second outcomes included stroke, spinal cord ischemia, acute kidney injury, hospital length of stay, and overall survival. Patient characteristics, operative data, and early outcomes were aggregated using the random-effects model, presenting pooled risk ratio (RR) or standardized mean difference along with their corresponding 95% confidence intervals (CIs). Overall survival was assessed by reconstructing individual patient data to generate sex-specific pooled Kaplan-Meier curves. This study was registered in PROSPERO (CRD42023426069)., Results: Of the 1785 studies retrieved, 14 studies met all eligibility criteria, encompassing a total of 17,374 patients, comprising 5026 female and 12,348 male patients. Female patients were older, had a smaller maximum aortic diameter, had lower rates of smoking and coronary artery disease, and had higher rates of anemia. Intraoperatively, female patients were more likely to use iliac conduits and require blood transfusions. There were no sex-based differences in operative mortality (RR: 1.12, 95% CI: 0.90-1.40; P = .309), stroke (RR: 1.14, 95% CI: 0.95-1.38; P = .165), spinal cord ischemia (RR: 1.33, 95% CI: 0.83-2.14; P = .234), acute kidney injury (RR: 0.78, 95% CI: 0.52-1.17; P = .228), and hospital length of stay (standardized mean difference: 0.09, 95% CI: -0.03 to 0.20; P = .141). Pooled Kaplan-Meier estimates showed a worse overall survival in female patients compared with male patients (87.2% vs 89.8% at 2 years, log-rank P = .001)., Conclusions: Among patients treated by TEVAR, female sex was not associated with increased risk of operative mortality or major morbidity. However, female patients exhibited a lower overall survival after TEVAR compared with male patients., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Women and underrepresented minorities (URMs) who are at an increased risk of presenting with severe peripheral artery disease (PAD) and have different responses to treatment compared with non-Hispanic White males yet are underrepresented in PAD research., Methods: ELEGANCE is a global, prospective, multi-center, post-market registry of PAD patients treated with drug-eluting device that aims to enroll at least 40% women and 40% URMs. The study design incorporates strategies to increase enrollment of women and URMs. Inclusion criteria are age ≥18 years and treatment with any commercially available Boston Scientific Corporation drug-eluting device marketed for peripheral vasculature lesions; exclusion criterion is life expectancy <1 year., Results: Of 750 patients currently enrolled (951 lesions) across 39 sites, 324 (43.2%) are female and 350 (47.3%) are URMs (21.6% Black, 11.2% Asian, 8.5% Hispanic/Latino, and 5.3% other). Rutherford classification is distributed differently between sexes (P = .019). Treatment indication differs among race/ethnicity groups (P = .003). Chronic limb-threatening ischemia was higher for Black (38.3%) and Hispanic/Latino (28.1%) patients compared with non-Hispanic White (21.8%) and Asian patients (21.4%). De-novo stenosis was higher in Asian patients (92.3%) compared with Black, non-Hispanic White, and Hispanic/Latino patients (72.2%, 68.7%, and 77.8%, respectively; P < .001). Mean lesion length was longest for Black patients (162.7 mm), then non-Hispanic White (135.2 mm), Asian (134.8 mm), and Hispanic/Latino patients (128.1 mm; P = .008)., Conclusions: Analyses of data from the ELEGANCE registry show that differences exist in baseline disease characteristics by sex and race/ethnicity; these may be the result of other underlying factors, including time to diagnosis, burden of undermanaged comorbidities, and access to care., Competing Interests: Disclosures E.A.S. reports research grants (to Beth Israel Deaconess Medical Center) from the National Institutes of Health/ National Heart, Lung, and Blood Institute K23HL150290, United States Food a d Drug Administration, BD, Boston Scientific, Cook, CSI, Laminate Medical, Medtronic, and Philips; and consulting/speaking for Abbott, Bayer, BD, Boston Scientific, Cook, Cordis, CSI, Inari, Medtronic, Philips, Shockwave, and VentureMed. J.G. reports research funds to the institution and advisory boards for Boston Scientific, Inari Medical, Abiomed, Recor Medical, and Abbott Vascular; and equity in Endovascular Engineering. M.B. reports consulting for Medtronic, BD Bard, Phillips, Boston Scientific, Cagent Vascular, Soundbite Medical, Shockwave, Resolv Medical, R3 Vascular, Bolt Medical, Bayer Healthcare, Cook Medical, and Biotronik. Y.G. received research funding from Abbott, Boston Scientific, General Electric, Veryan, and WL Gore; and personal fees and grants from Abbott, Bard, Biotronik, Boston Scientific, Cook, General Electric, Medtronic, Penumbra, Terumo, Veryan, WL Gore. F.W. serves as a member of the ELEGANCE Registry Steering Committee (Boston Scientific Corporation). A.J.G.-W. reports employee of Boston Scientific Corporation. M.R.J. reports employee of Boston Scientific Corporation. L.K. reports consultant to Boston Scientific, Gore Medical, Cook Medical, and 3M. M.P.K. reports VIVA board member; SIR Foundation board member; and Global PI for the ELEGANCE Registry (Boston Scientific Corporation)., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the risk factors for unrelieved malperfusion after thoracic endovascular aortic repair (TEVAR) alone., Methods: From January 2009 to December 2019, 86 patients with type B aortic dissection-induced malperfusion were enrolled. Demographics and clinical and imaging data, as well as treatment outcomes, were collected and compared between patients with malperfusion relieved by TEVAR alone (TR) or by TEVAR with adjunctive procedures (TA)., Results: Among the 86 enrolled patients, 17 (19.8%) had malperfusion requiring TA. Patients in the TA group were more likely to suffer lower limb ischemia (P = .004), present with severe ischemia (P = .003), and have more than one end-organ ischemia (P = .015). There were more involved vessels classified as the mixed type in the TA group (P = .002). Mixed ischemia was the only independent risk factor for malperfusion requiring TA (odds ratio, 4.7; 95% confidence interval [CI], 1.3-17.2; P = .017). The ischemia-related in-hospital mortality rate of the TA group was significantly higher than that of the TR group (P = .023), and malperfusion requiring TA was the only risk factor in the multivariate logistic regression (odds ratio, 14.6; 95% CI, 1.4-150.5; P = .025). The 5-year overall cumulative survival rates were 82.4% (95% CI, 66.1%-100.0%) in the TA group and 89.5% (95% CI, 81.6%-98.1%) in the TR group (P = .294)., Conclusions: Type B aortic dissection-induced malperfusion requiring TA was associated with a higher ischemia-related in-hospital mortality rate. Mixed obstruction was an independent risk factor for unrelieved malperfusion after TEVAR alone, and early identification of potential patients requiring TA could thereby be achieved. Reasonable treatment strategies could contribute to the successful management of malperfusion requiring TA., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We evaluated the long-term safety and efficacy of treatment using drug-coated balloons (DCBs) in Chinese patients with severe femoropopliteal artery (FPA) disease (FPAD)., Methods: In this prospective, multicenter, randomized controlled trial, 200 Chinese patients with FPAD were prospectively randomized to undergo percutaneous transluminal angioplasty with a DCB or an uncoated balloon (UCB). The clinical endpoints were all-cause mortality, clinically driven target lesion revascularization, and major amputation of the treated leg within 5 years after treatment., Results: During the 5-year follow-up period, freedom from all-cause mortality was 82.7% in the DCB group compared with 73.2% in the UCB group (log-rank P = .262). Freedom from clinically driven target lesion revascularization was 77.5% in the DCB group vs 59.1% in the UCB group (log-rank P < .001). No device- or procedure-related deaths occurred in either group. Cox regression analysis revealed that coronary heart disease and provisional FPA lesion stenting were associated with an increased mortality risk and the nominal paclitaxel dose was not associated with mortality during the 5-year follow-up period., Conclusions: We found no significant differences in 5-year mortality between patients with FPAD treated with DCBs vs UCBs. The clinical benefit of DCBs vs UCBs in terms of clinically driven target lesion revascularization persisted for the 5-year period., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To compare the surgical outcomes of benign and malignant carotid body tumor (CBT), and to evaluate the associated factors of malignant CBT., Methods: Patients who underwent surgical resection of CBT from 2005 to 2018 in a tertiary center were reviewed retrospectively. The common study follow-up end date was December 31, 2019. The tumor size was measured as the maximum transverse diameter on computed tomography scan. Surgical outcomes of benign and malignant CBT were compared. Associated factors of malignancy were analyzed by multivariate logistic analysis., Results: There were 229 patients undergoing CBT resection. Sixteen patients were diagnosed with malignant CBT. The median follow-up time was 66 months (range, 6-142 months). Basic information including age, sex, course of disease, family history, lesion side, tumor size, and Shamblin classification showed no significant differences between the benign and malignant CBT groups. Patients with malignant CBTs showed a higher rate of preoperative symptoms (31.3% vs 12.2%; P < .05). The rates of vascular reconstruction or repair (P < .01) and neurologic complications (P < .05) were significantly higher in the malignant CBT group. In addition, a significantly longer average procedural time was required for malignant CBTs (P < .05). However, the estimated blood loss and length of hospital stay showed no significant difference. Multivariate logistic regression analysis revealed that the malignant odds of CBT with bilateral lesions (P = .0042; odds ratio, 8.30; 95% confidence interval, 1.84-35.88) or CBT with preoperative symptoms (P = .0016; odds ratio, 7.59; 95% confidence interval, 2.13-27.89) were high., Conclusions: Compared with benign CBT, malignant CBT is prone to invasive clinical behaviors, resulting in an increased possibility of vascular reconstruction or repair during the surgery as well as postoperative neurologic complications. In addition, the malignant odds of CBT with bilateral lesions or CBT with preoperative symptoms are high., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Despite its association with static mesenteric malperfusion, the morphologic characteristics and optimal management of acute type B aortic dissection (ABAD) with superior mesenteric artery (SMA) involvement are poorly understood. We studied the associated risk factors and reported the outcomes of endovascular treatment., Methods: From May 2016 to May 2018, we examined 212 consecutive patients with ABAD in our center. Those with SMA involvement (SMAI) were included in the present study and divided into those with and without mesenteric malperfusion (MMP) according to the clinical findings. After thoracic endovascular aortic repair (TEVAR) with or without SMA revascularization, we compared the clinical data, imaging results, and outcomes for those with and without MMP., Results: Computed tomography angiography confirmed 44 cases of SMAI: 12 (27.3%) with MMP and 32 (72.7%) without MMP. The patients with MMP had presented more frequently with lower extremity malperfusion (33.3% vs 3.1%; P = .023) than had those without MMP, with an odds ratio of 14.15 (P = .047). Multivariate analysis showed that patients with a low true lumen (TL)/false lumen (FL) diameter ratio of the SMA (TL/FL-SMA <1) had a greater risk of developing MMP than those with a high TL/FL-SMA ratio of >1 (odds ratio, 8.49; 95% confidence interval, 1.24-58.26; P = .029). SMA TL thrombosis was a significant predictor of the requirement for additional SMA revascularization after TEVAR among patients with MMP (P = .045). During a mean 10-month follow-up period, complete FL thrombosis in the SMA was seen in 11 patients (25%; 33.3% with MMP vs 21.9% without MMP; P = .43). The overall mortality rate was 6.82% (16.7% in the MMP group and 3.1% in the non-MMP group; P = .09)., Conclusions: In the present study, limb ischemia and the TL/FL-SMA ratio were two independent predictors for the development of MMP in patients with ABAD and SMAI. We found that TEVAR can be safely performed for these patients, and SMA TL thrombosis predicted for the need for SMA revascularization., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We investigated the outcomes of endovascular repair for penetrating aortic ulcers (PAUs) with and without intramural hematoma (IMH)., Methods: Patients with PAUs who had undergone thoracic endovascular aortic repair (TEVAR) or endovascular abdominal aortic repair (EVAR) at our center were enrolled. Patient demographics, presenting symptoms, and anatomic characteristics were collected and analyzed to investigate the TEVAR/EVAR indications, perioperative complications, and mortality., Results: We identified 138 patients with PAU. Of the 138 patients, 58 (42.0%) had also had IMH. Compared with the patients without IMH, the patients with IMH had had significantly greater emergency admission rates (P < .01), a larger aortic diameter (P = .03), and a greater incidence of stent-induced new entry development (P = .02). No significant differences were found in mortality or freedom from reintervention between patients with PAUs with and without IMH during follow-up. However, the cumulative survival rates calculated using Kaplan-Meier analysis for patients who had undergone TEVAR/EVAR during their first hospitalization were significantly greater than those who had undergone delayed TEVAR/EVAR during follow-up., Conclusions: TEVAR/EVAR was safe and effective, with encouraging outcomes for patients with PAUs with or without IMH, and can be used more aggressively for symptomatic patients. The presence of PAUs with IMH did not seem to adversely affect long-term mortality. However, but stent-induced new entry was more likely to develop., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Mural angiogenesis and macrophage accumulation are two pathologic hallmarks of abdominal aortic aneurysm (AAA) disease. The heterodimeric transcription factor hypoxia-inducible factor 1 (HIF-1) is an essential regulator of angiogenesis and macrophage function. In this study, we investigated HIF-1 expression and activity in clinical and experimental AAA disease., Methods: Human aortic samples were obtained from 24 AAA patients and six organ donors during open abdominal surgery. Experimental AAAs were created in 10-week-old male C57BL/6J mice by transient intra-aortic infusion of porcine pancreatic elastase (PPE). Expression of HIF-1α and its target gene messenger RNA (mRNA) levels were assessed in aneurysmal and control aortae. The HIF-1α inhibitors 2-methoxyestradiol and digoxin, the prolyl hydroxylase domain-containing protein (PHD) inhibitors cobalt chloride and JNJ-42041935, and the vehicle alone as control were administered daily to mice at varying time points beginning before or after PPE infusion. Influences on experimental AAA formation and progression were assessed by serial transabdominal ultrasound measurements of aortic diameter and histopathologic analysis at sacrifice., Results: The mRNA levels for HIF-1α, vascular endothelial growth factor A, glucose transporter 1, and matrix metalloproteinase 2 were significantly increased in both human and experimental aneurysm tissue. Tissue immunostaining detected more HIF-1α protein in both human and experimental aneurysmal aortae compared with respective control aortae. Treatment with either HIF-1α inhibitor, beginning before or after PPE infusion, prevented enlargement of experimental aneurysms. Both HIF-1α inhibition regimens attenuated medial elastin degradation, smooth muscle cell depletion, and mural angiogenesis and the accumulation of macrophages, T cells, and B cells. Whereas mRNA levels for PHD1 and PHD2 were elevated in experimental aneurysmal aortae, pharmacologic inhibition of PHDs had limited effect on experimental aneurysm progression., Conclusions: Expression of HIF-1α and its target genes is increased in human and experimental AAAs. Treatment with HIF-1α inhibitors limits experimental AAA progression, with histologic evidence of attenuated mural leukocyte infiltration and angiogenesis. These findings underscore the potential significance of HIF-1α in aneurysm pathogenesis and as a target for pharmacologic suppression of AAA disease., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: New diffusion-weighted imaging (DWI) lesions on magnetic resonance imaging (MRI) after carotid artery stenting (CAS) are associated with an increased risk of future cerebrovascular events. Therefore, we evaluated the association between the expression levels of serum inflammatory markers and new DWI lesions after CAS and the presence of intraplaque hemorrhage (IPH). We also explored the mechanisms underlying this association., Methods: A total of 225 inpatients with severe carotid artery stenosis were consecutively enrolled in this cohort study. Serum inflammatory marker levels were detected in all patients by enzyme-linked immunosorbent assay. In the final analysis, 128 patients who underwent CAS and received pretreatment and post-treatment MRI scans were enrolled. DWI was performed to detect new ischemia brain lesions. T1-weighted, T2-weighted, and time-of-flight sequences were also conducted to identify IPH., Results: Serum tumor necrosis factor α (TNF-α) levels were significantly higher in symptomatic patients as well as in IPH+ patients identified by carotid MRI. New DWI lesions were identified in 50% of patients after CAS. Univariate analysis showed that DWI+ patients after CAS exhibited older mean age, higher mean TNF-α levels, and more IPH on preoperative MRI and were less likely to have right carotid stenosis than DWI- patients. Multivariate logistic regression analyses revealed that serum TNF-α concentrations were associated with new DWI lesions after CAS (odds ratio, 1.245; 95% confidence interval, 1.068-1.451; P = .005). Finally, the specificity and sensitivity of serum TNF-α levels in predicting DWI+ patients after CAS were 0.828 and 0.453, respectively., Conclusions: Higher serum TNF-α levels are associated with a higher likelihood of new DWI lesions after CAS and the presence of IPH. Therefore, TNF-α is a potentially valuable predictor of acute ischemic cerebral lesions after CAS and the presence of IPH., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Endovascular treatment (ET) is being increasingly used for splenic artery aneurysms (SAAs), but systematic treatment strategies have not been defined. We set out to investigate the optimal strategies for ET of complicated SAAs (CSAAs)., Methods: CSAAs were classified into three types: type I, rupture or impending rupture; type II, at the origin of the splenic artery; and type III, having an aberrant splenic artery from the splenomesenteric trunk (type IIIA) or celiacomesenteric trunk (type IIIB). SAAs treated at our center during the last decade were reviewed, and CSAAs were selected for analysis. Patients' demographics, clinical manifestations, aneurysm characteristics, ET strategies, and outcomes were analyzed., Results: A total of 154 SAAs were identified, with 24 (15.6%) being CSAAs. Open surgery was employed in two patients, whereas 22 patients underwent ET. There were 3 patients with type I (type IIIA co-occurred in one of them), 5 with type II, and 15 with type III CSAAs. Treatment strategies included the following: immediate and thorough exclusion with embolization of the collaterals for type I; and dense embolization of the sac and outflow artery, with or without embolization of the inflow artery, or covered stent placement in the splenomesenteric trunk or celiacomesenteric, for types II and III. Technical success was achieved in 21 patients (95.5%). Mean follow-up was 33.7 ± 31.2 months (range, 1.5-117.0 months). The aneurysms remained completely thrombosed and unenlarged in 21 patients (95.5%). Reintervention was needed in one patient (4.5%) for persistent sac enlargement. The covered stent was asymptomatically occluded in one patient (11.1%). No hepatic or intestinal ischemia or death developed perioperatively or during the follow-up period., Conclusions: With reasonable strategies toward the urgency and thoroughness needed for aneurysm exclusion as well as the anatomic challenges, ET appeared to be feasible, safe, and effective in the management of CSAAs., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Coil embolization is one of the most common endovascular approaches to treatment of renal artery aneurysms (RAAs). The purpose of this retrospective study was to compare complications, mortality, and morbidity associated with sac packing, coil trapping, and inflow occlusion., Methods: The records of all patients with RAAs treated with coil embolization at our center from June 2003 to May 2017 were retrospectively reviewed. Demographics of the patients, aneurysm characteristics, management strategies, perioperative and long-term outcomes, and complications were analyzed., Results: A total of 52 patient records were reviewed; 28 patients received sac packing and 24 patients underwent coil trapping/inflow occlusion. There was no significant difference in patients' demographics or RAA characteristics between the groups. The mean aneurysm diameter was 25.6 ± 8.4 mm in the sac packing group and 31.1 ± 16.8 mm in the coil trapping/inflow occlusion group (P = .130). Most aneurysms in the sac packing group originated from the main renal artery bifurcation (67.9%), whereas in the coil trapping/inflow occlusion group, most aneurysms originated from the renal segmental branch arteries (54.2%). The immediate technical success rate was 100%, and the in-hospital mortality rate was 0% in both groups. Sac packing was more likely to be associated with endoleak immediately after the procedure (28.6% vs 8.3%; P = .065). The overall perioperative complication rate was not statistically different between the groups (7.1% vs 16.7%; P = .284). The mean duration of follow-up was 37.67 ± 29.84 months and 49.35 ± 28.11 months in the sac packing and coil trapping/inflow occlusion groups, respectively (P = .192). No deaths related to RAAs or aneurysm rupture occurred in either group. The overall morbidity rate was similar between groups (12.5% vs 25%; P = .284). Partial renal infarction occurred in two and five patients in the sac packing and coil trapping/inflow occlusion groups, respectively (8.3% vs 25%; P = .132). Impaired renal function was more frequent after coil trapping/inflow occlusion (0% vs 15%; P = .049). A single patient in the sac packing group required further intervention for reperfusion of the aneurysmal sac at 4 months (4.2% vs 0%; P = .356)., Conclusions: Sac packing might be a safe and effective way to treat RAAs located at the main bifurcation or in branch arteries and may be preferable to coil trapping/inflow occlusion, considering the potential loss of functional renal mass., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We report the morphologic characteristics and endovascular treatment of primary infrarenal aortic dissections (PIRADs)., Methods: A retrospective study was conducted with 38 consecutive PIRAD patients between January 2010 and May 2016 in our vascular center. Patient demographics, morphologic characteristics, endovascular modalities, and periprocedural and follow-up outcomes were recorded. Patients with symptomatic PIRADs or asymptomatic PIRADs of a maximum diameter >30 mm were indicated for endovascular aneurysm repair (EVAR). We proposed a morphologic categorization of PIRADs into two types (I and II) according to the location of the entry tears and an endovascular strategy for treating type I PIRADs with tubular stent grafts (SGs) and type II PIRADs with bifurcated SGs., Results: According to the categorization, the study recruited 13 patients with type I and 25 patients with type II PIRADs. The patients were predominantly men, with an average age of 60.8 ± 15.2 years. Type I PIRADs usually had larger true lumens (22.6 ± 6.3 vs 13.6 ± 4.0 mm; P = .002) and