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Despite the progressive advancement of devices for endovascular aortic repair (EVAR), endografts continue to fail, requiring explant. We present a single-institutional experience of EVAR explants, characterizing modern failure modes, presentation, and outcomes for partial and complete EVAR explantation.A retrospective analysis was performed of all EVARs explanted at an urban quaternary center from 2001 to 2020, with one infected endograft excluded. Patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial versus complete explants were performed per surgeon discretion without a predefined protocol. This process was informed by patient risk factors; asymptomatic, symptomatic, or ruptured aneurysm presentation; and anatomical or intraoperative factors, including endoleak type.From 2001 to 2020, 52 explants met the inclusion and exclusion criteria. More than one-half (57.7%) were explants of EVAR devices placed at outside institutions, designated nonindex explants. Most patients were male (86.5%), the median age was 74 years (interquartile range, 70-78 years). More than one-half (61.5%) were performed in the second decade of the study period. The most commonly explanted grafts were Gore Excluder (n = 9 grafts), Cook Zenith (n = 8), Endologix AFX (n = 7), Medtronic Endurant (n = 5), and Medtronic Talent (n = 5). Most grafts (78.8%) were explanted for neck degeneration or sac expansion. Five were explanted for initial seal failure, five for symptomatic expansion, and seven for rupture. The median implant duration was 4.2 years, although ranging widely (interquartile range, 2.6-5.1 years), but similar between index and nonindex explants (4.2 years vs 4.1 years). Partial explantation was performed in 61.5%, with implant duration slightly lower, 3.2 years versus 4.4 years for complete explants. Partial explantation was more frequent in index explants (68.2% vs 56.7%). The median length of stay was 8 days. The median intensive care unit length of stay was 3 days, without significant differences in nonindex explants (4 days vs 3 days) and partial explants (4 days vs 3 days). Thirty-day mortality occurred in two nonindex explants (one partial and one complete explant). Thirty-day readmission was similar between partial and complete explants (9.7% vs 5.0%), without accounting for nonindex readmissions. Long-term survival was comparable between partial and complete explants in Cox regression (hazard ratio, 2.45; 95% confidence interval, 0.79-7.56; P = .12).Explants of EVAR devices have increased over time at our institution. Partial explant was performed in more than one-half of cases, per operating surgeon discretion, demonstrating higher blood loss, more frequent acute kidney injury, and longer intensive care unit stays, however with comparable short-term mortality and long-term survival.

Although percutaneous brachial access has been used more often for peripheral vascular interventions (PVIs), previous studies have suggested that open brachial artery exposure for access is associated with fewer complications than percutaneous access. The present study sought to determine the incidence of complications for each access method and identify the predictors of access site complications after brachial access.The Vascular Quality Initiative national database was queried for all patients who had undergone PVI with brachial artery access from 2016 to 2019. Procedures with simultaneous thrombolysis or open procedures were excluded. The primary outcome was any perioperative brachial artery access complications. Multivariable logistic regression was used to identify any associated predictors.A total of 1400 procedures had been performed for 1242 patients; 189 procedures (13.5%) had used an open exposure. The mean patient age was 67.3 ± 9.5 years, and 55.7% of the procedures were on men. No significant demographic differences were found between the open and percutaneous groups. Open exposure procedures were more likely to have used sheaths5F (79.4% vs 59.0%; P .001) and treated more arteries (2.0 ± 1.8 vs 1.7 ± 0.9; P .001) but less likely to have used multiple access sites (8.5% vs 20.1%; P .001). Access complications occurred in 7.5% of the percutaneous procedures and 1.6% of the open exposures (P = .003). Percutaneous access was independently associated with the occurrence of brachial access complications (odds ratio [OR], 5.92; 95% confidence interval [CI], 1.76-19.9; P = .004). Other associated factors included female sex (OR, 2.23; 95% CI, 1.44-3.44; P .001), congestive heart failure (OR, 2.02; 95% CI, 1.26-3.24; P = .003), and increasing sheath size (OR, 1.36 per each 1F increase in size; 95% CI, 1.07-1.72; P = .011); diabetes was protective (OR, 0.53; 95% CI, 0.33-0.83; P = .006).Open exposure might be advantageous compared with percutaneous access for preventing complications after brachial access. However, the difference in complications was driven by hematomas that were managed nonoperatively. Operative complications were more common in the percutaneous group, although this did not reach statistical significance. Percutaneous access should be used cautiously in women, patients with a history of congestive heart failure, those without diabetes, and interventions in which larger sheaths are required.

Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention.This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates.During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing 20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of .001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing30% had an increased odds of mortality with HR10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041).The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.

Objective The ideal mating stent for target vessel revascularization in fenestrated endovascular aneurysm repair (FEVAR) of juxtarenal and thoracoabdominal aortic aneurysms remains unknown. The objective of this study was to assess the outcomes associated with use of different stent types and configurations mated with reinforced fenestrations during FEVAR. Methods Clinical data from patients undergoing FEVAR for juxtarenal and thoracoabdominal aortic aneurysms in a prospective physician-sponsored investigational device exemption trial were analyzed. Outcomes for two different balloon-expandable covered stents (BECSs) mated with reinforced fenestrations were assessed along with the impact of distal extension with a self-expanding stent (SES). Primary patency, branch-related endoleak, and reintervention rates were determined. Cox proportional hazards model was used for time-to-event analysis. Results From 2001 to 2016, there were 918 patients who underwent fenestrated or branched endograft repair of complex aortic aneurysms; 1604 renal arteries (RAs), 714 superior mesenteric arteries (SMAs), and 333 celiac arteries (CAs) were mated with reinforced fenestrations using JOMED (n = 2014; Abbott Vascular, Santa Clara, Calif) or iCAST (n = 637; Atrium Medical, Hudson, NH) BECSs. The type of BECS did not affect short-term or long-term patency, branch-related endoleaks, or reintervention rates in the RA, SMA, or CA. Twenty-five percent (402/1604) of RAs, 84% (598/714) of SMAs, and 8% (27/333) of CAs underwent distal SES extension at the index operation. RAs with a distal SES in addition to the BECS had a higher likelihood of an occlusion event (hazard ratio, 2.791; 95% confidence interval, 1.42-5.48; P = .003) and reinterventions (P = .036) compared with those without an SES. Addition of a distal SES to the BECS in the SMA or CA did not have an impact on patency or reintervention rates. Conclusions BECS choice does not appear to have an impact on branch durability after FEVAR. Selective distal SES placement in RAs with high-risk anatomy does not appear to significantly protect against an occlusion event or to prevent secondary interventions. Routine addition of a distal SES does not improve SMA fenestration durability.

