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Drug-coated balloons (DCB) and drug-eluting stents (DES) have significantly altered treatment paradigms for femoropopliteal lesions. We aimed to describe changes in practice patterns as a result of the infusion of these technologies into the treatment of peripheral arterial disease.We queried the Vascular Quality Initiative registry from 2010 to 2017 for all peripheral vascular interventions involving the superficial femoral artery and/or the popliteal artery. Cases were divided into a PRE and a POST era with a cutoff of September 2016, when specific device identity was first recorded in Vascular Quality Initiative. For each artery, a primary treatment was identified as either plain balloon angioplasty, atherectomy, DCB, bare-metal stent, or DES. The relative distribution of primary treatments between the PRE and POST eras was evaluated, as were lesion characteristics associated with DCB and DES use and regional variability in the adoption of these new technologies.Of 210,666 arteries in the dataset, 91,864 femoropopliteal arteries (across 74,842 procedures in 55,437 patients) were included. Each artery received 1.5 ± 0.6 treatments. Primary treatment use changed from 40% balloon angioplasty, 45% stenting, and 15% atherectomy in the PRE era to 22% plain balloon angioplasty, 26% bare-metal stent, 8% atherectomy, 37% DCB, and 8% DES in the POST era (P .001). Forty-three percent of arteries received a drug-containing device as a primary or adjunctive therapy and 1.3% received both a DCB and DES in the POST era. DCB use as the primary treatment was highest in lesions with length 10.0 to 19.9 cm (42%), TransAtlantic InterSociety A, B, or C lesions (38%), and lesions with mild to no calcification (38%). DES use was highest in lesions with a length of 20 cm or more (12%), TransAtlantic InterSociety D lesions (13%), and lesions with moderate to severe calcification (9%). The range of use across 18 regions was 125 to 40% for DCB and 1% to 14% for DES. Regional variability was greater for DES (SD 4% vs mean 8%) than for DCB (SD 7% vs mean 29%).There has been a rapid dissemination of DCB and DES technology in the femoropopliteal vessels, with nearly one-half of arteries receiving a drug-containing therapy in modern practice. DCBs are most used in medium length, minimally calcified lesions and DESs are most used in longer, more heavily calcified lesions. There is significant regional variability in adoption, especially with DES.

We sought to compare immediate and early mortality among patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair. Evaluation of RAAA has focused on 30-day postoperative mortality. Other emergency conditions such as trauma have demonstrated a multimodal mortality distribution within the 30-day window, expanding the pathophysiologic understanding and allowing for intervention investigations with practice changing and lifesaving results. However, the temporal distribution and risk factors of postoperative morbidity and mortality in RAAA have yet to be investigated.We evaluated factors associated with RAAA postoperative mortality in immediate (1 day) and early (1-30 days) postoperative periods in a landmarked retrospective cohort study using data from the Vascular Quality Initiative (2010-2020).We identified 5157 RAAA repairs (mean age, 72 ± 10 years; 77% male; 88% White; 61% endovascular). The mortality rate in the immediate period was 10.2% (528/5157) and the early mortality rate was 22.1% (918/4163). In multivariable regression analyses, signs of hemorrhagic shock (ie, hemoglobin 7 g/dL: adjusted odds ratio [aOR], 1.87 [95% confidence interval [CI], 1.14-3.06]; any preoperative systolic blood pressure 70 mm Hg: aOR, 1.40 [95% CI, 1.04-1.89]; and estimated blood loss40%: aOR, 3.65 [95% CI, 2.29-5.83]) were associated with an increased risk of immediate mortality. Comorbid conditions (heart failure: aOR, 1.38 [95% CI, 1.00-1.92]; pulmonary disease: aOR, 1.29 [95% CI, 1.05-1.58]; elevated creatinine: aOR 1.26 [95% CI, 1.31-1.41]) were associated with increased risk of early mortality.Immediate deaths were associated predominantly with shock from massive hemorrhage, whereas early deaths were associated with comorbid conditions predisposing patients to multisystem organ failure despite successful repair. These temporal distinctions should guide future mechanistic and intervention evaluations to improve RAAA mortality.

The aim of this study was to evaluate changes in the utilization and outcomes of surgery after Medicaid Expansion (ME) for patients with peripheral artery disease (PAD).Recent studies have demonstrated increased insurance coverage and improved care with the Affordable Care Act's (ACA) state expansion of Medicaid.Infrainguinal bypass procedures performed due to occlusive pathology in the Vascular Quality Initiative database between 2010 and 2017 were included. Primary outcomes including postoperative mortality and major adverse limb events (MALE) at 1-year of follow-up were analyzed using interrupted time-series analysis (ITS).Out of 26,446 infrainguinal bypass procedures, 13,955 (52.8%) were included in this analysis. ME states witnessed an annual decrease in infrainguinal surgery for acute ischemia [annual change in post vs pre-ME period (95% confidence interval): -4.3% (-7.5% to -1.0%), P = 0.02] and an increase in revascularization for claudication [3.7% (1.7%-5.6%), P = 0.01]. Among nonacute cases, elective procedures increased in ME states [3.9% (0.1%-7.7%), P = 0.05] along with a significant annual decrease in in-hospital mortality [-0.4% (-0.8 to -0.02), P = 0.04) and MALE at 1 year of follow up [-9.0% (-20.3 to 2.3), P = 0.09]. These results were statistically significant after comparing them with the annual trend changes in states which did not adopt ME.The adoption of ME in 2014 was associated with significant increase in the use of infrainguinal bypass for nonsevere and elective cases, along with improved in-hospital mortality and MALE at 1 year. Longer follow-up is needed to evaluate the impact of ME on other aspects of care and longer term outcomes of PAD patients.

BACKGROUND: No independent comparisons, with midterm follow-up, of standard arteriovenous grafts (SAVGs) and immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this study was to compare “real-world” performance of SAVGs and IAAVGs. METHODS: Consecutive patients who underwent placement of a hemodialysis graft between November 2014 and April 2016 were retrospectively identified from the electronic medical record and Vascular Quality Initiative database at two tertiary centers. Only primary graft placements were included for analysis. Patients were divided into two groups based on the type of graft implanted. Patients’ comorbidities, graft configuration, operative characteristics, and follow-up were collected and analyzed with respect to primary and secondary patency. Additional outcomes included graft-related complications, time to first cannulation, time to tunneled catheter removal, catheter-related complications, and overall survival. Patency was determined from the time of the index procedure; χ(2), Kaplan-Meier, and Cox regression analyses were used, with the P value set as significant at < .05. RESULTS: There were 210 grafts identified, 148 SAVGs and 62 IAAVGs. At baseline, the patients’ characteristics were similar between groups, except for a greater prevalence of preoperative central venous occlusions in the IAAVG group (16.3% vs6.8%; P < .04). Of the IAAVG group, 50 were Acuseal (W. L. Gore & Associates, Flagstaff, Ariz) and 12 were Flixene (Atrium Medical Corporation, Hudson, NH). Primary patency was similar at both 1 year (SAVG, 39.4%; IAAVG, 56.7%; P = .4) and 18 months (SAVG, 29.0%; IAAVG, 43.7%; P = .4). Secondary patency was similar at 1 year (SAVG, 50.7%; IAAVG, 52.1%; P = .73) and 18 months (SAVG, 42.3%; IAAVG, 46.3%; P = .73). Overall survival was 48% at 24 months. IAAVG patients required fewer overall additional procedures to maintain patency (mean number of procedures, 0.99 for SAVGs vs 0.61 for IAAVGs; P = .025). There was no difference in occurrence of steal syndrome (SAVG, 6.8%; IAAVG, 8.1%; P = .74) or graft infection (SAVG, 19.0%; IAAVG, 12.0%; P = .276). Seventy-five percent of all grafts were successfully cannulated, with shorter median time to first cannulation in the IAAVG group (6 days; interquartile range [IQR], 1–19 days) compared with the SAVG group (31 days; IQR, 26–47 days; P < .01). Of all pre-existing catheters, 65.75% were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR, 22–50 days) vs 49 days (IQR, 39–67 days) in the SAVG group (P < .01). Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs 2.9%; P < .045). CONCLUSIONS: IAAVGs allow earlier cannulation and tunneled catheter removal, thereby significantly decreasing catheter-related complications. Patency and infection rates were similar between SAVGs and IAAVGs, but fewer secondary procedures were performed in IAAVGs.

OBJECTIVES: The peroneal artery is a well-established target for bypass in patients with critical limb ischemia (CLI). The objective of this study was to evaluate the outcomes of peroneal artery revascularization in terms of wound healing and limb salvage in patients with CLI. METHODS: Patients presenting between 2006 and 2013 with critical limb ischemia (Rutherford IV- VI) and isolated peroneal runoff were included in the study. They were divided into patients who underwent bypass to the peroneal artery and those who underwent endovascular peroneal artery intervention. Demographics, comorbidities, and follow up data were recorded. Wounds were classified by Wound, Ischemia, foot Infection (WIfI) score. The primary outcome was wound healing; secondary outcomes included mortality, major amputation, and patency. RESULTS: Two hundred limbs with peroneal bypass and 138 limbs with endovascular peroneal intervention were included with mean follow-up of 24.0 ± 26.3 and 14.5 ± 19.1 months, respectively (P = .0001). The two groups were comparable in comorbidities with the exception of the endovascular group having more patients with cardiac and renal disease and diabetes mellitus, but fewer patients with smoking history. Based on WIfI criteria, ischemia scores were worse in bypass patients, but wound and foot infection scores were worse in endovascular patients. Peri-operatively, bypass patients had higher rates of myocardial infarction (4.5% vs. 0%, P = .012) and incisional complications (13.0% vs. 4.4%, P = .008). At 12 months, the bypass group compared to the endovascular group had better primary patency (47.9% vs. 23.4%, P = .002) and primary assisted patency (63.6% vs. 42.2%, P = .003) and a trend toward better secondary patency (74.2% vs. 63.5%, P = .11). There were no differences in the rate of wound healing (52.6% vs. 37.7% at one year, P = .09) or freedom from major amputation (81.5% vs. 74.7% at one year, P = .37). In a multivariate analysis, neuropathy was associated with improved wound healing, while WIfI wound score, cancer, chronic renal insufficiency, and smoking were associated with decreased wound healing. Treatment modality was not a significant predictor (P = .15). CONCLUSIONS: Endovascular peroneal artery intervention results in poorer primary and primary assisted patency rates than surgical bypass to the peroneal artery, but provides similar wound healing and limb salvage rates with a lower rate of complications. In appropriately selected patients, endovascular intervention to treat the peroneal artery is a low-risk intervention that may be sufficient to heal ischemic foot wounds.

Background No independent reviews, with midterm follow-up, of current experience with immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this project was to assess the real-world performance of 2 different IAAVGs over a 2-year period at a large tertiary referral center. Methods Between January 2014 and April 2016, all consecutive patients who underwent placement of Acuseal (Gore) or Flixine (Maquet) IAAVGs were identified for retrospective analysis from the electronic medical record and Vascular Quality Initiative database. Primary, primary-assisted and secondary patency rates, time to first cannulation, time to tunneled catheter removal, and overall survival were recorded. Results Forty-three patients were identified to have undergone placement of IAAVG, 31 Acuseal (72%), and 12 Flixine (28%). Of the Acuseal cohort, 7 were implanted with outflow through a HeRO catheter system (Merit Medical). Mean follow-up time was 8.4 months. Overall survival was 57.4% at 18 months. Overall primary, primary assisted, and secondary patency at 18 months were 33.36%, 34.31%, and 51.03%, respectively. Eighty three percent of grafts were successfully cannulated, and 78% of preexisting catheters were removed. Mean time to successful graft cannulation and catheter removal were 14.85 and 32.26 days, respectively. Conclusions Real-world experience with novel arteriovenous access grafts is consistent with results from industry-sponsored studies. Early cannulation of immediate-access grafts can be successfully performed in a wide variety of patients. However, prolonged catheter dwell times persist despite increased rates of successful early-graft cannulation. Further study of methods for promoting catheter removal in this patient population is warranted.