relatively smaller false lumens (8.4 ± 2.3 vs 19.9 ± 16.1 mm; P = .012). Type II PIRADs had more entry tears (2.2 ± 0.6 vs 1.7 ± 0.6; P = .024) and longer dissections (109.4 ± 38.8 vs 73.9 ± 39.0 mm; P = .011). All patients underwent EVAR, with 19 tubular and 22 bifurcated SGs. One patient died during the hospital stay. The technical success rate was 94.8% (36/38), and the clinical success rate was 97.4% (37/38). During follow-up of 36 patients for 28.8 ± 17.7 months, 2 patients with type II PIRADs developed left iliac extension occlusion at 3 and 6 months after EVAR, and only 1 patient underwent reintervention. All patients survived throughout the follow-up. No endoleak or aortic enlargement was observed. Computed tomography angiography demonstrated a patent infrarenal aorta with completely thrombosed false lumen in all PIRAD patients (36/36 [100.0%]). In both types of PIRAD, EVAR yielded a significant decrease in the maximum diameter of the infrarenal aorta, with a significant increase in the true lumen size and a significant decrease in the false lumen size (P < .05)., Conclusions: The morphologic categorization of PIRADs based on the location of the entry tears appeared to be feasible. The endovascular strategy was safe and effective, with high rates of technical success and clinical success and favorable follow-up outcomes., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the safety, efficacy, and outcomes of the conformable thoracic endograft (Conformable TAG Thoracic Endoprosthesis [CTAG]; W. L. Gore & Associates, Flagstaff, Ariz) for acute complicated and uncomplicated type B aortic dissection (TBAD)., Methods: Between February and October 2016, 52 consecutive patients with acute complicated or uncomplicated TBAD were treated with a CTAG device. We assessed safety, complications, and device conformability using intraoperative angiography and computed tomography angiography. The mean follow-up period was 8.2 ± 3.5 months (range, 4-12 months)., Results: All patients survived through the follow-up period. No endoleaks, retrograde aortic dissection, distal new entry tear, stroke, or paraplegia was observed postoperatively. Two patients (3.8%) experienced minor wound hematomas without further treatment. Eleven patients (21.2%) underwent a chimney technique to rebuild supra-arch vessels. A bird-beak configuration was observed in seven (13.5%) patients, five of whom underwent a chimney technique. Analysis of aortic remodeling showed that the minimal true lumen area significantly increased in both complicated and uncomplicated acute TBAD (P < .001 and P = .047, respectively). Likewise, the maximal false lumen area significantly decreased in uncomplicated dissection (P = .006), but no change in maximal false lumen area was detected in complicated dissection (P = .32)., Conclusions: Early outcomes indicate that the CTAG device provides reliable clinical effectiveness and excellent conformability in treating acute complicated and uncomplicated TBAD without risk of major complications. Studies with larger sample sizes and longer follow-up periods are required to evaluate longer term outcomes., (Copyright © 2017. Published by Elsevier Inc.)

Objective: Clinical outcomes after thoracic endovascular aortic repair (TEVAR) for patients with multichanneled aortic dissection (MCAD) are poorly understood but seem substantially different from those for patients with double-channeled aortic dissection (AD). This study compared the anatomic and clinical factors for patients with MCAD who underwent TEVAR with or without full true lumen (TL) collapse., Methods: From January 2012 to March 2016, 54 of 644 consecutive type B AD patients (8.4%) who presented with MCAD were reviewed. Patients were classified as MCAD with full TL collapse and without full TL collapse according to computed tomography angiography findings. We analyzed potential variables including clinical characteristics, anatomic morphologic features, and procedural details. Multivariable analysis was performed to determine independent predictors of AD-related deaths., Results: A total of four patients (7.4%) died preoperatively of aortic rupture, all of whom experienced full TL collapse. MCAD patients with full TL collapse showed significantly higher 30-day major adverse events than those without full TL collapse (36.8% vs 9.7%; P = .030). The mean follow-up duration was 25.6 ± 13.2 months (range, 3-53 months). The overall mortality for all MCAD patients was 16.7%, whereas the follow-up major adverse events rate was 40.0% after TEVAR. Significant differences were present between patients with full TL collapse and patients without full TL collapse in survival at 3 years (55.4% vs 94.7%; P = .002). Maximum diameter of affected aorta (hazard ratio, 1.176; 95% confidence interval, 1.015-1.362; P = .031) was identified as the only predictor of AD-related deaths., Conclusions: MCAD was identified in a small but not insignificant number of our patients presenting with type B AD. Urgent or elective TEVAR was indicated in all our patients with MCAD. In patients with MCAD, full TL collapse was associated with worse outcomes, and this finding may indicate the need for more urgent or emergent repair., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Immediate type I and type III endoleaks after endovascular aneurysm repair (EVAR) could be persistent or temporary. Reintervention is necessary for persistent ones. Color-coded quantitative digital subtraction angiography (CQDSA) could provide a quantitative evaluation of the endoleak hemodynamics. We aimed to use CQDSA to quantify immediate type I and type III endoleaks after EVAR and to find a practical way to predict their outcomes., Methods: Between January 2012 and December 2014, 485 consecutive patients with abdominal aortic aneurysms underwent EVAR at our institution. Thirty-five patients (31 men, four women) with slight immediate type I and type III endoleaks after EVAR were recruited in the prospective observational nested case-control study. After at least 6 months of follow-up, these patients were divided into two groups based on endoleak-related