Although prior endovascular intervention is a risk factor for inferior outcomes after infrainguinal bypass, there are few studies evaluating the effect of prior aortoiliac endovascular intervention (AIEI) on outcomes after aortofemoral bypass (AFB). We sought to determine if prior AIEI was predictive of adverse events after AFB.The Vascular Quality Initiative was queried for all patients who underwent AFB form 2009 to 2019. Urgent/emergent cases and repeat procedures were excluded. Primary outcomes were major perioperative complications, major adverse limb event (MALE)-free survival, and long-term survival. Multivariable logistic regression identified predictors of major complications. Predictors of MALE-free survival were identified with Cox proportional hazards modeling.There were 3,056 patients who underwent AFB; 618 had a prior AIEI. Mean age was 60.3 ± 8.7 years, and 58.7% of patients were men. There was no difference in major complications between the 2 groups (AIEI: 23.8%, no AIEI: 24.5%; P-value = 0.70). Factors associated with major complications were chronic obstructive pulmonary disease (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.07-1.54; P = 0.008), simultaneous lower extremity intervention (endarterectomy, bypass, or transluminal intervention, OR 1.41, 95% CI: 1.18-1.69; P 0.001), congestive heart failure (CHF) (OR 1.58, 95% CI: 1.15-2.16; P = 0.004), increased age (OR 1.03 per year, 95% CI: 1.02-1.04; P 0.001), increasing operative blood loss (OR 1.35 per liter, 95% CI: 1.21-1.50; P 0.001), increasing operative time (OR 1.07 per hour, 95% CI: 1.02-1.13; P = 0.008), and end-to-side proximal anastomosis (OR 1.23, 95% CI: 1.03-1.46; P = 0.022). One-year MALE-Free survival was 88.2% (95% CI: 85.2-90.7%) for the prior AIEI group and 89.7% (95% CI: 88.3-90.7%) for the group without prior AIEI (logrank P-value = 0.201). Predictors of MALEs/death were history of a bypass (hazard ratio [HR] 1.51, 95% CI: 1.16-1.96; P = 0.002), increasing degree of ischemia on presentation (HR 1.28 per increasing level of ischemia, 95% CI: 1.16-1.41; P 0.001), diabetes (HR 1.29, 95% CI: 1.05-1.59; P = 0.014), simultaneous peripheral vascular intervention (HR 2.06, 95% CI: 1.02-4.15; P = 0.044), CHF (HR 1.60, 95% CI: 1.18-2.18; P = 0.002), end-stage renal disease on hemodialysis (HR 5.07, 95% CI: 2.45-10.48; P 0.001), and presenting hemoglobin9 g/dl (HR 1.76, 95% CI: 1.02-3.02; P = 0.041). One-year survival for the prior AIEI group was 94.5% (95% CI: 92.2-96.1%) and 94.0% (95% CI: 92.9-94.9%) for the group with no prior AIEI (logrank P = 0.486). Prior AIEI did not predict any of the primary outcomes in multivariable analysis.An endovascular-first approach for aortoiliac occlusive disease appears to be safe and does not portend to inferior results after AFB.

Objective To determine if premature menopause and early menarche are associated with increased risk of AAA, and to explore potential effect modification by smoking history. Summary of background data Despite worse outcomes for women with AAA, no studies have prospectively examined sex-specific risk factors, such as premature menopause and early menarche, with risk of AAA in a large, ethnically diverse cohort of women. Methods This was a post-hoc analysis of Women's Health Initiative participants who were beneficiaries of Medicare Parts A&B fee-for-service. AAA cases and interventions were identified from claims data. Follow-up period included Medicare coverage until death, end of follow-up or end of coverage inclusive of 2017. Results Of 101,119 participants included in the analysis, the mean age was 63 years and median follow-up was 11.3 years. Just under 10,000 (9.4%) women experienced premature menopause and 22,240 (22%) experienced early menarche. Women with premature menopause were more likely to be overweight, Black, have ≥20 pack years of smoking, history of cardiovascular disease, hypertension, and early menarche. During 1,091,840 person-years of follow-up, 1125 women were diagnosed with AAA, 134 had premature menopause (11.9%), 93 underwent surgical intervention and 45 (48%) required intervention for ruptured AAA. Premature menopause was associated with increased risk of AAA [hazard ratio 1.37 (1.14, 1.66)], but the association was no longer significant after multivariable adjustment for demographics and cardiovascular disease risk factors. Amongst women with ≥20 pack year smoking history (n = 19,286), 2148 (11.1%) had premature menopause, which was associated with greater risk of AAA in all models [hazard ratio 1.63 (1.24, 2.23)]. Early menarche was not associated with increased risk of AAA. Conclusions This study finds that premature menopause may be an important risk factor for AAA in women with significant smoking history. There was no significant association between premature menopause and risk of AAA amongst women who have never smoked. These results suggest an opportunity to develop strategies for better screening, risk reduction and stratification, and outcome improvement in the comprehensive vascular care of women.

BACKGROUND: Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT. METHODS: Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT + CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT + CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed. RESULTS: After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT + CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65 ± 12 years and SAT + CEA were older (69 vs. 64 years, P < 0.001), CEA + SAT were more likely to be men (53% vs. 42%, P < 0.001), have hypertension (86% vs. 75%, P < 0.001) and diabetes (26% vs. 20%, P = 0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT + CEA (71% vs. 54%, P < 0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT + CEA 3.7%, P = 0.09) or mortality (1.4% vs. 1.5%, P = 0.88). SAT + CEA had higher rates of SDM (7% vs. 4%, P = 0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5–8.4, P= 0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5–4.2, P = 0.52) or SDM (OR 1.5, 95% CI 0.6–3.6, P = 0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts. CONCLUSIONS: Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.