Background Mycotic aneurysms of the extremities occur infrequently but can cause severe life and limb complications. Traditional treatment typically includes debridement and revascularization, though in select patients ligation may be well tolerated. We reviewed our experience with these aneurysms treated with these 2 modalities. Methods A retrospective review of patients treated for peripheral mycotic aneurysms at one institution from January 2005 to December 2015 was performed under an institutional review board–approved protocol. Demographics, perioperative details, and long-term outcomes were collected, and standard statistical methods were used to compare treatments. Results We identified 28 patients with 29 peripheral mycotic aneurysms. Most patients (19: 67.9%) were male with an average age of 60.1 ± 17 years. Among cases with a known cause, direct injury to artery was the most common precursor to mycotic aneurysm formation; iatrogenic causes were the most common (15: 51.7%) followed by intravenous drug use (5: 17.2%). Distal bacterial translocation was the other cause of mycotic aneurysm formation due to osteomyelitis (2:10.5%) and bacterial endocarditis (1:3.5%). The causes of the remainder of cases (6:20.7%) were unknown. Symptoms included fever (46.4%), drainage (42.9%), rupture (35.7%), erythema (21.4%), and limb ischemia (17.9%). Staphylococcus aureus was the most common bacteria isolated (38.5%, from 7 positive blood cultures and 3 positive wound cultures) with 30% of these being methicillin-resistant Staphylococcus aureus), followed by Streptococcus species (11.5%), and other Staphylococcus (7.7%). Eight (30.7%) patients had negative cultures. The most common location of arterial aneurysm was the common femoral artery (17:58.6%), with 17.2% (5) occurring in the popliteal artery, 13.8% (4) in the brachial artery, 10.3% (3) in the radial or ulnar artery, and 3.5% (1) in the external iliac artery. Eighteen patients underwent revascularization, whereas 11 had resection/ligation without revascularization (4 femoral, 2 popliteal, 3 radial/ulnar, 1 brachial, and 1 external iliac). There was no significant difference in limb-threatening ischemia between these 2 groups (P = 0.14). Of those who were not revascularized, 1 developed significant initial ischemia but died before amputation, and the other underwent revascularization within 1 year after tolerating the initial ligation. Upper extremity aneurysms were more likely to be reintervention-free than those in the lower extremities (P = 0.01). Conclusions In this series, resection or ligation of peripheral mycotic aneurysms without revascularization was well tolerated. With close follow-up of these patients, resection or ligation may obviate the more extensive initial revascularization procedures in these infected fields.

Objective Reports of good short-term outcomes for endovascular repair of popliteal artery aneurysms have led to an increased use of the technique. However, data are lacking on long-term limb-related outcomes and factors associated with the failure of endovascular repair. Methods All patients who underwent endovascular popliteal aneurysm repair (EPAR) at a single institution from January 2006 to December 2018 were included in the study. Demographics, indications, anatomic and operative details, and outcomes were reviewed. Long-term patency, major adverse limb event-free survival (MALE-FS) and graft loss/occlusion were analyzed with multivariable cox regression analysis and Kaplan-Meier curves. Results We included 117 limbs from 101 patients with a mean follow-up of 55.6 months (range, 0.43-158 months). The average age was 73 ± 9.3 years. Thirty-two patients (29.1%) were symptomatic (claudication, rest pain, tissue loss, or rupture). The stent grafts crossed the knee joint in 91.4% of cases. In all, 36.8% of procedures used one stent graft, 41.0% used two stent grafts, and 22.2% of procedures used more than two stent grafts. The median arterial length covered was 100 mm, with an average length of stent overlap of 25 mm. Tapered configurations were used in 43.8% of cases. The majority of limbs (62.8%) had a three-vessel runoff, 20.2% had a two-vessel runoff, and 17% has a one-vessel runoff. The Kaplan-Meier estimates of graft occlusion at 1 and 3 years were 6.3% and 16.2%, respectively. The 1- and 3-year primary patency rates were 88.2% and 72.6%, and the 1- and 3-year major adverse limb event-free survival (MALE-FS) rates were 82% and 57.4%. The 1- and 3-year survival rates were 92.9% and 76.2%, respectively. On multivariable Cox regression, aneurysm size, one-vessel runoff, and coverage below the knee were associated with a lower 3-year MALE-FS. Coverage below the knee was also associated with a lower 3-year MALE-FS. Other anatomic or technical details were not associated with limb-related events or patency. Conclusions This study is the largest single center analysis to describe the predictors of poor outcomes after EPAR. EPAR is a safe and effective way to treat popliteal artery aneurysms. Factors associated with poor MALE-FS after EPAR include single-vessel tibial runoff and coverage below the knee.

Objective We present the 5-year results of a prospective regulatory study of the INCRAFT device, a low-profile endovascular stent graft system for repair of abdominal aortic aneurysms. Methods This was an open-label prospective nonrandomized single-arm study enrolling in centers in the United States and Japan. The primary effectiveness outcome was successful aneurysm treatment and the primary safety outcome was the incidence of major adverse events at 30 days after the procedure. Major long-term outcomes were mortality, reintervention, adverse limb outcomes, and suprarenal stent fracture. Results One hundred and ninety patients (mean age, 73.8 ± 7.6 years; 90% male; 69% white and 30% Asian) were enrolled from 32 centers throughout the United States and Japan. Minimal access vessel size was less than 7 mm on both sides in 43.9% of the study cohort. Thirty-day major adverse events occurred in 3.2% of patients (6/190). Periprocedural technical success was 94.1% (176/187). Successful aneurysm treatment was 100% at 30 days and 87.9% at 1 year. Two patients required open conversion for thromboembolic complications, 3 developed new type I or III endoleaks, and 7 experienced graft or limb occlusion. Freedom from graft occlusion was 96 ± 2% at 1 year and 94 ± 2% at 5 years. Freedom from stent fracture was 97 ± 1% at 1 year and 87 ± 3% at 5 years. Freedom from aneurysm-related mortality was 99 ± 1% at 1 and 5 years. Conclusions This study demonstrates good efficacy and safety and a very low rate of aneurysm related deaths with the INCRAFT device in a population with a high proportion of challenging anatomy.

OBJECTIVE: Superior mesenteric venous thrombosis (MVT) is a poorly understood clinical entity, and as such, outcomes are poorly described. This study aimed to identify predictors of bowel ischemia after MVT and to compare outcomes for patients treated medically (group 1) with those for patients treated with bowel resection (group 2). METHODS: This was a retrospective, single-institution study capturing all patients diagnosed with symptomatic acute MVT on computed tomography imaging from 2008 to 2018. Demographics, comorbidities, imaging, laboratory values, and treatment were included. Predictors of bowel resection were analyzed by univariate and multivariate statistics. Outcomes including mortality, readmissions for abdominal pain, and chronic mesenteric venous congestion were compared using χ(2) test. RESULTS: There were 121 patients included in the study; 98 patients were treated medically (group 1), 19 patients were treated with bowel resection (group 2), and 4 patients were treated with endovascular recanalization (group 3). Group 1 and group 2 were compared directly. Patients requiring bowel resection tended to have higher body mass index (P = .051) and a hypercoagulable disorder (P = .003). Patients who required bowel resection were more likely to present with lactic acidosis (P < .001) and leukocytosis (P < .001) with bowel wall thickening on scan (P < .001). On multivariable analysis, a genetic thrombophilia was a strong predictor of bowel ischemia (odds ratio, 3.81; 95% confidence interval, 1.12–12.37). One-year mortality and readmission rates did not differ between groups. However, readmission rates for abdominal pain were high for both groups (group 1, 44.90%; group 2, 57.89%; P = .317), and a significant proportion of patients exhibited chronic mesenteric venous congestion on repeated scan (group 1, 42.86%; group 2, 47.37%; P = .104). CONCLUSIONS: A genetic hypercoagulable disorder is a predictor of bowel ischemia due to MVT. Regardless of treatment, outcomes after MVT are morbid, with high rates of readmission for abdominal pain. An alternative approach to treat these patients is needed, given the poor outcomes with current strategies.

There is increasing recognition that decreased reserve in multiple organ systems, known as accumulated deficits (AD), may better stratify perioperative risk than traditional risk indices. We hypothesized that an AD model would predict both perioperative adverse events and long-term survival after carotid endarterectomy (CEA), particularly important in asymptomatic patients.Consecutive patients undergoing CEA between 1st January 2000 and 31st December 2010 were retrospectively identified. Seven of the deficit items from the Canadian Study of Health and Aging-frailty index (coronary disease, renal insufficiency, pulmonary disease, peripheral vascular disease, heart failure, hypertension, and diabetes) were tabulated for each patient. Predictors of perioperative and long-term outcomes were evaluated using regression analysis.About 1,782 CEAs in 1,496 patients (mean age: 71.3 ± 9.3 years, 56.3% male, 35.4% symptomatic) were included. The risk of major adverse events (stroke, death, or myocardial infarction) at 30 days for patients with ≤3 deficits was 2.53% vs. 8.81% for patients with ≥4 deficits (P 0.001). For patients with ≥5 deficits, the risk was 15.18%. Each additional deficit increased the odds of a 30-day major adverse event and hospital stay2 days by 1.64 (P 0.001) and 1.15 (P 0.001), respectively. In multivariate analysis, the presence of ≥4 deficits was more predictive of perioperative major adverse events (odds ratio [OR] = 3.62, P 0.001) than symptomatology within 6 months (OR = 1.57, P = 0.08) or octogenarian status (OR = 2.00, P = 0.02). Kaplan-Meier analysis showed significantly decreased survival over time with accumulating deficits (P 0.001). Patients with ≥4 deficits have a hazards ratio for death of 2.6 compared to patients with ≤3 deficits (P 0.001). Overall survival is estimated at 79.5% (95% confidence interval [CI]: 0.77-0.82) at 5 years in patients with ≤3 deficits versus 52.4% (95% CI: 0.46-0.58) in patients with ≥4 deficits, respectively. In subgroup analysis of asymptomatic patients, 5-year survival for octogenarian male patients with ≥4 deficits was only 26.8%. For asymptomatic males aged 70-79 years with ≥4 deficits, 5-year survival was 59.9%.An AD model is more predictive of perioperative adverse events after CEA than age or symptomatic status. This model remains predictive of long-term survival. In asymptomatic male octogenarians with 4 or more AD, 5-year survival is severely limited.

This cohort study uses data from the Veterans Affairs Surgical Quality Improvement Program database to examine the risk of early postoperative mortality among US veterans with a robust physiologic reserve undergoing open or endovascular abdominal aortic aneurysm repair.

Morbidity and mortality have improved with the evolution of endovascular techniques (thoracic endovascular aortic repair [TEVAR]) for thoracic aortic disease, but results after aortic intervention in patients with end-stage renal disease (ESRD) remain unclear. The objective of this study was to evaluate outcomes of open and endovascular descending thoracic aortic repair in dialysis-dependent patients.We identified 352 patients with ESRD on dialysis undergoing open repair (n = 136) or TEVAR (n = 216) of the thoracic aorta from 2005 to 2008 using the United States Renal Data System database. Acute presentation was defined as ruptured aneurysm, dissection, or traumatic injury; all other interventions were considered elective. End points were 30-day mortality, overall survival, rates of perioperative complications, and procedural trends over time. Between-group comparisons and survival analysis used standard statistical methods. Logistic regression and Cox regression were performed using multivariate analysis.TEVAR subjects were older than those undergoing open repair (68.2 ± 11.5 vs 60.8 ± 13.2 years; P .001); no other demographics differed. There were 303 patients who had thoracic or thoracoabdominal aneurysms; 47 (13.4%) were ruptured on presentation. There were 44 patients (12.5%) who had aortic dissection and 5 (1.4%) with aortic trauma. Overall 30-day mortality was 21.3% (n = 75), and it was greater for open repair (n = 41 [30.1%]) than for TEVAR (n = 34 [15.7%]; P = .002). Elective 30-day mortality for open repair (n = 27 [29.3%]) was also greater than for TEVAR (n = 24 [14.3%]; P = .005). Those with acute presentation trended toward higher mortality for open repair (n = 14 [31.8%] vs n = 10 [15.7%]; P = .17). Respiratory failure was higher for open repair (n = 69 [50.7%] vs n = 56 [25.9%]; P .001); postoperative stroke was higher with TEVAR (n = 21 [9.7%] vs n 10 [7%]; P = .02). Estimated 1-year survival was 50% and did not differ between groups (44% for open repair, 53% for TEVAR). In multivariate analysis, TEVAR decreased odds of 30-day mortality compared with open repair (odds ratio, 0.41; 95% confidence interval, 0.24-0.71) but failed to demonstrate long-term survival advantage.In ESRD patients, TEVAR provides short-term mortality benefits compared with open repair, but long-term mortality remains high regardless of treatment modality. Elective intervention for thoracic aortic disease in this population remains high risk and should be approached with caution.