adverse events. Their final intraprocedure DSA images were collected and converted into a single polychromatic image for CQDSA measurements. The parameter time to peak (TTP) of the selected regions of interest in the endoleak area and a reference area at the same latitude within the stent graft were derived from the time-intensity curve. A receiver operating characteristic curve was generated to test the ability of TTP to predict endoleak-related adverse events and to identify the optimal cutoff value., Results: Finally, two groups were identified: 12 patients with endoleak-related adverse events and 23 patients without endoleak-related adverse events. Median follow-up time for all patients was 24.0 months. Age, gender, and comorbidity were similar in these two groups. TTP was significantly lower in patients with endoleak-related adverse events (P = .002). The risk of endoleak-related adverse events was significantly higher in patients with mixed-type endoleak than in those with simple-type endoleak (P = .003). According to the receiver operating characteristic curves, TTP ≤5 seconds reached the maximal sum of sensitivity and specificity (sensitivity, 91.67%; specificity, 69.57%). Logistic regression analysis confirmed that TTP ≤5 seconds (P = .016) and mixed-type endoleak (P = .044) were associated with higher risk of endoleak-related adverse events., Conclusions: CQDSA could help predict the outcomes of immediate type I or type III endoleaks after EVAR. TTP ≤5 seconds and mixed-type endoleak were two potential predictors of endoleak-related adverse events. This approach may offer an objective assessment of such immediate endoleaks and reference for immediate reintervention or conservative therapy., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Axial deep venous reflux causes skin changes or ulcers in patients with chronic venous insufficiency (CVI). The study aimed to review the results of correcting axial deep venous reflux using the novel valve-free popliteal vein external banding (PVEB) technique in patients with severe CVI., Methods: We retrospectively reviewed 1252 patients (1252 limbs) who underwent PVEB for treatment of severe CVI from 2000 to 2015. The number and position of popliteal vein valves (PVVs) and gastrocnemius vein entries were analyzed. Preprocedural and postprocedural intraluminal pressure and other hemodynamic parameters were measured and compared. Synchronous skin grafting was used for large ulcers. The healing time and ulcer and symptom recurrence rate were analyzed. Long-term Venous Clinical Severity Score was compared., Results: One pair of PVV leaflets, gastrocnemius vein entries proximal to the PVV, and PVV located in the distal-third popliteal vein segment were confirmed in 87.38% of cases in the venographic study. A total of 1252 patients underwent PVEB, and 1041 patients were followed up (mean follow-up, 55.12 months; range, 9-183 months). In the short term, limb swelling and pain were relieved in 1187 patients (94.81%) without use of compression therapy. The reflux time and reflux volume were significantly reduced (P < .001). All the ulcers were healed in an average of 18 days (95% confidence interval, 16.68-19.32). In the long term, the ulcer recurrence rate was 3.63%. The Venous Clinical Severity Score was significantly reduced (P < .001)., Conclusions: PVEB, which neither opens the vein wall nor relies on the existing vein valves, can promote venous return, improve hemodynamic status, and heal venous ulcer in <2 months, with low complication and symptom recurrence rates., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The treatment outcomes of symptomatic visceral artery aneurysms (SVAAs) have been sparsely characterized, with no clear comparisons between different treatment modalities. The purpose of this study was to review the outcomes of SVAAs and asymptomatic visceral artery aneurysms (ASVAAs) after endovascular treatment (ET)., Methods: The records of all patients with visceral artery aneurysms (VAAs) at our center from March 2004 to December 2014 were retrospectively reviewed. Patient demographics, aneurysm characteristics, management, perioperative and long-term outcomes, and complications were recorded., Results: A total of 155 patients' records were reviewed; 106 patients (113 VAAs) were repaired with ET, including 27 symptomatic and 79 asymptomatic patients. The remaining 49 patients were treated with open surgery repair or conservative therapy. There was no significant difference of the diameters between SVAA and ASVAA (36.9 ± 15.3 mm vs 33.6 ± 36.1 mm, respectively; P = .746), and pseudoaneurysms were more common in the SVAA patients (13.8% vs 2.4%; P = .037). The most common presentation was abdominal pain. In the SVAA group, 17.2% of patients presented with rupture. The immediate technical success rates of SVAA and ASVAA repairs were 96.3% and 97.5%, respectively. The 30-day mortality rate was 2.8% for all VAAs; however, this was significantly higher in the SVAA group (11.1%) than in the ASVAA group (0%; P = .015). The perioperative complication rate was not statistically different between the two groups (P = .553). The median duration of follow-up was 39.1 ± 29.2 months (range, 1-112 months). Overall mortality in all VAA patients was 6.6%, and the direct and indirect aneurysm-related mortality was 3.8%. There was a statistical difference in the overall survival rate between the SVAA and ASVAA groups at 3 years (85.2% vs 97.5%; P = .044). The reintervention rate was 3.8%, and this tended to be higher for SVAAs (11.1%) than for ASVAAs (1.3%; P = .050)., Conclusions: ET for VAA is safe and effective; however, SVAA has a significantly higher 30-day mortality rate than ASVAA., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study investigated the feasibility, safety, and efficacy of the intramuscular injection of CD34+ cells isolated from peripheral blood mononuclear cells (PB-MNCs) mobilized by granulocyte colony-stimulating factor (G-CSF) for the management of patients with critical limb ischemia (CLI) who were considered unlikely to have successful long-term revascularization