This study reports the clinical impact of iliac artery aneurysms (IAAs) in a population of patients with juxtarenal and thoracoabdominal aortic aneurysms being treated with fenestrated or branched aortic endografts.Data from 364 patients with IAA (33%) were extracted from the 1118 patients treated for juxtarenal or thoracoabdominal aortic aneurysms with a fenestrated or branched aortic endograft in a physician-sponsored investigational device exemption trial (2001-2016). IAAs were defined as ≥21 mm in diameter, as measured by an imaging core laboratory. Outcomes were assessed by univariate and multivariable analysis.IAAs were unilateral in 219 (60%) and bilateral in 145 (40%) of the 364 patients. Treatment was iliac leg endoprosthesis without coverage of the hypogastric artery (seal distal to the IAA in the common iliac artery), placement of a hypogastric branched endograft in 105 (21%), and hypogastric artery coverage with extension into the external iliac artery in 103 (20%); 67 (13%) were untreated. Procedure duration was longer for those with IAA (5.3 ± 1.79 hours vs 4.6 ± 1.74 hours; P .001), although hospital stay was not. There was no difference in aneurysm-related mortality and all-cause mortality for patients with unilateral and bilateral IAAs compared with those without an IAA. Treatment of patients with a hypogastric branched endograft had similar all-cause mortality compared with treatment of patients without a hypogastric branched endograft but also with an IAA. Reintervention rates were significantly higher in those with bilateral IAAs compared with no IAA (hazard ratio, 1.886; P .001). Spinal cord ischemia trended higher in patients with bilateral IAA.IAA management at the time of fenestrated or branched endovascular aneurysm repair increases procedure time without increasing hospitalization. The reintervention rate and spinal cord ischemia rate are higher in patients with bilateral IAA compared with those with no IAA.

The current management of acute complicated type B aortic dissection is a combination of medical therapy and endovascular repair. Endovascular repair is not feasible when the dissection extends into the aortic arch. We describe 3 patients with acute type B aortic dissection complicated by retrograde arch extension and visceral malperfusion who were successfully treated with a total arch replacement and frozen elephant trunk.

Patients undergoing lower extremity bypass (LEB) for peripheral artery disease require intensive health care resource utilization including rehabilitation and skilled nursing facilities. However, few studies have evaluated factors that lead to nonhome discharge (NHD) in this population of patients. This study sought to predict NHD by preoperative risk factors in patients undergoing LEB for peripheral artery disease using a novel risk score.The Vascular Study Group of New England database was queried for elective LEB for peripheral artery disease including claudication and critical limb ischemia from 2003 to 2017. Patients were excluded if the procedure was not elective, if they were not admitted from home, if they were bedridden, or if they died during the index admission. Only preoperative factors were considered in the analysis. The primary end point was NHD including rehabilitation and skilled nursing facilities. Data were split two-thirds for model derivation and one-third for validation. In the derivation cohort, bivariate analysis assessed the association of preoperative factors with NHD. A parsimonious manual stepwise binary logistic regression for NHD aimed at maximizing the C statistic while maintaining model simplicity was performed. A risk score was developed using the β coefficients and applied to the validation data set. The risk score performance was assessed using a C statistic and Hosmer-Lemeshow test for model fit.There were 10,145 cases included with an overall NHD rate of 26.4% (n = 2676). Mean age was 66 years (range, 41-90 years). NHD patients were older (72 years vs 64 years; P .01) and more frequently male (57.2% vs 42.8%; P .01) and nonwhite (16.1% vs 9.9%; P .01); they more frequently had tissue loss (54.2% vs 23.0%; P .01), anemia (16.0% vs 5.3%; P .01), severe cardiac comorbidity (21.8% vs 10.5%; P .01), and insulin-dependent diabetes (33.3% vs 18.2%; P .01). On multivariable analysis, factors associated with NHD included age, sex, nonwhite race, tissue loss, cardiac comorbidity, partial ambulatory deficit, and insulin-dependent diabetes. The C statistic was 0.78 in the derivation group and 0.79 in the validation group, with Hosmer-Lemeshow P.999. The risk score ranged from 0 to 18, with a mean score of 4 (standard deviation ±3.5). The risk score was divided into low risk (0-4 points; n = 5272 [52%]; NHD = 10.1%]), moderate risk (5-9 points; n = 3663 [36.7%]; NHD = 36.7%), and high risk (≥10 points; n = 1210 [11.9%]; NHD = 66.1%).This novel risk score was highly predictive for NHD after LEB for peripheral artery disease using only preoperative comorbidities. High-risk patients account for 12% of LEB but nearly a third of all patients requiring NHD. This risk score can be used preoperatively to determine high-risk patients for NHD, which may help improve preoperative counseling and hospital efficiency by allocating resources appropriately.

The management of patients with carotid stenosis and symptomatic coronary artery disease (CAD) is challenging. This study assessed the impact of clinical coronary disease severity on carotid endarterectomy (CEA) with and without combined coronary artery bypass (CCAB).Using the Vascular Quality Initiative, patients with symptomatic CAD who underwent CCAB or isolated CEA (ICEA) from 2003 to 2017 were identified. Patients were stratified by CAD severity: stable angina (SA) and recent myocardial infarction/unstable angina (UA). Primary outcomes, including perioperative stroke, myocardial infarction (MI), and stroke/death/MI (SDM), were assessed between procedures within each CAD cohort.There were 9098 patients identified: 887 CCAB patients (215 [24%] SA, 672 [76%] UA) and 8211 ICEA patients (6385 [78%] SA, 1826 [22%] UA). Overall, CCAB patients had higher rates of stroke (2.6% vs 1.3%; P = .002) and SDM (7.3% vs 3.5%, P .001) but similar rates of MI (0.9% vs 1.6%; P = .12) compared with ICEA patients. In SA patients, no difference was seen in stroke (ICEA 1.2% vs CCAB 1.9%; P = .36), MI (1.3% vs 1.4%; P = .95), or SDM (2.9% vs 4.7%; P = .13). In UA patients, no difference was seen in stroke (ICEA 1.6% vs CCAB 2.8%; P = .06), but ICEA patients had higher rates of MI (2.4% vs 0.7%; P = .01) and CCAB patients had higher rates of SDM (8.2% vs 5.5%; P = .01). After logistic regression in the UA cohort, predictors of MI included ICEA (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-7.0; P = .04) and carotid symptomatic status (OR, 2.1; 95% CI, 1.1-3.8; P = .01); carotid symptomatic status also predicted stroke (OR, 2.0; 95% CI, 1.1-3.6; P = .03), but CCAB did not.In patients with symptomatic CAD, both clinical CAD severity and operative strategy affect outcomes. In SA patients, CCAB does not increase perioperative morbidity. However, CCAB in UA patients prevents MI while not appreciably increasing stroke risk. This suggests that coronary revascularization before or concomitant with CEA should be considered in UA patients but that prioritizing coronary intervention is less important in SA patients.