Early and midterm outcomes of the Prospective Aneurysm Trial: High Angle Aorfix Bifurcated Stent Graft (PYTHAGORAS) trial in patients with highly angulated aortic necks (≥60 degrees) have already been published and shown comparable outcomes to other endografts in normal anatomy. Herein, we present the long-term outcomes of the PYTHAGORAS trial of Aorfix (Lombard Medical, Irvine, Calif) for patients with highly angulated aortic neck anatomy.The Aorfix endograft is a highly conformable nitinol/polyester device designed for transrenal fixation. The U.S. trial enrolled 218 patients and observed all patients at 1 month, 6 months, and 12 months and then annually for a total of 5 years. Endovascular aneurysm repair (EVAR)-specific complications were compared between the standard-angle (60 degrees) and highly angulated (≥60 degrees) neck groups at 5 years using standard statistical methods. Kaplan-Meier analysis was performed to evaluate the overall 5-year survival and freedom from aneurysm rupture, aneurysm-related mortality, and reintervention.Of the 218 patients enrolled in the trial, there were 67 patients in the standard-angle neck group (I) and 151 patients in the highly angulated neck group (II). Mean proximal neck angle was 45 degrees in group I vs 83 degrees in group II (P .001). At 5 years, 87% of surviving patients were followed up. The 5-year EVAR-specific results showed no type I or type III endoleak in either group, 4% migration in group I vs 3% in group II, and 4% sac expansion in group I vs 15.0% in group II (P ≥ .27). The 5-year freedom from all-cause mortality was 69% (73% in group I vs 68% in group II; P = .43); from aneurysm-related mortality, 96% (99% vs 95%; P = .44); from aneurysm rupture, 99% (99% vs 99%; P = 1.0); and from device-related secondary intervention, 83% (88% vs 80%; P = .18). None of these differed between groups.The U.S. PYTHAGORAS trial of the Aorfix endograft is the first EVAR clinical trial to include a majority of highly angulated (≥60 degrees) infrarenal aortic necks and is the first to produce evidence after 5 years of implantation. Despite predictors of worse short- and long-term outcomes, pertinent outcomes were better than or similar to those of trials with less severe anatomy. These results support the use of this "on-label" endovascular option, particularly in patients with highly angulated aortic neck anatomy.

BACKGROUND: The durability of endovascular aneurysm repair (EVAR) when compared to open surgical repair (OSR) in younger patients for elective, infrarenal abdominal aortic aneurysms (AAA) remains unclear due to limited follow up. STUDY DESIGN: We identified all patients

Objective This study aimed to develop risk predictive models of 30-day mortality, morbidity, and major adverse limb events (MALE) after bypass surgery for aortoiliac occlusive disease (AIOD) and to compare their performances with a 5-Factor Frailty Index. Methods The American College of Surgeons National Surgical Quality Improvement Program 2012-2017 Procedure Targeted Aortoiliac (Open) Participant Use Data Files were queried to identify all patients who had elective bypass for AIOD: femorofemoral bypass, aortofemoral bypass, and axillofemoral bypass (AXB). Outcomes assessed included mortality, major morbidity, and MALE within 30 days postoperatively. Major morbidity was defined as pneumonia, unplanned intubation, ventilator support for >48 hours, progressive or acute renal failure, cerebrovascular accident, cardiac arrest, or myocardial infarction. Demographics, comorbidities, procedure type, and laboratory values were considered for inclusion in the risk predictive models. Logistic regression models for mortality, major morbidity and MALE were developed. The discriminative ability of these models (C-indices) were compared with that of the 5-Factor Modified Frailty Index (mFI-5): a general frailty tool determined from diabetes, functional status, history of chronic obstructive pulmonary disease, history of congestive heart failure, and hypertension. Calculators were derived using the most significant variables for each of the three risk predictive models. Results A total of 2612 cases (mean age 65.0, 60% male) were identified, of which 1149 (44.0%) were femorofemoral bypass, 1138 (43.6%) were aortofemoral bypass, and 325 (12.4%) were axillofemoral bypass. Overall, the rates of mortality, major morbidity, and MALE were 2.0%, 8.5%, and 4.9%, respectively. Twenty preoperative risk factors were considered for incorporation in the risk tools. Apart from procedure type, age was the most statistically significant predictor of both mortality and morbidity. Preoperative anemia and critical limb ischemia were the most significant predictors of MALE. All three constructed models demonstrated significantly better discriminative ability (P Conclusions Our models outperformed the mFI-5 in predicting 30-day mortality, major morbidity, and adverse limb events in patients with AIOD undergoing elective bypass surgery. Calculators were created using the most statistically significant variables to help calculate individual patient's postoperative risks and allow for better informed consent and risk-adjusted comparison of provider outcomes.

Purpose To report 5-year results of the prospective, multicenter study designed to evaluate the Zenith Fenestrated AAA Endovascular Graft (William A. Cook Australia, Brisbane, Australia) for juxtarenal abdominal aortic aneurysms (AAAs). Methods Sixty-seven patients (54 male, mean age 74 ± 8 years) were prospectively enrolled at 14 U.S. centers from 2005 to 2012. Fenestrated stent grafts were used in patients with infrarenal aortic neck lengths of 4 to 14 mm to target 178 renal-mesenteric arteries with a mean of 2.7 vessels per patient. At 5 years, 42 of the 67 patients completed the final study follow-up, with clinical examination obtained in 41 and computed tomography imaging in 39. Outcomes adjudicated by a clinical events committee included all-cause and aneurysm-related mortality, major adverse events, renal stent occlusion/stenosis, renal function changes and renal infarcts, aneurysm sac enlargement (>5 mm), device migration (≥10 mm), type I/III endoleak, and secondary interventions. Results Median follow-up was 59.8 months (range, 0.1-67.5 months). There were seven deaths, including one (1.5%) within 30 days (procedure-related) and six beyond 30 days (not procedure-related in five, indeterminate in one). At 5 years, freedom from all-cause mortality was 88.8 ± 4.2% and freedom from aneurysm-related mortality was 96.8 ± 2.3%. There were no aneurysm ruptures or conversions to open surgery. Of the 129 renal arteries targeted by fenestrations, five (4%) occluded and 14 (11%) developed in-stent stenosis. Treatment included redo stenting/angioplasty in 13 vessels, renal artery bypass in 2 vessels, and failed thrombectomy in 1 vessel. Primary and secondary renal target patency was 82.7 ± 4.1% and 95.7 ± 2.1% at 5 years, respectively. Dialysis was required in one patient who had pre-existing chronic kidney disease. During the 5 years, there was 1 type IA endoleak (1.5%), 1 type IB endoleak (1.5%), 2 device migrations (3%), and 4 aneurysm sac enlargements (6%). Overall, 81% of patients had sac shrinkage at 5 years. Of 20 patients who underwent secondary interventions, 12 were for renal in-stent stenosis or occlusion, 7 were for endoleak, and 1 was for both indications. Freedom from secondary intervention was 63.5 ± 7.2% at 5 years. Conclusions These 5-year results confirm the safety and effectiveness of the Zenith Fenestrated AAA stent graft with no late graft- or aneurysm-related deaths. In-stent stenosis of bare metal renal stents was the most frequent indication for secondary intervention. The low rate of type IA endoleak, sac enlargement, and device migration support its use in patients with juxtarenal AAAs.

Objectives: The objective of this study was to compare the outcomes of patients undergoing ultrasound-accelerated thrombolysis (USAT) and standard catheter-directed thrombolysis (CDT) for the treatment of acute pulmonary embolism (PE). Methods: The records of all patients in our institution having undergone CDT or USAT for massive or submassive PE from 2009 to 2014 were retrospectively reviewed. Standard statistical methods were used to compare characteristics and to assess for longitudinal change in outcomes. Results: Sixty-three patients, 27 CDT and 36 USAT, were treated for massive (12.7%) or submassive (87.3%) PE. Of which, 96.8% were treated for bilateral PE. Baseline patient characteristics did not differ between the 2 treatment groups. There was no difference in total dose of lytic administered (CDT: 23.2 ± 13.7 mg; USAT: 27.5 ± 12.9 mg; P = .2). Two patients in the CDT and 1 in the USAT groups required conversion to surgical thrombectomy (CDT: 7.4%; USAT: 2.8%; P = .6). Rates of major and minor bleeding complications (CDT: 11.0%; USAT: 13.9%; P = .8) did not differ significantly between the CDT and USAT groups. Estimated survival at 90 days was 92% for CDT and 93% for USAT and 82% at 1 year for both groups ( P = .8). All echocardiographic parameters improved significantly from baseline to 1-year follow-up, but quantitative improvement did not differ between groups. Conclusion: This study suggests no statistical differences in clinical and hemodynamic outcomes or procedural complication rates between USAT and standard CDT for the treatment of acute PE. Prospective studies are needed to further evaluate comparative and cost-effectiveness of different interventions for acute massive and submassive PE.

The purpose of this study was to evaluate contemporary practice and outcomes of open repair (OR) or endovascular repair (ER) for popliteal artery aneurysms (PAAs).Consecutive patients with PAA treated at one institution from January 2006 to March 2014 were reviewed under an Institutional Review Board-approved protocol. Demographics, indications, anatomic characteristics, and outcomes were collected. Standard statistical methods were used.A total of 186 PAAs were repaired in 156 patients (110 ORs, 76 ERs) with a mean age of 71 ± 11 years, and most were male (96%). Mean follow-up was 34.9 ± 28.6 months for OR and 28.3 ± 25.8 months for ER (P = .12). Comorbidities were similar between groups. OR was used in more patients with PAA thrombosis (41.8% vs 5.3%; P.001), acute ischemia (24.5% vs 9.2%; P = .010), and ischemic rest pain (34.5% vs 6.6%; P.001). Mean tibial (Society for Vascular Surgery) runoff score was 5.0 for OR vs 3.3 for ER (P = .006). OR was associated with increased 30-day complications (22% vs 2.6%; P.001) and mean postoperative stay (5.8 vs 1.6 days; P.001). There was no difference in 30-day mortality (OR, 1.8%; ER, 0%; P = .56) or major amputation rate (OR, 3.7%; ER, 1.3%; P = .65). Primary, primary assisted, and secondary patency rates were similar at 3 years (OR, 79.5%, 83.7%, and 85%; ER, 73.2%, 76.3%, and 83%; P = NS). Among 130 patients presenting electively without acute ischemia or thrombosed PAA (63 ORs and 67 ERs), OR had better 3-year primary patency (88.3% vs 69.8%; P = .030) and primary assisted patency (90.2% vs 73.5%; P = .051) but similar secondary patency (90.2% vs 82%; P = .260). ER thrombosis was noted in 8 of 24 patients treated in 2006-2008 (33%; mean time to failure, 49 months) but in only 4 of 51 patients treated in 2009-2013 (7.8%; mean time to failure, 30 months), suggesting a steep learning curve.ER is a safe and durable option for PAA, with lower complication rates and a shorter length of stay. OR has superior primary patency in patients treated electively but no difference in midterm secondary patency and amputations.