with open bypass or endovascular methods. Cell therapy represents a new treatment modality for this subgroup of patients with CLI. To date, bone marrow or PB-MNCs have usually been used for transplantation. The current pilot study investigated whether the transplantation of purified CD34+ cells only would be competent in ischemia relief and limb salvage., Methods: From May 2009 to July 2011, 25 patients (mean age, 44 ± 12 years) were enrolled, and 25 lower extremities and three upper extremities were treated. After subcutaneous administration of G-CSF for 5 days at a dose of 5 to 10 μg/kg, apheresis and immunomagnetic separation were performed to acquire the isolated CD34+ cells, which were then intramuscularly injected into the ischemic sites. The patients were divided into three groups: low-dose, 10(5)/kg; medium-dose, 5 × 10(5)/kg; and high-dose, 10(6)/kg. The overall outcomes among all patients and the comparison among the groups were evaluated., Results: During the follow-up of 6 to 33 months, the overall outcomes showed that the Wong-Baker FACES pain rating scale score (WFPRSS) decreased from 7 ± 2 to 3 ± 3 (P < .001) and 1 ± 2 (P < .001) at 1 and 2 months, respectively; at 3 and 6 months, respectively, the peak pain-free walking time increased from 4 ± 3 to 13 ± 7 (P < .001) and 18 ± 6 minutes (P < .001), the ankle-brachial index increased from 0.46 ± 0.21 to 0.60 ± 0.17 (P = .003) and 0.67 ± 0.15 (P = .001), and the transcutaneous partial oxygen pressure increased from 27 ± 10 to 41 ± 11 (P < .001) and 55 ± 12 mm Hg (P < .001). Ulcers were healed in 10 of the 14 patients; four patients required above-knee or below-knee amputation ≤ 3 months. The Kaplan-Meier estimate of the rate of freedom from major amputation at 6 months was 84% (95% confidence interval, 63%-94%). The comparison among the three groups (low-dose, 5; medium-dose, 11; high-dose, 9) revealed no significant difference, except that the WFPRSS improvement at 1 month from baseline in the high-dose group (6.3 ± 1.7) was significantly superior to that in the low-dose (3.2 ± 3.3; P = .0487) and medium-dose (3.7 ± 2.8; P = .0352) groups., Conclusions: Transplantation of CD34+ cells isolated from G-CSF-mobilized PB-MNCs appears to be feasible and safe, showing encouraging outcomes in the treatment of CLI patients who appear to have compromised options for long-term revascularization., (Copyright © 2013. Published by Mosby, Inc.)

Objective: To present the short- to midterm outcomes after management of 14 patients with symptomatic isolated dissection of superior mesenteric artery (SIDSMA) and propose a preliminary treatment algorithm., Background: SIDSMA is a rare but potentially fatal entity. However, most of these reports were isolated case reports, and a consensus treatment protocol remains lacking so far. It would be meaningful to propose a reasonable treatment algorithm for it., Methods: Patients with SIDSMA who were treated in our center between July 2007 and June 2011 were retrospectively collected and analyzed. Based upon the abdominal pain and signs, the clinical manifestations have been retrospectively classified into grade I (peritonitis absent) and grade II (peritonitis present). Medical treatment mainly included anticoagulation, antiplatelet, and bowel rest. Endovascular stent placement and surgical fenestration with exploratory laparotomy have been selected according to the grade classification. Computed tomographic angiography, magnetic resonance angiography, or duplex scans have been used for diagnosis and follow-up., Results: Fourteen consecutive patients with SIDSMA were collected; among them, 13 cases belonged to grade I and one to grade II. The mean duration from the onset to the admission was 12 ± 12 days (range, 0.5-45 days). The mean distance from the primary tear to the ostium of superior mesenteric artery (SMA) was 26 ± 4 mm (range, 15-32 mm). Medical treatment was given for 13 patients of grade I for the first 3 to 5 days after admission, and the abdominal pain remarkably or completely resolved in four patients who received continued medical treatment, whereas the other unresolved nine patients were converted to endovascular stent placement that succeeded in four and failed in five patients. Since these five cases were free from peritoneal signs, medical treatment was given again instead of an immediate surgical intervention, and ultimately achieved complete alleviation of abdominal pain within the following 1 week. The mean duration from the start of medical treatment to the alleviation of symptoms, including the continued medical treatment after the failed endovascular stent placement, was 8 ± 3 days (range, 4-12 days). The grade II patient underwent a successful emergency surgical SMA fenestration without bowel resection. Follow-up was accomplished in all 14 cases, ranging from 2 to 48 months (mean, 30 ± 15 months). No intestinal necrosis, morbidity, or mortality developed during hospitalization. During the follow-up, all patients were free from aneurysmal formation of SMA or chronic intestinal ischemia, and all stents remained patent., Conclusions: For grade I SIDSMA, most cases might be successfully treated with medical therapy, and the endovascular stent placement appears to be an acceptable alternative if medical treatment fails. For grade II SIDSMA, the endovascular stenting combined with laparoscopic exploration and/or open surgery could be a reasonable option., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Extracellular matrix dysregulation in the aortic media has been considered as the intrinsic factor for the formation of thoracic aortic dissection. However, the mechanisms of extracellular matrix disorders in the dissected aortic media remain unclear. This study was designed to investigate the relevance between smooth muscle cell phenotypes and extracellular matrix disorders in the dissected media. Their interaction may account for the pathogenesis of thoracic aortic dissection., Methods and Results: Thoracic aortic samples were collected from 10 patients with thoracic aortic dissection and 10 controls. Primary cultures of aortic medial