Trainee burnout is on the rise and negative training environments may contribute. In addition, as the proportion of women entering vascular surgery increases, identifying factors that challenge recruitment and retention is vital as we grow our workforce to meet demand. This study sought to characterize the learning environment of vascular residents and to determine how gender-based discrimination and bias (GBDB) affect the clinical experience.A survey was developed to evaluate the trainee experience; demographics and a two-item burnout index were also included. The instrument was sent electronically to all integrated (0 + 5) vascular surgery residents in the United States. Univariate analyses were performed and predictors of burnout identified.A total of 284 integrated vascular residents were invited to participate and 212 (75%) completed the survey. Participants were predominantly male (64%) and white (56%), with a median age of 30 years (interquartile range, 28-32 years). Seventy-nine percent of respondents endorsed some form of negative workplace experience and 30% met high-risk criteria for burnout. More than a third (38%) of residents endorsed personally experiencing GBDB, with a significant difference between men and women (14% vs 80%; P .001). Women were more likely than men to report witnessing GBDB (76% vs 56%; P = .003). Patients and nurses were the most frequently cited sources of GBDB (80% and 64%, respectively), with vascular surgery attendings cited by 41% of trainees. One in four female resident respondents indicated being sexually harassed during the course of training; this was significantly higher than for male residents (25% vs 1%; P .001). Nearly half (46%) of trainees who witnessed or experienced GBDB thought that quality of patient care, job satisfaction, personal well-being, and personal risk of burnout were directly affected as a result of GBDB. GBDB was predictive of burnout (odds ratio, 1.9; 95% confidence interval, 1.1-3.5; P = .04), as were longer work hours (80 h/wk; odds ratio, 2.8; 95% confidence interval, 1.1-7.1; P = .03).GBDB was experienced by 38% of integrated trainees, with women significantly more affected than men. GBDB is predictive of burnout, and this has significant implications for our specialty in the recruitment and retention of female physicians. Resources addressing these issues are needed to maintain a diverse workforce and to promote physician well-being.

Endovascular therapy is first-line treatment for aortoiliac occlusive disease. This shift has altered case volume, patient selection, and risk profile for aortobifemoral bypass (ABF). Given this, we sought to investigate factors influencing morbidity and mortality after ABF in the endovascular era.Data for patients undergoing primary ABF from 2000 to 2017 were queried. Primary endpoints included major complication (unplanned return to the operating room, life-or-limb-threatening complications, and 30-day readmission or death) and long-term survival. Logistic regression and Cox proportional hazard models determined predictors of primary endpoints. Kaplan-Meier analysis estimated patency, freedom from reintervention, and long-term survival.During these 17 years, 256 patients underwent primary ABF. Mean age was 67.9 ± 10.6 years and 51.2% were women. Most had claudication (69.5%); 28.9% had critical ischemia. Sixty-five (25.4%) patients had prior aortoiliac endovascular intervention, 106 (41.4%) required aortic cuff endarterectomy, 111 (43.3%) femoral outflow adjunct, 9 (3.5%) simultaneous lower extremity bypass, and 230 (89.8%) had Trans-Atlantic Inter-Society Consensus D lesions. Concomitant renovisceral revascularization was needed in 42 (16.4%) patients. Thirty-day mortality was 2.7%. Major complication occurred in 92 patients (35.9%). Predictors included prior endovascular intervention (odds ratio [OR], 2.2; 95% confidence interval [CI]: 1.2-4.1; P = 0.01), malignancy (OR, 2.6; 95% CI: 1.3-5.3; P = 0.01), intraoperative complication (OR, 3.3; 95% CI: 1.3-9.2; P = 0.03), operative blood loss, (OR, 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.03), and cuff endarterectomy (OR, 1.8; 95% CI: 1.0-3.1; P = 0.04). Median follow-up was 5.3 years (interquartile range: 7.2 years). Survival at 1, 3, and 5 years was 94%, 90%, and 82% respectively. Primary patency and freedom from reintervention at 5 years were 76% and 79%, respectively. Predictors of late mortality included malignancy (hazard ratio [HR], 2.3; 95% CI: 1.3-3.9; P 0.01), chronic obstructive pulmonary disease (HR, 1.8; 95% CI: 1.1-3.1; P = 0.02), congestive heart failure (HR, 2.3; 95% CI: 1.2-4.3; P = 0.01), Rutherford's class (HR, 1.5; 95% CI: 1.1-2.1; P = 0.01), operative blood loss (HR 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.04) and chronic kidney disease (HR, 2.3; 95% CI: 1.2-4.2; P = 0.01).Although late outcomes after ABF in the contemporary era remain acceptable, major complications are frequent. Operative complexity and prior endovascular revascularization predict complications. Long-term survival is driven by degree of limb ischemia and comorbidities. These should be considered in selection for ABF, potentially modifying approach to improve outcomes.