Acute limb ischemia (ALI) is a highly morbid and fatal vascular emergency with little known about contemporary, long-term patient outcomes. The goal was to determine predictors of long-term mortality and amputation after open and endovascular treatment of ALI.A retrospective review of ALI patients at a single institution from 2005 to 2011 was performed to determine the impact of revascularization technique on 5-year mortality and amputation. For each main outcome 2 multivariable models were developed; the first adjusted for preoperative clinical presentation and procedure type, the second also adjusted for postoperative adverse events (AEs).A total of 445 limbs in 411 patients were treated for ALI. Interventions included surgical thrombectomy (48%), emergent bypass (18%), and endovascular revascularization (34%). Mean age was 68 ± 15 years, 54% were male, and 23% had cancer. Most patients presented with Rutherford classification IIa (54%) or IIb (39%). The etiology of ALI included embolism (27%), in situ thrombosis (28%), thrombosed bypass grafts (32%), and thrombosed stents (13%). Patients treated with open procedures had significantly more advanced ischemia and higher rates of postoperative respiratory failure, whereas patients undergoing endovascular interventions had higher rates of technical failure. Rates of postprocedural bleeding and cardiac events were similar between both treatments. Excluding Rutherford class III patients (n = 12), overall 5-year mortality was 54% (stratified by treatment, 65% for thrombectomy, 63% for bypass, and 36% for endovascular, P0.001); 5-year amputation was 28% (stratified by treatment, 18% for thrombectomy, 27% for bypass, and 17% for endovascular, P = 0.042). Adjusting for comorbidities, patient presentation, AEs, and treatment method, the risk of mortality increased with age (hazard ratio [HR] = 1.04, P0.001), female gender (HR = 1.50, P = 0.031), cancer (HR = 2.19, P0.001), fasciotomy (HR = 1.69, P = 0.204) in situ thrombosis or embolic etiology (HR = 1.73, P = 0.007), cardiac AEs (HR = 2.25, P0.001), respiratory failure (HR = 2.72, P0.001), renal failure (HR = 4.70, P0.001), and hemorrhagic events (HR = 2.25, P = 0.003). Risk of amputation increased with advanced ischemia (Rutherford IIb compared with IIa, HR = 2.57, P0.001), thrombosed bypass etiology (HR = 3.53, P = 0.002), open revascularization (OR; HR = 1.95, P = 0.022), and technical failure of primary intervention (HR = 6.01, P0.001).After the treatment of ALI, long-term mortality and amputation rates were greater in patients treated with open techniques; OR patients presented with a higher number of comorbidities and advanced ischemia, while also experiencing a higher rate of major postoperative complications. Overall, mortality rates remained high and were most strongly associated with baseline comorbidities, acuity of presentation, and perioperative AEs, particularly respiratory failure. Comparatively, amputation risk was most highly associated with advanced ischemia, thrombosed bypass, and failure of the initial revascularization procedure.

OBJECTIVES: End-stage renal disease (ESRD) patients with peripheral arterial disease (PAD) are at high risk for complications following open surgical revascularization (OSR). Endovascular revascularization (ER) is an option, but its role is unclear. We sought to characterize the outcomes of ER and OSR in ESRD patients treated for claudication or critical limb ischemia (CLI). METHODS: We used the United States Renal Data System to investigate outcomes after lower extremity ER and OSR from 2005–2011. Primary outcomes were mortality, amputation, and periprocedural myocardial infarction (MI). We generated Kaplan-Meier (K-M) estimates for mortality and amputation, logistic regression models for 30-day predictors, and proportional hazards models for long-term predictors. RESULTS: A total of 20,347 patients underwent OSR and ER (20.3% OSR, 79.7% ER). CLI was the indication in 80.8% of ER and 88.4% of OSR. Unadjusted major amputation rate at 30 days was higher after ER compared to OSR (8.8% vs 6.4%, P

OBJECTIVE: Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis (ST) while decreasing the associated complications. The purpose of this study was to compare outcomes between CDI and ST. METHODS: Consecutive patients who underwent CDIs or ST for massive or submassive PE between 2006 and 2016 were identified. Clinical and echocardiographic parameters at baseline and after treatment were recorded. Clinical success was defined as decompensation resolution (or prevention) without major bleeding, stroke, other major treatment-related event, or in-hospital death. The χ(2) test and t-test were used for between-groups comparisons. RESULTS: There were 213 patients who received CDIs (standard catheter thrombolysis in 56, ultrasound-assisted thrombolysis in 146, suction thrombectomies in 10, and pharmacomechanical thrombolysis in 1) and 104 patients who received ST (94 high dose [100 mg], 10 low dose [50 mg]). At baseline, CDI and ST groups had comparable echocardiographic parameters, demographics, and comorbidities, except for PE type (massive PE, 8.5% for CDIs vs 69.2% for ST; P < .001), age (60.2 ± 14.9 years for CDIs vs 55.9 ± 17.3 years for ST; P =.023), and renal function (glomerular filtration rate, 78.1 ± 33.7 mL/min/1.73 m(2) for CDIs vs 64.1 ± 35.2 mL/min/1.73 m(2) for ST; P =.001). Without stratifying per PE type, CDIs had a higher clinical success rate (87.8% vs 66.3%; P < .001) and a lower rate of major bleed (8.0% vs 19.2%; P =.003), stroke (1.4% vs 4.8%; P = .120), and death (1.4% vs 13.5%; P < .001). On stratifying by PE type, there was no difference in clinical success between groups. The mean reduction in right ventricular/left ventricular diameter ratio between baseline and the first post-treatment echocardiographic examination (within 30 days) was significantly higher for CDI (0.27 ± 0.20 vs 0.18 ± 0.15; P =.037). Beyond 30 days, there was no echocardiographic difference between groups. There was no significant difference in clinical outcomes and echocardiographic parameters between standard and ultrasound-assisted CDIs. CONCLUSIONS: CDIs provide improved recovery of right ventricular function compared with ST. Major bleeding and stroke complications may be lower, but larger studies are needed to validate this. CDIs are complementary to ST, and their use should be individualized on the basis of the patients’ clinical presentation, risk profile, and local resources.

Background Nutcracker syndrome (NCS) is a rare condition that can be manifested with hematuria, flank pain, pelvic varicosities, or chronic pelvic congestion related to left renal vein (LRV) compression. Open surgery, specifically LRV transposition, has been the mainstay of treatment, but in the past few years, LRV stenting has emerged as a less invasive alternative without sufficient evidence to support it. This study aimed to assess outcomes of renal vein stenting in the treatment of NCS. Methods A retrospective chart review of patients with NCS who underwent LRV stenting between 2010 and 2018 was performed. End points were perioperative adverse outcomes, symptom relief, and stent patency. Symptom resolution was classified as complete, partial, and none on the basis of the interpretation of medical records on clinical follow-up. Standard descriptive statistics and survival analysis were used. Results Eighteen patients (17 female; mean age, 38.1 ± 16.9 years) diagnosed with NCS and treated with LRV stenting were identified. Five of these had a prior LRV transposition that had failed within a mean of 7.0 ± 4.9 months, manifested by symptom recurrence (or no improvement) along with imaging evidence of persistently severe renal vein stenosis. Twelve patients had coexisting pelvic congestion syndrome treated with gonadal vein embolization. The most frequent sign and symptom were hematuria (10/18 patients) and flank pain (15/18 patients), respectively. All patients received self-expanding stents (mean diameter, 12.8 ± 1.6 mm), the smaller ones typically placed in the previously transposed LRVs. No perioperative complications occurred. Nine patients were discharged on the same day; the remaining patients stayed longer for pain control (mean hospital stay, 1.0 ± 1.3 days). At an average follow-up of 41.4 ± 26.6 months, 13 (72.2%) patients had symptoms resolved or improved (9 complete, 4 partial). Three of the five patients whose symptoms remained unchanged had previous LRV transposition surgery, and two of these three patients eventually required renal autotransplantation. Six of 10 patients who presented with hematuria had it resolved. Three patients underwent a stent reintervention at 5.8 months, 16.8 months, and 51.7 months because of symptom recurrence or stent restenosis. The two early ones required balloon venoplasty and the third one restenting. Two-year primary and primary assisted patency was 85.2% and 100%, respectively. No stent migration occurred. Conclusions Endovascular treatment with renal vein stenting is safe, providing encouraging results with good midterm patency rates and symptom relief. Minimally invasive approaches may have a potential role in the treatment of NCS. Larger series and longer follow-up are needed to better assess the comparative performance against LRV transposition.

Long-term atherosclerotic adverse events are anticipated in patients undergoing carotid endarterectomy (CEA); however, their incidence and risk predictors remain unknown.A consecutive cohort of CEAs between 1/1/2000-12/31/2007 was analyzed. End points were any stroke, coronary event (myocardial infarction, coronary bypass, or stenting), vascular interventions for critical limb ischemia, aortic aneurysm or carotid disease, and death. Survival analysis and Cox regression models were used to identify clinical predictors.A total of 1,136 CEAs (bilateral, 89; mean age, 71.2 ± 9.2 years; 56.5% male; 36.3% symptomatic, and 3.9% combined with coronary bypass) were performed during the study period with a mean clinical follow-up of 60 months (0-155 months). The postoperative combined stroke and/or death rate was 2.7% and 1.9% for asymptomatic and 4.1% for symptomatic patients. Five and 10-year risks of the end points were 7.2% and 16.1% for stroke, 18.4% and 31.5% for coronary interventions, 20.6% and 28.5% for major vascular interventions, and 25.8% and 50.1% for death. Statins conferred a significant protective effect for stroke (hazard ratio [HR], 0.53; P = 0.016) and death (HR, 0.66; P0.0001). Baseline vascular disease predicted future vascular interventions: aortic aneurysm (HR, 1.90; P = 0.003), peripheral arterial disease (HR, 2.03; P0.0001), and contralateral internal carotid artery (ICA) stenosis ≥50% (HR, 4.61; P0.0001). Renal insufficiency predicted worse outcomes for all other end points (HR, 2.21; P = 0.023 for stroke; HR, 1.62; P = 0.008 for coronary events; HR, 2.38; P0.0001 for death).Patients undergoing CEA continue to derive long-term low stroke rate benefit but still sustain major coronary events and require vascular interventions, indicating a need for more intensive medical treatment and rigorous follow-up.

Multiple studies have evaluated the perioperative outcomes of patients with chronic renal insufficiency (CRI) undergoing carotid endarterectomy (CEA), generally indicating worse survival and cardiovascular (CV) outcomes, although not consistently and with a paucity of long-term data. The present study addresses the perioperative and long-term impact of CRI on CV events and survival after CEA.A cohort of consecutive patients treated with CEA between January 1, 2000, and December 31, 2008, was analyzed based on medical records and Social Security Death Index. Estimated glomerular filtration rate (GFR) was assessed at baseline. Renal function was used to divide patients into 3 groups: normal (GFR ≥ 60 mL/min/1.73 m(2)), moderate CRI (GFR, 30-59), and severe CRI (GFR30). The end points were major coronary events, major cerebrovascular events (any stroke), noncardiac vascular interventions (aortic disease, carotid disease, and critical limb ischemia), and mortality. Subgroup analysis based on the presence of preoperative neurologic symptoms was also performed. Survival analysis and Cox regression models were used to assess the effect of baseline predictors.A total of 1,342 CEAs (mean age, 71.2 ± 9.2 years; 55.6% male; 35.3% symptomatic) were performed during the study period with a mean clinical follow-up of 57 months (median, 55; range, 0-155 months). Eight hundred sixty-eight (65%) patients had normal renal function, 414 (31%) had moderate CRI, and 60 (4%) had severe CRI (24 on dialysis). The combined 30-day stroke/death rates for the symptomatic and asymptomatic groups were 3.2% and 1.4% (normal renal function), 5.7% and 2.6% (moderate CRI), and 14.3% and 10.3% (severe CRI), respectively, with the differences being significant only for the severe-CRI group. At 5 years, the severe-CRI group experienced significantly more coronary events (36.9% vs. 16.3%, P0.001), more cerebrovascular events (21.6% vs. 6.3%, P0.001), and deaths (70.0% vs. 20.3%, P0.001), whereas the moderate-CRI group had no significantly different outcomes compared with the normal group, except for mortality (29.8% vs. 20.3%, P0.001). After adjusting for all risk factors, severe CRI remained predictive of coronary events (hazard ratio [HR], 2.21; 95% confidence interval [CI], 1.25-3.90; P = 0.007), cerebrovascular events (HR, 3.11; 95% CI, 1.44-6.74; P = 0.004), and mortality (HR, 4.36; 95% CI, 3.00-6.34; P0.001). Symptomatology at baseline was predictive of 5-year mortality (HR, 1.43; 95% CI, 1.14-1.81; P = 0.002). The need for noncardiac vascular interventions was equally distributed among all the groups.Severe but not moderate CRI is associated with poor perioperative outcomes and is an independent predictor of CV events and death at 5 years after CEA. The decision to perform CEA in symptomatic and asymptomatic patients with severe CRI should be individualized given the poor reported outcomes.