smooth muscle cells were obtained with optimized explant technique. In this study, α-smooth muscle actin, smooth muscle myosin heavy chain 2, and smoothelin were applied as the contractile phenotypic markers and osteopontin was applied as the synthetic marker. Compared with controls, immunostaining and immunoblotting demonstrated that in vivo expression of α-smooth muscle actin, smooth muscle myosin heavy chain 2, and smoothelin were significantly decreased in the dissected media, whereas that of osteopontin was elevated (P<.01 for all). In vitro expression of the phenotypic markers showed the similar patterns. Furthermore, smooth muscle cells derived from the dissected media exhibited enhanced proliferation (P<.01), increased collagens I and III synthesis (2.6- and 4.4-fold, respectively; P<.01 for both), and elevated matrix metalloproteinase-2 production (4.2-fold; P<.01). Consistently, the protein levels of type I and III collagens and matrix metalloproteinase-2 in the dissected media were raised by 4.6-, 4.0-, and 3.7-fold, respectively (P<.01 for all). Collagen deposition was correspondingly increased and elastic fibers were decreased and disrupted., Conclusions: Smooth muscle cells in the dissected media exhibit phenotypic switching from the contractile to the synthetic type. The synthetic smooth muscle cells increase collagen synthesis and matrix metalloproteinase-2 production, both of which can promote collagen deposition and elastin degradation in thoracic aortic dissection., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Stent graft-induced new entry (SINE), defined as the new tear caused by the stent graft and excluding those arising from natural disease progression or iatrogenic injury from the endovascular manipulation, has been increasingly observed after thoracic endovascular aortic repair (TEVAR) for Stanford type B dissection in our center. SINE appears to be remarkably life threatening. We investigated the incidence, mortality, causes, and preventions of SINE after TEVAR for Stanford type B dissection., Methods: Data for 22 patients with SINE were retrospectively collected and analyzed from 650 patients undergoing TEVAR for type B dissection from August 2000 to June 2008. An additional patient was referred to our center 14 months after TEVAR was performed in another hospital. The potential associations of SINE with Marfan syndrome, location of SINE and endograft placement, and the oversizing rate were analyzed by Fisher exact probability test or t test., Results: We found 24 SINE tears in 23 patients, including SINE at the proximal end of the endograft in 15, at the distal end in 7, and at both ends in 1. Six patients died. SINE incidence and mortality reached 3.4% and 26.1%, respectively. Two SINE patients were diagnosed with Marfan syndrome, whereas there were only 6 Marfan patients among the 651 patients. The 16 proximal SINEs were evidenced at the greater curve of the arch and caused retrograde type A dissection. The eight distal SINEs occurred at the dissected flap, and five caused enlarging aneurysm whereas three remained stable. The endograft was placed across the distal aortic arch during the primary TEVAR in all 23 patients. The incidence of SINE was 33.33% among Marfan patients vs 3.26% among non-Marfan patients (P = .016). There was no significant difference in mortality between proximal and distal SINE (25% vs 28.6%, P > .99), incidence of SINE between endograft placement across the arch and at the straight portion of descending thoracic aorta (23 of 613 vs 0 of 38, P = .39), and the oversizing rate between SINE and non-SINE patients (13% ± 4.5% vs 16% ± 6.5%, P = .98)., Conclusions: SINE appears not to be rare after TEVAR for type B dissection and is associated with substantial mortality. The stress yielded by the endograft seems to play a predominant role in its occurrence. It is important to take this stress-induced injury into account during both design and placement of the endograft., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: Human immune deficiency virus (HIV) infection is often associated with chronic diseases, including atherosclerosis. However, the molecular mechanisms are largely unknown. We examined the effect of Tat protein, an HIV regulatory protein, on endothelial function in porcine coronary arteries., Methods: Porcine coronary arteries were dissected from nine pig hearts and cut into 5-mm ring segments, which were incubated as controls or with Tat protein (10(-7), 10(-9), 10(-11) mol/L) or Tat protein plus anti-Tat antibody, for 24 hours. Myography was performed with thromboxane A(2) analog U46619 (10 (-7) mol/L) for contraction and with graded doses of bradykinin (10(-8), 10(-7), and 10(-6) mol/L) or sodium nitroprusside (10(-5) mol/L) for relaxation. Endothelial nitric oxide synthase (eNOS) messenger RNA was determined with reverse transcriptase polymerase chain reaction (RT-PCR), and protein levels were determined with Western blot analysis. Immunoreactivity of eNOS of treated rings was also detected., Results: Endothelium-dependent vasorelaxation (10-7 mol/L of bradykinin) was significantly reduced (46.41%) in pig coronary artery rings treated with 10(-7) mol/L of Tat protein, as compared with control arteries (P <.05). Arteries treated with Tat protein plus anti-Tat antibody relaxed similarly as control arteries. There were no differences in smooth muscle contractility (U46619) or endothelium-independent vasorelaxation (sodium nitroprusside) between control and Tat protein-treated groups. RT-PCR for eNOS mRNA showed reduction in eNOS levels for Tat-treated coronary artery rings by 73%, as compared with control vessels (P <.05). Tat protein-treated vessels demonstrated substantially less eNOS protein band intensity and immunoreactivity compared with control vessels., Conclusions: Tat protein significantly decreased endothelium-dependent vasorelaxation and eNOS mRNA and protein expression in endothelial cells of porcine coronary arteries. This study suggests that Tat protein-mediated endothelial dysfunction may be important in coronary heart disease in HIV-infected patients.