MINI: The objective of this study was to evaluate the outcome of endovascular repair of chronic aortic arch dissecting aneurysms with a custom-made branched endograft during follow-up after acute type A aortic dissection open repair. Unmatched outcomes are reported in a population at high risk for a redo sternotomy. OBJECTIVE The objective of this study was to evaluate the outcome of endovascular aortic arch repair for chronic dissection with a custom-made branched endograft. BACKGROUND Acute type A aortic dissections are often treated with prosthetic replacement of the ascending aorta. During follow-up, repair of an aneurysmal evolution of the false lumen distal to the ascending prosthesis can be a challenge both for the surgeon and the patient. METHODS We conducted a multicenter, retrospective study of consecutive patients from 14 vascular units treated with a custom-made, inner-branched device (Cook Medical, Bloomington, IN) for chronic aortic arch dissection. Rates of in-hospital mortality and stroke, technical success, early and late complications, reinterventions, and mortality during follow-up were evaluated. RESULTS Seventy consecutive patients were treated between 2011 and 2018. All patients were considered unfit for conventional surgery. In-hospital combined mortality and stroke rate was 4% (n = 3), including 1 minor stroke, 1 major stroke causing death, and 1 death following multiorgan failure. Technical success rate was 94.3%. Twelve (17.1%) patients required early reinterventions: 8 for vascular access complication, 2 for endoleak correction, and 2 for pericardial effusion drainage. Median follow-up was 301 (138-642) days. During follow-up, 20 (29%) patients underwent secondary interventions: 9 endoleak corrections, 1 open repair for prosthetic kink, and 10 distal extensions of the graft to the thoracic or thoracoabdominal aorta. Eight patients (11%) died during follow-up because of nonaortic-related cause in 7 cases. CONCLUSIONS Endovascular treatment of aortic arch chronic dissections with a branched endograft is associated with low mortality and stroke rates but has a high reintervention rate. Further follow-up is required to confirm the benefits of this novel approach.

Objectives There are no societal ultrasound guidelines detailing appropriate patient selection for deep vein thrombosis (DVT) imaging in COVID-19 patients nor are there protocol recommendations aimed at decreasing exposure time for ultrasound technologists. We aimed to provide COVID-19 specific protocol optimization recommendations limiting ultrasound technologist exposure while optimizing patient selection. Methods A novel two-pronged algorithm was implemented to limit the DVT ultrasound studies on COVID-19 patients prospectively which included direct physician communication with the care team and a COVID-19 specific imaging protocol was instated to reduce ultrasound technologist exposure. In order to assess pretest risk of DVT, sensitivity and specificity of serum D-Dimer in 500-unit increments from 500 to 8000 ng/mL and a receiver operating characteristic curve (ROC) to assess performance of serum D-Dimer in predicting DVT was generated. Rates of DVT, pulmonary embolism (PE) and scan times were compared using t-test and Fisher’s exact test (before and after implementation of the protocol). Results Direct physician communication resulted in cancellation or deferral of 72% of requested exams in COVID-19 positive patients. A serum D-Dimer > 4000ng/mL yielded a sensitivity of 80% and a specificity of 70% (CI: 0.54-0.86) for venous thromboembolism. Using the COVID-19 specific protocol, there was a significant (50%) reduction in scan time (p

Objectives Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes of AMI over the past two decades. Methods AMI patients presenting at a single institution were reviewed (1993–2016). Venous thrombosis patients were excluded. Primary outcome was 30-day mortality. Patients were stratified by etiology and diagnosis date (before 2004 versus 2004 and later). Ordered logistic regression was performed for longitudinal temporal analysis. Results 303 patients were identified. AMI mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive (NOMI) (22%). The majority were women (55%), 50% had atrial fibrillation, and 23% were on anticoagulation (AC) therapy. Mean age was 72±13 years. 345 procedures were performed in 242 patients: 321 open and 24 hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n=85) underwent mesenteric revascularization while 39 (21%) had findings of non-survivable bowel necrosis (NSBN). Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). 30-day mortality was 61% and stable over time (P=0.91); when stratified by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since 2000, there was a significant decrease in the percentage of embolic AMI events (P=0.04). The percentage of patients who underwent operative management decreased also over time (P=0.01, 81% → 61%), which was correlated with an increasing number of patients being made comfort measures only (CMO) prior to surgical intervention (50% → 70%, P=0.02). The majority of patients (55%) were ultimately made CMO during their hospitalization. Predictors of 30-day mortality included a preoperative white blood cell count (WBC) ≥ 25 K/ µL. (OR 3.0, P=0.002) and lactate ≥ 2.3 mmol/L (OR 2.8, P=0.045). NSBN predictors included WBC ≥ 24 K/ µL. (OR 3.4 P=0.03) and lactate ≥ 3.8 mmol/L (OR 3.6, P=0.04). Conclusions Despite advances in critical care over the past 25 years, AMI continues to be associated with poor prognosis. The survival benefit observed in patients who undergo revascularization supports an aggressive approach towards early vascular intervention, although this requires further study. The importance of early diagnosis, prognostication and advanced directives is highlighted given the high morbidity, mortality and use of comfort measures associated with AMI.

Fenestrated-branched endovascular aneurysm repair (FBEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Previous studies have demonstrated that women are less likely to be treated with standard infrarenal endovascular aneurysm repair because of anatomic ineligibility and experience greater mortality after both infrarenal and thoracic aortic aneurysm repair. The purpose of the present study was to describe the sex-related outcomes after FBEVAR for treatment of TAAAs.The data from 886 patients with extent I to IV TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective, physician-sponsored, investigational device exemption studies from 2013 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to Food and Drug Administration oversight. All the patients had been treated with Cook-manufactured patient-specific FBEVAR devices or the Cook t-Branch off-the-shelf device (Cook Medical, Brisbane, Australia).Of the 886 patients who underwent FBEVAR, 288 (33%) were women. The women had more extensive aneurysms and a greater prevalence of diabetes (33% vs 26%; P = .043) but a lower prevalence of coronary artery disease (33% vs 52%; P .0001) and previous infrarenal endovascular aneurysm repair (7.6% vs 16%; P .001). The women had required a longer operative time from incision to surgery end (5.0 ± 1.8 hours vs 4.6 ± 1.7 hours; P .001), experienced lower technical success (93% vs 98%; P = .002), and were less likely to be discharged to home (72% vs 83%; P = .009). Despite the smaller access vessels, the women did not have an increased incidence of access site complications. Also, the 30-day outcomes were broadly similar between the sexes. At 1 year, no differences were found between the women and men in freedom from type I or III endoleak (91.4% vs 92.0%; P = .64), freedom from reintervention (81.7% vs 85.3%; P = .10), target vessel instability (87.5% vs 89.2%; P = .31), and survival (89.6% vs 91.7%; P = .26). The women had a greater incidence of postoperative sac expansion (12% vs 6.5%; P = .006). Multivariable modeling adjusted for age, aneurysm extent, aneurysm size, urgent procedure, and renal function showed that patient sex was not an independent predictor of survival (hazard ratio, 0.83; 95% confidence interval, 0.50-1.37; P = .46).Women undergoing FBEVAR demonstrated metrics of increased complexity and had a lower level of technical success, especially those with extensive aneurysms. Compared with the men, the women had similar 30-day mortality and 1-year outcomes, with the exception of an increased incidence of sac expansion. These data have demonstrated that FBEVAR is safe and effective for women and men but that further efforts to improve outcome parity are indicated.