ObjectiveThe objective of this study was to review the current anatomic indications for and early results of aortouni-iliac (AUI) devices for endovascular aneurysm repair.MethodsA total of 128 patients receiving an Endurant (Medtronic Inc, Minneapolis, Minn) AUI device in the U.S. Investigational Device Exemption trial (44 patients) or the Endurant Stent Graft Natural Selection Global Postmarket Registry (84 patients) were reviewed. Preoperative computed tomography imaging of patients in the Investigational Device Exemption trial and case report forms of Registry patients were used to determine anatomic indications. Baseline characteristics and early results were compared with those of 1305 patients receiving a bifurcated (BIF) device in sister studies.ResultsThe indication for the AUI device was unclear from case report forms in two Registry cases. The remaining 126 patients had a unilateral iliac occlusion in 30 (23%), a severely narrowed aortic segment in 58 (45%), severe iliac occlusive disease in 28 (22%), severe iliac tortuosity in 29 (23%), or complex iliac aneurysms in 19 (15%). Two patients had a previous aortobifemoral graft; 38 patients (30%) had multiple indications. The AUI cohort included more women than the BIF group did (19% vs 10%; P < .01) and had more severe comorbidities. Successful deployment was achieved in all AUI cases. The 30-day mortality was 2% (BIF cohort, 1%; P = .21). More AUI patients underwent repair under general anesthesia (81% vs 64%; P < .01), and procedures were longer (110.9 ± 54.9 minutes vs 99.2 ± 44.3 minutes; P = .02). Except for longer intensive care unit stays (19.6 ± 80.0 hours vs 9.0 ± 34.8 hours; P = .01) and higher myocardial infarction rates (4% vs 1%; P < .01), outcomes of the AUI cohort were similar to those of the BIF cohort. There were no migrations, ruptures, fractures, or open conversions at up to 1-year follow-up.ConclusionsThe AUI configuration extends endovascular aneurysm repair feasibility to several hostile anatomic conditions. Despite increased comorbidities in the recipient patient population and associated higher rates of postoperative myocardial infarction and respiratory complications, early outcomes with the new generation of AUI devices are acceptable and comparable to those after treatment with BIF configurations.

Objective Retrograde infrageniculate access is an alternative treatment strategy for patients who have failed to respond to antegrade endovascular intervention. This study compares the outcomes of infrageniculate retrograde arterial access with the conventional transfemoral access for the endovascular management of chronic lower extremity ischemia. Methods This was a retrospective single-center review of retrograde endovascular intervention (REI) from 2012 to 2016. Indications for intervention, comorbidities, complications, procedural success, limb outcomes, and mortality were analyzed. Technical failure was defined as the inability to complete the procedure because of failed access or unsuccessful recanalization. Infrageniculate access and transfemoral access were obtained with ultrasound or angiographic roadmap guidance. Patency rates were calculated for technically successful interventions. Results There were 47 patients (85% presenting with critical limb ischemia) who underwent sheathless REI after failed antegrade recanalization of TransAtlantic Inter-Society Consensus class D infrainguinal lesions, whereas 93 patients (83% with critical limb ischemia) underwent standard transfemoral access. There were 16 (34%) femoropopliteal, 14 (30%) tibial, and 17 (36%) multilevel interventions in the retrograde group compared with 41 (41%) femoropopliteal, 20 (20%) tibial, and 39 (39%) multilevel interventions in the transfemoral group. Access sites for the retrograde group included the dorsalis pedis (26%), midcalf peroneal (24%), anterior tibial (22%), posterior tibial (26%), and popliteal (2%) arteries. Overall technical success was achieved in 57% of the retrograde group compared with 78% of the transfemoral group. Mean follow-up was 20 months (range, 1-45 months). There were no significant differences in the primary patency rates between the two groups at 1 year and 2 years. The primary assisted patency rates were significantly better in the transfemoral group at 1 year (66% vs 46%; P = .031) and 2 years (56% vs 29%; P = .031). The secondary patency rates were higher in the transfemoral group at 1 year (93% vs 83%; P = .079) and 2 years (91% vs 76%; P = .079), although this did not reach statistical significance. The rate of reintervention was 41% for the retrograde group vs 40% for the transfemoral group. Most of the reinterventions (70% in the retrograde group and 61% in the transfemoral group) were endovascular interventions for a restenosis or occlusion. Conclusions Infrageniculate access for REI can result in primary patency rates similar to those of antegrade interventions and does not compromise the access site. Technical failure is high in this initial experience and is mostly due to failed recanalization. Limb salvage may be achieved after technical failure with either repeated antegrade intervention or surgical bypass.

OBJECTIVE: In addition to age and comorbidities, health-related quality of life (HRQOL) is known to predict mortality in hemodialysis (HD) patients. Understanding the association of vascular access type with HRQOL can help surgeons to provide patient-centered dialysis access recommendations. We sought to understand the impact of HD access type on HRQOL. METHODS: We conducted a cross-sectional prospective study of community-dwelling prevalent HD patients in Pittsburgh, Pennsylvania. We assessed patient satisfaction with their access using the Vascular Access Questionnaire (VAQ) and HRQOL with the Short Form Health Survey. We compared access satisfaction and HRQOL across access types. We used logistic regression modeling to evaluate the association of access type with satisfaction and multivariate analysis of variance to evaluate the association of both of these variables on HRQOL. RESULTS: We surveyed 77 patients. The mean age was 61.8 ± 15.9 years. Arteriovenous fistula (AVF) was used by 62.3%, tunneled dialysis catheter (TDC) by 23.4%, and arteriovenous graft (AVG) by 14.3%. There was a significant difference in satisfaction by access type with lowest median VAQ score (indicating highest satisfaction) in patients with AVF followed by TDC and AVG (4.5 vs 6.5 vs 7.0; P = .013). Defining a VAQ score of

Objective Aortic sources of peripheral and visceral embolization remain challenging to treat. The safety of stent graft coverage continues to be debated. This study reports the outcomes of stent coverage of these complex lesions. Methods Hospital records were retrospectively reviewed for patients undergoing aortic stenting between 2006 and 2013 for visceral and peripheral embolic disease. Renal function, method of coverage, and mortality after stent grafting were reviewed. Results Twenty-five cases of embolizing aortic lesions treated with an endovascular approach were identified. The mean age was 65 ± 13 years (range, 45-87 years), and 64% were female. Sixteen (64%) patients presented with peripheral embolic events, six with concomitant renal embolization. Five patients presented with abdominal or flank pain, and two were discovered incidentally. Three patients had undergone an endovascular procedure for other indications within the preceding 6 months of presentation. Nineteen patients had existing chronic kidney disease (stage II or higher), but only three had stage IV disease. Of the eight patients tested, four had a diagnosed hypercoagulable state. Eight of the patients had lesions identified in multiple aortic segments, and aortic aneurysm disease was present in 24%. Coverage of both abdominal and thoracic sources occurred in eight patients, whereas 17 had only one segment covered. Minimal intraluminal catheter and wire manipulation was paired with the use of intravascular ultrasound in an effort to reduce embolization and contrast use. Intravascular ultrasound was used in the majority of cases and transesophageal echo in 28% of patients. Two patients with stage IV kidney disease became dialysis-dependent within 3 months of the procedure. No other patients had an increase in their postoperative or predischarge serum creatinine levels. No embolic events were precipitated during the procedure, nor were there any recurrent embolic events detected on follow-up. The 1-year mortality rate was 25%. Conclusions Endovascular coverage of atheroembolic sources in the aorta is feasible and is safe and effective in properly selected patients. It does not appear to worsen renal function when performed with the use of specific technical strategies.

ObjectiveThrombolysis as a treatment for acute limb ischemia (ALI) has become a first-line therapy based on studies published over 2 decades ago. The purpose of this study was to assess outcomes of patients treated for ALI using contemporary thrombolytic agents and endovascular techniques.MethodsConsecutive patients with ALI of the lower extremities treated between 2005 and 2011 were identified, and their records were retrospectively reviewed. All patients were treated with tissue plasminogen activator delivered via catheter-directed thrombolysis (CDT) and/or pharmacomechanical thrombolysis (PMT), with other adjunctive endovascular or surgical interventions. Procedural success, thrombolysis duration, and 30-day and long-term outcomes were obtained for the whole series and were also compared between the CDT and PMT groups. Limb salvage and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and Cox proportional hazards models.ResultsA total of 154 limbs were treated in 147 patients presenting with ALI (Rutherford class I, 9.7%; class IIa, 70.1%; class IIb, 20.1%). The mean follow-up was 15.20 months (range, 0.56-56.84 months). Indications for intervention included embolization (14.3%), thrombosed bypass (36.4%), thrombosed stent (26.6%), native artery thrombosis (24.0%), and thrombosed popliteal aneurysm (3.2%). Technical success was achieved in 83.8% of cases, with a 30-day mortality rate of 5.2%. Procedural complications included systemic bleeding (5.2%), access site hematoma (4.5%), acute renal failure (1.9%), and distal embolization (9.7%). The mean runoff score decreased from 13.42 preintervention to 7.43 postintervention. Adjuvant revascularization procedures were required in 89.0% of patients and were endovascular (68.8%), hybrid (9.1%), or open (11.0%). Only 3.2% of patients required a fasciotomy. The overall rate of major amputation was 15.0% (18.1% for CDT only, 11.3% for PMT; P = NS). Predictors of limb loss by Cox proportional hazards models included end-stage renal disease (hazard ratio [HR], 8.563; P < .001) and poor pedal outflow, with an incremental protective effect for improved pedal outflow (HR, 0.205; P < .001 for one pedal outflow vessel; HR, 0.074; P < .001 for ≥ two pedal outflow vessels). Gender, smoking, diabetes, Rutherford score, runoff score, thrombosed popliteal aneurysm, and PMT were not significant predictors of limb loss. The use of PMT was a significant predictor of technical success (odds ratio, 2.67; P = .046).ConclusionsEndovascular therapy with thrombolysis using tissue plasminogen activator remains an effective treatment option for patients presenting with mild or moderate lower extremity ALI, with equal benefit derived with CDT or PMT. Patients with end-stage renal disease or poor pedal outflow have an increased risk of limb loss and may benefit from alternative revascularization strategies.

Objective There is limited investigation into the use of bio-absorbable antibiotic beads for the treatment of prosthetic vascular graft infections. Our goal was to investigate the rates of infection eradication, graft preservation, and limb salvage in patients who are not candidates for graft explant or extensive reconstruction. Methods A retrospective review of patients implanted with antibiotic impregnated bio-absorbable calcium sulfate beads at a major university center was conducted. Results Six patients with prosthetic graft infections were treated with bio-absorbable antibiotics beads from 2012–2014. Grafts included an aortobifemoral, an aorto-hepatic/superior mesenteric artery, and four extra-anatomic bypasses. Pathogens included Gram-positive and Gram-negative bacteria. Half of the patients underwent graft explant with reconstruction and half debridement of the original graft, all with antibiotic bead placement around the graft. Mean follow-up was 7.3 ± 8.3 months; all patients had infection resolution, healed wounds, and 100% graft patency, limb salvage, and survival. Conclusion This report details the successful use of bio-absorbable antibiotic beads for the treatment prosthetic vascular graft infections in patients at high risk for graft explant or major vascular reconstruction. At early follow-up, we demonstrate successful infection suppression, graft preservation, and limb salvage with the use of these beads in a subset of vascular patients.

Objective This study reports the technical aspects and 30-day outcomes of the prospective, multicenter early feasibility study designed to evaluate the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz). Methods Thirteen patients with pararenal or extent IV thoracoabdominal aortic aneurysms were prospectively enrolled at five U.S sites and one non-U.S. site from 2014 to 2016. The TAMBE included four portals with either retrograde or antegrade renal portal configuration and used GORE VIABAHN Balloon-Expandable Endoprosthesis (W. L. Gore & Associates) for stenting of the renal and mesenteric arteries. The primary end point was procedural safety at 30 days, defined by absence of major adverse events, including any-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, severe acute kidney injury (>50% decline in estimated glomerular filtration rate), dialysis, and procedural blood loss >1000 mL. Results There were 11 male and two female patients with a mean age of 69 ± 8 years. Mean aneurysm diameter was 61 ± 13 mm. A total of 52 renal and mesenteric arteries were incorporated (4 vessels/patient). Technical success was achieved in 12 patients (92%). One patient had inadvertent occlusion of a right renal artery due to dissection. There was no mortality, aneurysm rupture, conversion to open repair, dialysis, or spinal cord injury. Mean length of hospital stay was 5 ± 3 days. At 30 days, four patients (31%) had major adverse events, all due to procedural blood loss >1000 mL. One patient had a type I endoleak at the distal renal branch, which was successfully treated by placement of an additional renal stent before dismissal. Computed tomography angiography at 30 days showed patent target vessels and no type I or type III endoleak. Conclusions This study confirms the early feasibility of the TAMBE for treatment of pararenal and extent IV thoracoabdominal aortic aneurysms. The high technical success, no mortality, and low morbidity rate support continuation of clinical investigation in a larger population of patients.

ObjectivePerioperative stroke and death (PSD) are more common after carotid artery stenting (CAS) than after carotid endarterectomy (CEA) in symptomatic patients, but whether this is also true in asymptomatic patients is unclear. Furthermore, use of both CEA and CAS varies geographically, suggesting possible variation in outcomes. We compared odds of PSD after CAS and CEA in asymptomatic patients to determine the impact of this variation.MethodsWe identified CAS and CEA procedures and hospitals where they were performed from 2005 to 2009 California hospital discharge data. Preoperative symptom status and medical comorbidities were determined using administrative codes. We compared PSD rates after CAS and CEA using logistic regression and propensity score matching. We quantified hospital-level variation in the relative utilization of CAS by calculating hospital-specific probabilities of CAS use among propensity score-matched patients. We then calculated a weighted average for each hospital and used this as a predictor of PSD.ResultsWe identified 6053 CAS and 36,524 CEA procedures that were used to treat asymptomatic patients in 278 hospitals. Perioperative stroke and death occurred in 250 CAS and 660 CEA patients, yielding unadjusted PSD rates of 4.1% and 1.8%, respectively (P < .001). Compared with CAS patients, CEA patients were more likely to be older than 70 years (66% vs 62%; P < .001) but less likely to have three or more Elixhauser comorbidities (37% vs 39%; P < .001). Multivariate models demonstrated that CAS was associated with increased odds of PSD (odds ratio [OR], 1.865; 95% confidence interval [CI], 1.373-2.534; P < .001). Estimation of average treatment effects based on propensity scores also demonstrated 1.9% increased probability of PSD with CAS (P < .001). The average probability of receiving CAS across all hospitals and strata was 13.8%, but the interquartile range was 0.9% to 21.5%, suggesting significant hospital-level variation. In univariate analysis, patients treated at hospitals with higher CAS utilization had higher odds of PSD compared with patients in hospitals that performed CAS less (OR, 2.141; 95% CI, 1.328-3.454; P = .002). Multivariate analysis did not demonstrate this effect but again demonstrated higher odds of PSD after CAS (OR, 1.963; 95% CI, 1.393-2.765; P < .001).ConclusionsCarotid endarterectomy has lower odds of PSD compared with CAS in asymptomatic patients. Increased utilization of CAS at the hospital level is associated with increased odds of PSD among asymptomatic patients, but this effect appears to be related to generally worse outcomes after CAS compared with CEA.

ObjectiveRestenosis following tibial artery endovascular interventions (TAEIs) is thought to be benign but is not well characterized. This study examines the consequences and predictors of recurrent stenosis of TAEIs for critical limb ischemia.MethodsAll TAEIs for critical limb ischemia performed between 2004 and 2010 were retrospectively reviewed. Restenosis was detected by noninvasive imaging and angiography when indicated. Restenoses were identified and the limb outcomes recorded. Tibial reinterventions were performed only for persistent, worsening, or recurrent tissue loss or rest pain with evidence of recurrence on duplex ultrasound or hemodynamic imaging. The χ2 test and logistic regression were applied as indicated. One-year patency rates were calculated using the Kaplan-Meier method.ResultsA total of 235 limbs in 210 patients were treated for critical limb ischemia (70% tissue loss, 30% rest pain). Tissue loss included gangrene (49%) and ulcers (51%), and involved the forefoot (80%), the heel (14%), or both (6%). Seventy-eight percent of limbs had Trans-Atlantic InterSociety Consensus C/D lesions, with mean preoperative runoff score of 12. Interventions were isolated tibial (45%) or multilevel (55%) (including tibial). Mean postoperative runoff score improved to 6.6, but restenosis occurred in 96 limbs (41%) at a mean of 4 months. The 1-year primary patency was 59% with a mean follow-up of 9 months. Restenosis presented with a persistent wound (32%), worsened wound (42%), rest pain (16%), or no symptoms (10%). A repeat TAEI was performed in 42 (44%), major amputation in 26 (27%), open bypass in 20 (21%), and observation in eight (8%). The overall amputation rate was 13%, but limb loss was significantly higher in patients with restenosis (n = 26 [27%]) than in patients with no restenosis (n = 5 [4%]; P < .001). Patients with restenosis and tissue loss were more likely to have presented with gangrene (63% vs 38%; P = .0003) but had comparable wound distribution (P = NS). There was a trend toward a higher restenosis rate in patients with renal insufficiency (odds ratio, 5.57; P = .08), but this was unaffected by diabetes, statin therapy, or smoking (P = NS). The rate of repeat intervention after the first reintervention was 36%, with an 87% overall limb salvage rate.ConclusionsTAEIs can be used successfully to treat patients with critical limb ischemia with acceptable limb salvage rates. Special attention should be given to patients with extensive tissue loss or gangrene because they are at risk for early restenosis and subsequent limb loss. Strict wound and hemodynamic surveillance, wound care, and timely reinterventions are crucial to achieve successful outcomes in this patient population. Amputation or alternative revascularization options, when feasible, should be considered in patients with restenosis and tissue loss given the high rate of limb loss with tibial reinterventions.

Objective The hemodynamic benefits of catheter-directed thrombolysis for acute pulmonary embolism have not been clearly defined beyond the periprocedural period. The objective of this study is to report midterm outcomes of catheter-directed thrombolysis for treatment of acute pulmonary embolism. Methods Records of all patients undergoing catheter-directed thrombolysis for high- or intermediate-risk pulmonary embolism were retrospectively reviewed. Endpoints were clinical success, procedure-related complications, mortality, and longitudinal echocardiographic parameter improvement. Results A total of 69 patients underwent catheter-directed thrombolysis (mean age 59 ± 15 y, 56% male). Eleven had high-risk and 58 intermediate-risk pulmonary embolism. Baseline characteristics did not differ by pulmonary embolism subtype. Fifty-two percent of patients underwent ultrasound-assisted thrombolysis, 39% standard catheter-directed thrombolysis, and 9% other interventional therapy; 89.9% had bilateral treatment. Average treatment time was 17.7 ± 11.3 h with average t-Pa dose of 28.5 ± 19.6 mg. The rate of clinical success was 88%. There were two major (3%) and six minor (9%) periprocedural bleeding complications with no strokes. All echocardiographic parameters demonstrated significant improvement at one-year follow-up. Pulmonary embolism-related in-hospital mortality was 3.3%, and estimated survival was 81.2% at one year. Conclusions Catheter-directed thrombolysis is safe and effective for treatment of acute pulmonary embolism, with sustained hemodynamic improvement at one year. Further prospective large-scale studies are needed to determine comparative effectiveness of interventions for acute pulmonary embolism.

Postoperative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however, little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication, and the overall impact of RAEs on patient outcomes.The Vascular Quality Initiative was queried (2003-2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm repair, thoracic endovascular aortic repair, suprainguinal bypass, or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created, and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables, and other postoperative adverse events.The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (9.9%), chronic obstructive pulmonary disease requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open abdominal aortic aneurysm repairs (17.6%), in situ suprainguinal bypasses (9.68%), and thoracic endovascular aortic repairs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, congestive heart failure severity, chronic obstructive pulmonary disease severity, degree of renal insufficiency, ambulatory status, transfer status, urgency, and operative type. The predicted compared with the actual RAE incidence were highly correlated, with a correlation coefficient of 0.943 (P .0001) and a c-statistic = 0.818. RAEs had a significantly higher rates of in-hospital mortality (25.4% vs 1.2%; P .0001; adjusted odds ratio, 5.85; P .0001), and discharge to a nursing facility (57.8% vs 19.0%; P .0001; adjusted odds ratio, 3.14; P .0001).RAEs are frequent and one of the strongest risk factors for in-hospital mortality and inability to be discharged home. Our risk prediction score accurately stratifies patients based on key demographics, comorbidities, presentation, and operative type that can be used to guide patient counseling, preoperative optimization, and postoperative management. Furthermore, it may be useful in developing quality benchmarks for RAE following major vascular surgery.

Therapeutic anticoagulation (AC) is used clinically for prolongation of infrainguinal bypass patency, but evidence for the efficacy of this practice is conflicting. The objective of our study was to determine the association of AC with bypass graft primary patency.Clinical and comorbid data of patients undergoing infrainguinal bypass grafts to a below-knee target with at least 1 year of follow-up performed from 2003 to 2015 were obtained from the Society for Vascular Surgery Vascular Quality Initiative. Inverse propensity of treatment-weighted Cox regression was used to assess the effect of AC on patency in the total cohort while adjusting for clinical, operative, and comorbid differences between treatment groups. Subgroup analyses of distal targets and conduit type were performed. Perioperative complications were analyzed using propensity-weighted logistic regression.We identified 7612 bypass grafts with intact 1-year follow-up information from 2003 to 2015. The mean age was 67.5 ± 11.2 years; 30.5% (n = 2320) were female, and 28.6% (n = 2165) were discharged on therapeutic AC. The anticoagulated group had a higher rate of tibial, ankle, and pedal targets (52.1% [n = 1127] vs 47.6% [n = 2269]; P .001), had a greater use of non-single-segment vein conduits (44.3% [n = 951] vs 26.5% [n = 1426]; P .001), and was more likely to have had a previous ipsilateral bypass (27.2% [n = 589] vs 14.7% [n = 794]; P .001) or stent (25.4% [n = 550] vs 20.9% [n = 1130]; P .001). Estimated unadjusted primary patency was 70.8% ± 0.6% at 1 year and lower for anticoagulated bypasses (66.9% ± 1.2% vs 72.4% ± 0.7%; P .001). Propensity-weighted analysis showed no significant association of AC with primary patency in the overall cohort (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.86-1.11; P = .8) but demonstrated a trend toward improvement of primary patency in those with a non-single-segment vein conduit to a below-knee popliteal target (HR, 0.85; 95% CI, 0.80-1.02; P = .09). AC was associated with significantly improved secondary patency in those with prosthetic bypass grafts (HR, 0.77; 95% CI, 0.62-0.96; P = .02) or prosthetic bypasses to an infrapopliteal target (HR, 0.72; 95% CI, 0.54-0.97; P = .02). Odds of postoperative wound complications were significantly higher in those receiving AC (odds ratio, 1.33; 95% CI, 1.11-1.61; P = .002).This study does not demonstrate a significant impact of therapeutic AC on primary patency for infrainguinal bypass grafts. Treatment with AC may benefit secondary patency in those with a prosthetic bypass, especially to an infrapopliteal target, but at an increased risk of postoperative wound complications.

Gender-related differences in type B aortic dissection (TBAD) presentation and outcomes are not well understood. The objective of this study is to assess the impact of gender on short-term outcomes in patients with TBAD.Patients with TBAD were identified from the National Inpatient Sample datasets from 2009 to 2012 according to previously published methods. The primary outcomes of interest were in-hospital mortality and major complications (renal, cardiac, pulmonary, paraplegia, and stroke related) between men and women. An inverse propensity-weighted regression was used to balance comorbid and clinical presentation differences. Subgroup analyses were performed on those undergoing endovascular (thoracic endovascular aortic repair [TEVAR]) and open repair, and for elderly patients over the age of 70.We identified 9855 patients with TBAD; women were fewer (43.6%, n = 4293) and presented at a later age (69.8 ± 15.5 vs. 62.8 ± 15.6, P 0.001). Women had more comorbidities (median Elixhauser 4 [interquartile range, IQR 2-5] vs. 3 [IQR 2-5], P 0.001) and were more often managed nonoperatively (87.4% vs. 81.8%, P 0.001) compared with men. For those undergoing intervention, 58% (n = 903) had open repair and TEVAR rates were higher in women compared with men (45.6% vs. 40.0%, P 0.001). Unadjusted mortality rates did not differ significantly by gender (male: 11.6% vs. female: 10.7%). In an adjusted propensity-weighted regression, gender did not significantly affect in-hospital mortality or stroke rates, but women were less likely to have acute renal failure during their hospitalization and more likely to experience cardiac events when undergoing open repair. Elderly women were also less likely to experience acute renal failure but had higher odds of cardiac events regardless of intervention compared with elderly men.In comparison with men, women with TBAD presented at a later age, were more likely to undergo TEVAR, sustain a perioperative cardiac event with open surgery, and were less likely to experience acute renal complications overall. Elderly women were additionally more likely to sustain a cardiac event regardless of operative status. Future studies should attempt to identify anatomic and epidemiologic reasons for these differences.