Objective Duplex ultrasonography is the reference standard for diagnosing chronic venous insufficiency. Bilateral venous reflux ultrasound studies are among the most time-consuming and physically demanding tests for vascular ultrasound technologists to perform. Furthermore, if a venous procedure is required, many insurance policies require that a diagnostic venous ultrasound scan for reflux must be performed within 1 year of the procedure. If the intervention is scheduled for >1 year after the ultrasound scan, the insurance company might require a repeat venous ultrasound scan before granting insurance authorization. Hence, ordering bilateral venous duplex ultrasound scans to evaluate for reflux when an intervention might only be performed on one limb within the year could be a waste of time and resources. The aim of the present study was to determine the utility of ordering bilateral vs unilateral studies to evaluate for reflux in patients with suspected chronic venous insufficiency and to determine whether a resource-saving potential exists for vascular laboratories through optimization of the process of ordering venous duplex ultrasound studies. Methods A retrospective review of all patients who had undergone bilateral lower extremity ultrasound scanning to evaluate for reflux from January 1, 2016 to December 31, 2016 at the Massachusetts General Hospital vascular laboratory was performed. The demographics, indications for ultrasound scanning, comorbidities, time required to perform the ultrasound study, and interval to intervention were documented. The data were analyzed using SPSS statistical software (IBM Corp, Armonk, NY). Results During the study period, 13,854 ultrasound studies had been performed in our vascular laboratory, of which 606 (4.4%) had been bilateral ultrasound scans for venous insufficiency. The time allotted for a bilateral study was 2 hours. Of the 606 studies evaluated, 152 (25.1%) showed no evidence of reflux, 284 (46.9%) showed bilateral lower extremity reflux, and 170 (28.1%) showed only venous insufficiency in one leg. Venous ablation, phlebectomy, and/or sclerotherapy were performed for 28.7% of the patients. However only 6.2% of patients had undergone venous procedures on both legs within 1 year after the ultrasound studies. Ablation was the most common procedure performed (54.6%), followed by phlebectomy (27.%) and sclerotherapy (17.9%). Overall, 94.7% of patients had not undergone a venous procedure on both legs within 1 year after the ultrasound studies and, hence, would have required a repeat duplex ultrasound scan to ensure insurance coverage for future procedures. Conclusions Most bilateral ultrasound scans for venous insufficiency will not result in an intervention. Thus, most patients (95%) could have undergone a unilateral scan before the initial intervention instead of bilateral duplex ultrasound scanning.

OBJECTIVE The presence of cancer increases arterial thromboembolic events, specifically myocardial infarction and stroke, before a formal diagnosis of cancer. To the best of our knowledge, this increase in thrombotic risk has not been studied in patients with lower extremity bypass grafts. In the present study, we aimed to determine the effect of occult cancer on femoropopliteal bypass patency. METHODS A retrospective review of femoropopliteal bypass procedures completed from 2001 to 2018 was performed. International Classification of Diseases, 9th and 10th revision, codes corresponding to breast, lung, prostate, colorectal, skin, brain, and hematologic cancer were used to identify patients who had had occult cancer. Occult cancer was defined as cancer diagnosed within ≤1 year after the bypass procedure. The demographics, comorbidities, bypass configuration and conduit, 1-month, 3-month, 6-month, and 1-year occlusion rates, major adverse limb events, and mortality rates were analyzed. Statistical analysis included t tests, χ2 tests, and Cox regression analysis. RESULTS A total of 621 procedures in 517 patients met the inclusion criteria. Of the 621 procedures, 36 (5.8%) were classified as procedures in patients with occult cancer. The patients with occult cancer had had higher occlusion rates at 3 months (27.8% vs 8.0%; P < .001), 6 months (30.5% vs 15.1%; P < .01), and 1 year (44.4% vs 19.8%; P < .001). In Cox regression analysis for bypass thrombosis at 1 year, the only significant predictors were occult cancer (hazard ratio [HR], 2.03; P = .01), below-the-knee distal target (HR, 1.88; P < .01), and a compromised conduit (HR, 2.14; P < .001). CONCLUSIONS We found an increase in bypass graft thrombosis rates in patients who had undergone femoropopliteal bypass who had had occult cancer. Thrombosis of the graft within 1 year postoperatively might be a sign of occult cancer.

Objective The purpose of this study was to report prospective data of an off-the-shelf fenestrated endograft (Zenith p-Branch; Cook Medical, Bloomington, Ind) from four centers for the treatment of patients with pararenal abdominal aortic aneurysms. Methods Data were combined from four single-center investigational studies conducted in the United States and Europe. The p-Branch endograft consists of a proximal off-the-shelf component incorporating a scallop for the celiac artery, a superior mesenteric artery fenestration, and two conical pivot fenestrations to preserve flow to the renal vessels. The device is available in two configurations, a left renal fenestration at the same (configuration A) or lower (configuration B) longitudinal position than the right to accommodate varied anatomy of the patients. Results Between August 2011 and September 2015, 76 patients (82% male; mean age, 72 years; 65 elective and 11 emergent) were enrolled, with 55% implanted with option A and 45% with B. The device was deployed successfully in all patients, and stents were placed in all target vessels except in three cases (one elective, two emergent): a left kidney was sacrificed in one patient, and a right renal artery was left unstented in two patients during the index procedure. There was no 30-day mortality. During follow-up (mean, 25 ± 13 months), 10 late deaths occurred (6 elective, 4 emergent; none related to device or procedure), and there were no ruptures or conversions to open repair. Two patients experienced bowel ischemia; one case resolved with nonoperative treatment and one required superior mesenteric artery and celiac artery angioplasty and stent placement. Renal artery occlusion occurred in eight patients (11%) and was deemed procedure related in 63% (5/8) of these patients. Four of these were successfully intervened on with preservation of renal function. The overall renal insufficiency incidence was 7% (5/76). One patient developed renal failure requiring dialysis. Conclusions Early results incorporating learning curves for physicians with a new device and delivery system indicate that the use of the Zenith p-Branch device is feasible and safe. Long-term follow-up is needed to assess the effectiveness and durability of this treatment strategy and to refine the indications for use.