Objective The purpose of this study was to determine the short-term and midterm outcomes of catheter-directed intervention (CDI) compared with anticoagulation (AC) alone in patients with submassive pulmonary embolism (sPE). Methods This was a retrospective review of all patients treated for sPE between January 2009 and October 2014. Two groups were identified on the basis of the therapy: AC and CDI. End points included complications, mortality, and change in echocardiographic parameters. Standard statistical techniques were used. Results There were 64 patients who received AC and 64 patients who received CDI (five were initially treated with AC but did not improve or worsened; six received ≤8 mg of tissue plasminogen activator). Most baseline characteristics, including the Pulmonary Embolism Severity Index, were similar among the AC and CDI groups. There was no difference in PE-related death (one in each group) or major bleeding events (three in the AC group, four in the CDI group), but CDIs had two additional procedural complications that required open heart surgery. CDIs showed significantly more minor bleeding events (6 vs 0; P = .028) and significantly shorter intensive care unit stay (2.7 ± 2.1 vs 5.6 ± 7.5 days; P = .04). The mean difference in right ventricular/left ventricular ratio from baseline to the first subsequent echocardiogram (within 30 days) showed a trend for higher reduction in favor of CDI (AC, 0.17 ± 0.12; CDI, 0.27 ± 0.15; P = .076). Between 3 and 8 months, significant improvement was evident within groups in all assessed right-sided heart echocardiographic parameters, but there was no difference between groups. Pulmonary hypertension (pulmonary artery pressure >40 mm Hg) was present in 7 of 15 of the AC group vs 6 of 19 of the CDI group (P = .484). During the follow-up, dyspnea or oxygen dependence, not existing before the index PE event, was recorded in 5 of 49 (10.2%) of the AC patients and 8 of 52 (15.4%) of the CDI patients (P = .556). Conclusions CDI for sPE can result in faster restoration of right ventricular function and shorter intensive care unit stay, but at the cost of a higher complication rate, with similar midterm outcomes compared with AC alone. A potential effect of CDI on mortality and pulmonary hypertension needs further investigation through larger studies.

Objective Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) is being increasingly performed despite lack of good evidence for its superiority. Other reported studies suffer from patient selection and publication bias with limited follow-up. This study is a single-center propensity score comparing early and midterm outcomes between open surgical repair (OSR) and endovascular repair of rAAA (REVAR). Methods A retrospective review from January 2001 to November 2010 identified 312 patients who underwent rAAA repairs. Thirty-one patients with antecedent AAA repair and three with incomplete records were excluded, leaving 37 REVARs and 241 OSRs. Propensity score-based matching for sex, age, preoperative hemodynamic status, surgeon's annual AAA volume, and preoperative cardiopulmonary resuscitation was performed in a 1:3 ratio to compare outcomes. Thirty-seven REVARs were matched with 111 OSRs. Late survival was estimated by Kaplan-Meier methods. Results Operative time and blood replacement were higher with OSR. Overall complication rates were similar (54% REVAR vs 66% OSR; P = .23), except for higher incidences of tracheostomies (21% vs 3%; P = .015), myocardial infarction (38% vs 18%; P = .036), and acute tubular necrosis (47% vs 21%; P = .009) with OSR. Operative mortality rates were similar (22% REVAR vs 32% OSR), with an odds ratio of 0.63 for REVAR (95% confidence interval=[0.24, 1.48]; P = .40). No differences in the incidences for secondary interventions for aneurysm- or graft-related complications were noted (22% REVAR vs 22% OSR; P = .99). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates were also similar (50%, 50%, 42% REVAR vs 54%, 52%, 47% OSR; P = .66). Conclusions REVAR for rAAA does not seem to conclusively confer either acute or late survival advantages. Routine use of REVAR should be deferred until prospective, randomized trial data become available.

Objective To review the evolution of traumatic thoracic aortic injury (TTAI) treatment at a single institution. Methods Retrospective analysis of all patients included in an institutional trauma registry and vascular surgery database who underwent treatment of TTAI between January 1999 and January 2011. Results Ninety-one patients (69 males) were treated for TTAI. The mean age was 38.5 years (range, 16-79 years). Forty-one patients underwent open repair (OR) and 50 thoracic endovascular repair (TEVAR), 37 with thoracic stent grafts (TSG) alone, 11 with infrarenal aortic extender cuffs (AEC), and two with a combination of TSG and AEC. OR was performed exclusively until 2004; the last one was performed in January 2007. All TTAIs have since been treated with TEVAR. The left subclavian artery (LSA) was fully covered in 10 patients (20%) and partially covered in eight patients, with revascularization in only two cases. The use of AEC and avoidance of LSA coverage increased after 2007. Baseline characteristics and injury severity scores were similar between groups. The mortality rate was higher in the OR group (19.5% vs 6.0%; P = .06), although it did not reach statistical significance. The overall incidence of morbidities was similar between the two groups (42% OR vs 50% TEVAR). Two patients developed paraplegia (4.4%) after OR compared with none after TEVAR. In the TEVAR group, a pseudoaneurysm, an iliac artery thrombosis, and a retroperitoneal hematoma developed in one patient each. Overall, eight patients (16%) developed stent graft-related complications (SRC), with two developing early (within 30 days) complications. All complications were related to poor apposition, requiring 10 reinterventions. Four patients underwent open conversions with no mortality. Nine out of 10 SRCs were associated with the use of thoracic stent graft malapposition. No patient treated with AEC had endoleaks or SRC. Conclusions TEVAR for TTAI has superior survival outcomes and has replaced OR. SRC requiring reintervention is associated with malapposition and the use of TSG. Until TTAI-specific endografts become available, use of AEC may minimize malapposition and reduce reinterventions. Routine overstenting of the LSA is not necessary and may increase SRC.

Objective To determine if there are any differences in outcomes between infrarenal fixation (IF) and suprarenal fixation (SF) endograft systems for the endovascular treatment (endovascular aneurysm repair [ EVAR]) of abdominal aortic aneurysms (AAAs) with short, straight proximal aortic necks ( Methods A retrospective review of 1379 EVAR procedures was performed between the years of 2002 and 2009 at a single institution. The charts and radiographic images of all patients were reviewed. Patients who underwent EVAR with AAA morphology with short proximal necks were stratified into two groups: IF, Gore Excluder (W. L. Gore, Flagstaff, Ariz) group and SF, Cook Zenith (Cook, Bloomington, Ind) group. The primary end point for the study was the presence of proximal type 1 endoleaks. Secondary end points were graft migration at 1- and 2-year follow-up and aneurysm sac regression. The groups' demographics and comorbidities were also compared. Results A total of 1379 EVARS were performed during the study period and 84 were identified as having a short proximal aortic neck. Sixty patients were in the IF group and 24 in the SF group. The average follow-up period was 18.6 months (IF) and 18.5 months (SF). There was no difference in the average proximal neck length (1.19 cm IF vs 1.14 cm SF; P = not significant [NS]) or the preoperative AAA size (5.8 cm IF vs 5.9 cm SF; P = NS). There were no significant differences in age (76.6 years IF vs 74.8 years SF; P = .32), gender (IF 66.7% vs SF 21.88% men; P = .053), or length of stay (2.2 days IF vs 1.9 days SF; P = .39). The comorbidities (diabetes, hypertension, and warfarin use) were also similar. There were five type 1a endoleaks in group IF and one in group SF ( P = .44) identified at the 1-month follow-up; however, only one patient in the IF group underwent intervention for enlargement of the AAA sac. At 1 year, there was persistence of one type 1a endoleak in both groups, but these were deemed dead-end leaks as they did not fill the sac nor lead to aneurysm growth. There were no migrations (>0.5 cm) noted in either group. Sac regression was observed at an average rate of 0.24 cm/year in the IF group and 0.26 cm/year in the SF group ( P = NS). There were no aneurysm ruptures during the study period. Conclusions There are no significant differences in endograft migration or in the incidence of early and late type 1a endoleaks between endografts that use IF (Gore Excluder) and SF (Cook Zenith) fixation for patients with short aortic necks undergoing EVAR.

Objective Device-related complications in the thoracic aorta are partly due to the unavoidable proximal angulation and increased flow-related forces. The present study evaluated the incidence, predictors, and outcome of the complication of infolding with the GORE TAG thoracic endoprosthesis (TAG device) to better understand the factors that might help predict these events. Methods We reviewed all complaints reported to W. L. Gore and Associates (Flagstaff, Ariz) related to device infolding after the use of the GORE TAG device on or before December 2008. Events related to device infolding were evaluated. Reporting physicians and local company representatives were contacted, when necessary, to assemble all available imaging, data, and outcomes related to these case reports. When available, computed tomography images were reviewed to confirm aortic landing zone diameters, which were subsequently compared with the implanted device size. Results From 1998 through December 2008, device infolding was reported in 139 patients (mean age, 40 ± 17 years; 73.4% men) from 33,289 device implants (reported incidence, 0.4%). Events were noted in implants for trauma (60%), dissection (19%), aneurysm (10%), and other (9%) and unknown (2%) etiologies. In 77 patients with available imaging, the average minimum aortic diameter was 21.4 ± 4.4 mm. The mean device diameter was 28.5 ± 3.5 mm, with an average oversizing of nearly 33%. Of reported patients, 51% were asymptomatic, with the diagnosis being made on routine chest imaging. Time to diagnosis was 76 ± 222 days (median, 9.5 days). Only 16 patients received no intervention after the diagnosis of device infolding, all of whom were asymptomatic. The other 123 patients underwent 135 interventions. Of these, 30 patients (24%) underwent open surgical conversion and complete or partial endograft removal. The other interventions included a variety of endovascular techniques, such as large balloon-expandable stent(s) in 40%, relining with additional endograft(s) in 31%, and repeat ballooning in seven patients. Ten patients died after device infolding, all after one or more attempts to repair the infolded device: five died of symptoms related to the infolding and five secondary to the intervention undertaken to correct the device infolding. Conclusions TAG device infolding appears to be an infrequent event, primarily occurring in young trauma patients secondary to excessive oversizing and severe proximal aortic angulation. However, there clearly exists a need for devices that treat such patients. As a result, future device designs should consider the compression failure mode when being designed in order to help prevent such events.

Objective During the last decade, there has been a dramatic improvement in best medical treatment for patients with vascular disease. Yet, there is a paucity of contemporary long-term data for restenosis and contralateral internal carotid artery (ICA) progression. This study assessed ipsilateral and contralateral disease progression and cerebrovascular events after carotid endarterectomy (CEA). Methods A consecutive cohort of CEAs between January 1, 2000, and December 31, 2010, was retrospectively analyzed. End points were restenosis ≥50% and ≥70%, contralateral carotid disease progression (50%-69%, 70%-99%, or occlusion) and stroke. Survival analysis and Cox regression models were used to assess the effect of baseline predictors. Results During the 11-year study period, 1639 patients underwent 1782 CEAs (50.0% patch closure, 23.9% primary closure, 26.1% eversion, and 2.5% combined with coronary artery bypass grafting). The combined stroke/death rate was 2.6% overall and 1.8% in the asymptomatic cohort. The rate of restenosis ≥50% at 2, 5, and 10 years was 8.5%, 15.6%, 27.2%, and the rate for restenosis ≥70% was 3.4%, 6.5%, 10.2%, respectively. Restenosis ≥50% was predicted by hypertension (hazard ratio [HR], 2.09; P = .027), female gender (HR, 1.43; P = .042), and younger age (≤65 years; HR, 1.56; P = .016), but not by statins, surgical technique, symptoms, or other baseline risk factors. Restenoses remained asymptomatic in 125 of 148 (84.5%). Progression of contralateral ICA disease at 2, 5, and 10 years was estimated at 5.4%, 15.5%, and 46.8%, respectively. Contralateral progression was only predicted by smoking (HR, 1.74; P = .008). The stroke rate in patients with disease progression of the contralateral ICA was not different compared with those without progression (7.0% vs 3.3%; P = .063). Any-stroke rates at 2, 5, and 10 years were 4.6%, 7.3%, and 15.7%, respectively. Predictors were symptomatic lesion (HR, 1.48; P = .039), renal insufficiency, defined as a glomerular filtration rate (GFR) of 30 to 59 vs 2 (HR, 0.34; P = .009) or GFR ≥60 vs GFR 2 (HR, 0.55; P = .109), and statin use (HR, 0.59; P = .006). Conclusions Restenosis or contralateral disease progression after CEA, to a level that might warrant consideration for treatment, is very low. The potentially associated stroke rates are also very low and not clearly related to disease progression. With the exception of the postoperative duplex, surveillance within short intervals of

Objective Primary closure after carotid endarterectomy (CEA) has been much maligned as an inferior technique with worse outcomes than in patch closure. Our purpose was to compare perioperative and long-term results of different CEA closure techniques in a large institutional experience. Methods A consecutive cohort of CEAs between January 1, 2000, and December 31, 2010, was retrospectively analyzed. Closure technique was used to divide patients into three groups: primary longitudinal arteriotomy closure (PRC), patch closure (PAC), and eversion closure (EVC). End points were perioperative events, long-term strokes, and restenosis ≥70%. Multivariate regression models were used to assess the effect of baseline predictors. Results There were 1737 CEA cases (bilateral, 143; mean age, 71.4 ± 9.3 years; 56.2% men; 35.3% symptomatic) performed during the study period with a mean clinical follow-up of 49.8 ± 36.4 months (range, 0-155 months). More men had primary closure, but other demographic and baseline symptoms were similar between groups. Half the patients had PAC, with the rest evenly distributed between PRC and EVC. The rate of nerve injury was 2.7%, the rate of reintervention for hematoma was 1.5%, and the length of hospital stay was 2.4 ± 3.0 days, with no significant differences among groups. The combined stroke and death rate was 2.5% overall and 3.9% and 1.7% in the symptomatic and asymptomatic cohort, respectively. Stroke and death rates were similar between groups: PRC, 11 (2.7%); PAC, 19 (2.2%); EVC, 13 (2.9%). Multivariate analysis showed baseline symptomatic disease (odds ratio, 2.4; P = .007) and heart failure (odds ratio, 3.1; P = .003) as predictors of perioperative stroke and death, but not the type of closure. Cox regression analysis demonstrated, among other risk factors, no statin use (hazard ratio, 2.1; P = .008) as a predictor of ipsilateral stroke and severe (glomerular filtration rate 2 ) renal insufficiency (hazard ratio, 2.6; P = .032) as the only predictor of restenosis ≥70%. Type of closure did not have any predictive value. Conclusions In our study, baseline risk factors and statin use, but not the type of closure, affect perioperative and long-term outcomes after CEA.

ObjectiveEndovascular interventions for critical limb ischemia (CLI) continue to have variable reported results. The purpose of this study is to determine the effect of disease level and distribution on the outcomes of tibial interventions.MethodsA retrospective analysis of all tibial interventions done for CLI between 2006 and 2009 was performed. Outcomes of isolated tibial (group I) and multilevel interventions (group II) (femoropopliteal and tibial) were compared.ResultsEndovascular interventions were utilized to treat 136 limbs in 123 patients for CLI: 54 isolated tibial (85% tissue loss), and 82 multilevel (80% tissue loss). Mean age and baseline comorbidities were comparable. The mean ankle-brachial index (ABI) was significantly lower prior to intervention in group II (0.53 vs 0.74; P < .001) but was similar postintervention (0.86 vs 0.88; P = NS). Wound healing or improvement was achieved in 69% in group I and in 87% in group II (P = .05). Mean overall follow-up was 12.6 ± 5.3 months. Time to healing was significantly longer in group I: 11.5 ± 8.8 months vs 7.7 ± 6.6 months (P = .03). Limb salvage was achieved in 81% of group I and 95% of group II (P = .05). The rate of reintervention was similar (13% vs 18%, P = NS), so was the rate of late surgical conversion (0% vs 6%; P = NS). Limb loss resulted from lack of conduit or initial target vessel for bypass and high-risk systemic comorbidities. Overall mortality rates were similar among both groups. An isolated tibial intervention was a predictor of limb loss at 1 year on multivariate analysis and resulted in a lower rate of limb salvage at 1 year compared with multilevel interventions. Additionally, despite comparable primary patency rates, there was improved secondary patency with multilevel interventions compared with the isolated tibial interventions. Predictors of limb loss in patients treated with isolated tibial intervention included multiple synchronous tibial revascularization (P = .005) and advanced coronary artery disease requiring revascularization (P = .005).ConclusionsAdequate rates of limb salvage can be achieved in patients undergoing multilevel interventions for CLI, and improved patency is seen with multilevel compared to isolated tibial interventions. Patients with isolated tibial disease appear to have a higher incidence of limb loss secondary to poor initial pedal runoff, more extensive distal disease, and severe comorbidities precluding surgical bypass. Other therapeutic strategies should be considered in these patients, including primary amputation or pedal bypass when applicable.

Objective The natural history of acute carotid artery dissection is poorly characterized. The purpose of this study is to report on single institutional long-term outcomes. Methods A retrospective review of patients treated for acute spontaneous or posttraumatic carotid artery dissection over a 20-year period from August 1989 to July 2009 was performed. Results Twenty-nine patients with a mean age of 47 ± 19.6 years were identified with acute carotid dissection. Six (25%) were related to trauma, while 23 (79%) were spontaneous. Neurologic symptoms included contralateral limb weakness (55%), facial pain (35%), and Horner's syndrome (21%). Eight patients (28%) presented with an acute hemispheric stroke. Diagnostic imaging modalities used included computed tomography angiography (52%), magnetic resonance angiography (41%), and conventional angiography (48%). Twenty percent of patients had complete carotid occlusion and 25% had near occlusion. Most dissections (65%) had intracranial extension, and 35% were limited to the extracranial cervical internal carotid. The majority (96%) of patients were treated conservatively with anticoagulation or antiplatelet therapy or both. One patient underwent stenting for persistent symptoms resulting in complete recovery. There were two deaths, one from unrelated traumatic injuries and the other from unknown causes. Long-term follow-up was available for 20 patients: 14 had complete symptom resolution (70%) and five (25%) had partial clinical symptom resolution. Two patients had initial resolution of symptoms, with subsequent recurrence that was successfully managed conservatively. Follow-up imaging revealed luminal patency in 79% of patients with minimal residual stenosis. Two patients developed a small asymptomatic internal carotid aneurysm that did not require treatment. Mean follow-up was 1133.2 days. Conclusions Most cervical carotid dissections can safely be conservatively managed, with the majority achieving anatomic and symptomatic resolution, with low rates of recurrence over long-term follow-up.

IntroductionIschemic steal syndrome (ISS) associated with arteriovenous (AV) access is rare but can result in severe complications. Multiple techniques have been described to treat ISS with varying degrees of success. This study compares the management and success associated with these techniques.MethodsPatients with ISS between June 2003 and June of 2008 at the University of Pittsburgh Medical Center were retrospectively reviewed. Demographics, type of AV access, management technique, and success of intervention were recorded. Success was defined as resolution of ISS symptoms while preserving access function. One hundred consecutive AV access procedures were reviewed for comparison. Data were analyzed using χ2 test, Fisher's exact test, and Student's t test. The study was approved by our institutional review board.ResultsA total of 114 patients with ISS had a mean age of 65 years (range, 20-90 years), were predominantly female (66%), diabetic (61%), and with a brachial origin fistula (69%). Risk factors for ISS included coronary artery disease (CAD; P < .001), hypertension (P < .001), and tobacco use (P = .048). Women were noted to have a brachial origin access more frequently than men (odds ratio [OR], 3.1; P = .009). Forty-four patients with mild steal were observed. Seventy patients underwent 87 procedures. Procedures performed included ligation (n = 27), banding (n = 22), distal revascularization and interval ligation (DRIL; n = 21), improvement of proximal inflow (n = 9), revision using distal inflow (RUDI; n = 4), and proximalization of arterial inflow (PAI; n = 3). Early procedures (

Background Advances in endovascular techniques have provided new options in the treatment of complex infrainguinal occlusive lesions. The purpose of this study was to evaluate outcomes of endovascular interventions on TransAtlantic InterSociety (TASC) II D femoropopliteal occlusive disease. Methods All patients undergoing endovascular interventions for femoropopliteal occlusive disease between July 2004 and July 2009 were reviewed. Patient demographics, pre- and postprocedure ankle-brachial indices (ABI) and anatomic factors were analyzed. Outcomes evaluated included primary patency, assisted-patency, secondary patency, predictors of restenosis, and wound healing. Results Five hundred eighty-five limbs were treated during the period reviewed. The study group included 79 TASC D limbs in 74 patients (mean age 76.5 ± 11.9 years, male sex: 53%). Fifty-six limbs (71%) underwent treatment for critical limb ischemia, including 42 (53%) with tissue loss. Eleven patients (15%) had previous failed bypasses. Preoperative ABIs were unobtainable for 23 patients, while the remaining 56 had a mean baseline ABI of 0.54 ± 0.28. There was one periprocedural mortality. Five patients (6.3%) had periprocedural complications. Mean increase in ABI postprocedure was 0.49 ± 0.35. Follow-up was available for 74 limbs at a mean of 10.7 months (range, 1-35). There were 18 mortalities (24.3%) during the follow-up period. No patient required a major amputation during this follow-up period. Twenty-one limbs (26.6%) experienced restenosis and nine limbs (11.4%) experienced occlusion. Twenty-nine limbs underwent reintervention during the follow-up time, including nine which underwent multiple reinterventions. Primary, assisted-primary, and secondary patency rates at 12 and 24 months were 52.2%, 88.4%, 92.6% and 27.5%, 74.2%, and 88.9%, respectively. Predictors of restenosis/occlusion included hypercholesterolemia, the presence of a popliteal artery stent, and patients who were current or former smokers. Conclusions Endovascular interventions for TASC II D lesions can be safely performed with excellent hemodynamic improvement and limb salvage rates. Restenosis is not uncommon in this population, which mandates strict follow-up. Further follow-up is necessary to determine the long-term efficacy of these interventions.

Objective Open procedures are often required for late complications after endovascular aneurysm repair (EVAR). Our aim was to describe the indications for open interventions and their postoperative outcomes and to specifically examine our experience with limited conversions in which problem endoleaks are targeted without endograft explantation. Methods We reviewed patients from 2002 to 2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, preoperative imaging, procedural details, and postoperative outcomes were reviewed. The primary end point was 30-day mortality. Results There were 102 patients who underwent open conversion 3.8 ± 3.1 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016; 48.5% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 85 patients and infection in 15. One patient had a limb occlusion and another a proximal aneurysm. The 30-day mortality was 6.2% in 65 patients treated electively for endoleak but higher in 20 ruptures (40.0%) and 15 infections (40.0%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (odds ratio [OR], 6.70; 95% confidence interval [CI], 1.75-25.60; P = .005), endograft infection (OR, 8.48; 95% CI, 1.99-36.20; P = .004), and use of a supraceliac clamp (OR, 4.80; 95% CI, 1.47-15.66; P = .009). Transient acute kidney injury (12.8%) and prolonged intubation (11.8%) were the most common postoperative complications. In 65 patients treated for endoleak without rupture, 37 underwent endograft explantation, whereas 28 had a graft-preserving intervention (branch vessel ligation for type II endoleak in 26, external banding of the aneurysm neck for type IA endoleak in 8). Mortality was 8.1% when the endograft was explanted and 3.6% when it was not (P = .63). During 3.0 ± 3.5 years of follow-up, there was one reintervention after endograft explantation (for rupture secondary to type IB endoleak) and two reinterventions after graft preservation (for a new type IA endoleak and a new type II endoleak). Survival was 87.4% at 1 year and 70.9% at 5 years. Conclusions Open conversion is playing an increasing role in the management of late EVAR complications. Endoleaks treated electively by open conversion are reasonably safe and show good midterm durability, even with graft-preserving interventions that avoid endograft explantation.