Open repair of complex aortic aneurysms is frequently not an option for octogenarians because of prohibitive surgical risks. This study aimed to analyze the outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) in octogenarians (≥80 years old) compared with nonoctogenarians (80 years old).We reviewed 893 patients with pararenal or extent I to V thoracoabdominal aneurysms, enrolled in six prospective physician-sponsored investigational device exemption studies from 2012 to 2018. All patients were treated with either company-manufactured off-the-shelf or patient-specific F-BEVAR stent grafts. Data analyzed included demographics, cardiovascular risk factors, history of active cancer, American Society of Anesthesiologists classification, aortic anatomy characteristics, and procedural data. End points included mortality, major adverse events (all-cause mortality, stroke, paralysis, acute kidney injury [RIFLE criteria], dialysis, myocardial infarction, respiratory failure, and bowel ischemia), technical success, hospital length of stay, target artery instability (occlusion/stenosis, endoleak, rupture or death), and secondary interventions.During the study period, 195 octogenarian patients (22%) and 698 (78%) nonoctogenarian patients were treated with F-BEVAR. Octogenarians presented more frequently with a history of cancer (17% vs 11%; P = .01), whereas nonoctogenarians more frequently had hyperlipidemia (76% vs 65%; P = .003), chronic obstructive pulmonary disease (42% vs 33%; P = .04) and American Society of Anesthesiologists class III to V (78% vs 70%; P = .02). Male sex was similar between groups (68% [octogenarians] vs 70% [nonoctogenarians]; P = .62). Octogenarians had a larger mean aneurysm diameter (67 ± 1 mm vs 65 ± 1 mm; P = .002). The thoracoabdominal classification and the use of upper extremity access were similar between groups. Estimated blood loss was also similar (484 ± 454 mL [octogenarian] vs 416 ± 457 mL [nonoctogenarian]; P = .07). Octogenarians had an increased mean number of vessels incorporated into the repair (3.1 ± 1.4 vs 2.7 ± 1.7; P .001). The technical success rate was 99% for octogenarians and 97% for nonoctogenarians (P = .19). The 30-day mortality rate was 0.5% for octogenarians and 1.3% for the nonoctogenarians (P = .70). Major adverse events (9.2% vs 9.7%), types I/III endoleak (4.6% vs 2.4%) access complication (3.1% vs 3.3%), and length of stay (8.2 ± 27 days vs 5.7 ± 6.3 days) were all similar between the groups. Freedom from target artery instability and freedom from secondary interventions at 3 years were similar between the groups. Octogenarian survival was lower at 3 years compared with nonoctogenarians on univariate analysis (log-rank P .01) and on multivariable analysis after adjusting for history of active cancer, hyperlipidemia, and chronic obstructive pulmonary disease.Despite small differences in demographics, anatomic factors, and procedural data, F-BEVAR was safe and effective with nearly identical early outcomes in octogenarians in these experienced aortic centers. More extensive clinical experience and longer follow-up are needed to better delineate factors impacting longer term mortality.

Objective The short- and mid-term outcomes of endovascular aortic aneurysm repair have made it a standard treatment of abdominal aortic aneurysms. However, newer generation devices have yet to demonstrate improved long-term rates for complications, reinterventions, and survival. The TREO stent graft is a latest generation device and was evaluated for approval in the United States. Methods In a multicenter, nonrandomized, investigational device exemption clinical trial, we assessed the safety and effectiveness of the TREO device, with core laboratory assessment of the imaging studies and an independent adjudication of safety. The primary effectiveness endpoint was successful aneurysm treatment at 1 year. The primary safety endpoint was the incidence of major adverse events (MAE) at 30 days. Results A total of 150 patients (132 men; 88.0%) with infrarenal abdominal aortic (87.3%) or aortoiliac (12.7%) aneurysms were enrolled. The data were normally distributed. The mean age was 71.7 ± 7.4 years. The MAE incidence at 30 days was 0.7%. One subject experienced two MAE: myocardial infarction and procedural blood loss of 1000 mL. The proportion of successful aneurysm treatment at 1 year was 93.1%. Longer term follow-up continues, with no aneurysm-related mortality at the latest follow-up. At 3 years, the cumulative all-cause mortality and incidence of type I and type III endoleaks was 10.7% (n = 16), 2.7% (n = 4), and 0% (n = 0), respectively. In addition, aneurysm sac shrinkage >5 mm at 3 years had occurred in 54.3% of patients, and 9.3% had required a secondary intervention (n = 14). Conclusions The safety and effectiveness of endovascular repair of abdominal aneurysms with TREO were demonstrated, with 93.1% successful aneurysm treatment at 1 year and aneurysm sac shrinkage >5 mm at 3 years in 54.3% of patients. Long-term follow-up continues to determine whether these favorable outcomes will be sustained.

OBJECTIVES The objectives are to (i) report characteristics and outcomes of patients with inoperable acute type A aortic dissection, (ii) describe proximal aortic morphology and (iii) identify potential for endovascular treatment of the entry tear. METHODS Fifty-three (7.7%) of 686 patients with acute type A dissection between 2005 and 2015 were deemed inoperable. Chart review and active follow-up were performed for clinical characteristics and outcomes. Specific attention was directed at determining the reasons for inoperability. Twenty-four patients had computed tomography scans available for 3D reconstruction and imaging analysis. Measurements included diameter and cross-sectional area at multiple levels; plus lengths along the centreline, greater and lesser curves and outer wall of dissection. The entry tear location was identified. Entry tears between the sinotubular junction and innominate artery, or distal to the left subclavian artery, were considered amenable to endovascular repair. RESULTS The reasons for inoperability were characterized as very high-risk 35 (66%) or prohibitive 18 (34%). Prohibitive risk factors included dementia, severe stroke, malperfusion and advanced malignancy. Thirty-day mortality occurred in 35 (66%). On imaging analysis, the sinotubular junction was

Thoracic endovascular aortic repair (TEVAR) with stent grafting is effective for acute dissection in selected patients, but most remain at risk for reintervention. The effect of the extent of dissection on outcome is unclear. Objectives of this study were to compare characteristics, outcomes, and aortic remodeling after TEVAR between patients with DeBakey extent IIIA and IIIB dissection.From 2005 to 2013, 520 patients presented with acute aortic syndrome. TEVAR was performed in 108 (41 IIIA, 67 IIIB) during the acute phase. Detailed three-dimensional computed tomography imaging analysis was performed in all patients.Patients with IIIA dissection were older (69.9 ± 10 vs 59.5 ± 13 years; p0.001) and more likely to have had prior cardiovascular operations (p = 0.01) than IIIB. The most common indication for TEVAR was ischemia in IIIB (66%), and pain (34%) in IIIA. Rupture was more common in IIIA (24.3% vs 1.5%; p0.001). Aortic diameters were similar between groups, but IIIB patients had smaller true/false lumen ratio (0.89 ± 1.08 vs 1.76 ± 1.27; p = 0.003). Stent graft coverage was 152 ± 42 mm for IIIA vs 212 ± 85 mm for IIIB (p0.001). Additional branch stents were used in 20 IIIB patients (30%), and 7 had infrarenal stenting. Early mortality and complications were similar between groups, except for renal failure (4.4% IIIB vs 0% IIIA; p = 0.04). Mean follow-up was 30 ± 28 months. Estimated survival at 1, 3 and 5 years was 84%, 65%, and 38% for IIIA, and 70%, 66%, and 59% for IIIB, respectively, with no significant difference. Significant expansion of the true lumen occurred in both groups after stenting, and the aortic and false lumen diameter increased only at the level of the abdominal aorta in IIIB patients. The false lumen was thrombosed in 91% of IIIA vs 62% of IIIB patients at the mid-descending aorta. Intervention was required in 15% (6 of 39) of IIIA and in 26% (15 of 58) of IIIB patients.In patients requiring TEVAR for acute dissection, patient factors and aortic morphology differ by the extent of the dissection. Aortic remodeling after TEVAR was better in patients with limited extent (IIIA) dissection than in than patients with extensive (IIIB) dissection. Despite these differences, very little difference was noted in early and late outcomes, which may be explained by differences in patient characteristics.

Despite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention.Institutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications.There were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P = .01) and hypertension (P = .01). Protective factors were thoracoabdominal approach (P .01) and aortounifemoral bypass (P .01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P = .018), anticoagulation (2.59; CI, 1.01-8.37; P = .049), and previous iliac stents (2.60; CI, 1.36-4.94; P = .004).Whereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes.

The goal of this study was to determine the incidence of postoperative urinary retention (POUR) in men after carotid endarterectomy (CEA) and to identify preventable risk factors for the development of this complication.All male patients who underwent CEA from 2014 to June 2018 were identified. Exclusions included CEA with concomitant cardiac surgery, baseline dialysis, and indwelling or straight catheterization. POUR was the primary end point, defined as inability to void requiring catheterization within 24 hours postoperatively or after removal of a preoperatively placed Foley catheter. POUR was further classified as mild (single catheterization), moderate (multiple catheterizations), or severe (catheterization prolonging discharge or discharge with catheter). Logistic regression assessed for POUR risk factors.There were 294 male patients who underwent CEA during the study period; 82 (28.2%) developed POUR. Of these, 48 (57.8%) were mild, 15 (18.1%) were moderate, and 20 (24.1%) were severe. At baseline, POUR was associated with older age, peripheral artery disease (PAD), chronic kidney disease, diabetes, ambulation deficit, prior urinary retention, and statin and chronic tamsulosin use. Overall, 31.6% (93) of the cohort had a Foley catheter placed before the procedure, and this was protective against POUR (no Foley vs Foley, 31.8% vs 20.4%; P = .043). Independent risk factors for POUR included prior urinary retention (odds ratio [OR], 3.4 [1.6-7.3]; P = .002), diabetes (OR, 2.1 [1.1-3.7]; P = .016), PAD (OR, 2.3 [1.1-5.2]; P = .036), and age (per year: OR, 1.1 [1.02-1.10]; P .001). Preoperative Foley catheter placement remained protective (OR, 0.4 [0.2-0.7]; P = .003). Preoperative Foley catheter placement was not associated with urinary tract infection (preoperative Foley catheter: 0% vs 1%; P = .54). However, POUR was associated with an increased risk for urinary tract infections (10% vs 1%; P = .001), which was highest in severe POUR (20% vs 1%; P = .001). POUR was also associated with a discharge to rehabilitation (16% vs 4%; P = .002), with highest rates in the moderate and severe POUR cohorts (20% each).POUR is common in men undergoing CEA, and almost a quarter of those with POUR have a discharge delay or are discharged with a Foley catheter. Preoperative Foley catheterization is protective against POUR and should be considered in older patients, diabetics, patients with PAD, and those with a history of urinary retention.

Chair of the Department of Surgery, sometimes known as the Chief, holds a title that has significant historical connotations. Our goal was to assess a group of objectively measurable characteristics that unify these individuals as a group.Utilizing publicly available data for all US teaching hospitals, demographic information was accumulated for the named chiefs/chairs of surgery. Information collected included location of their program, their medical/surgical training history, their surgical specialty, previous chair/chief titles held, and academic productivity.Of the 259 programs listed, data were available on 244 individuals who were trained in 19 different specialties. The top three specialties of these practitioners are General Surgery (40, 16.3%), Surgical Oncology (38, 15.5%), and Vascular Surgery (33, 13.5%). There were only 14 female chairs (5.7%) and only one chair with a doctor of osteopathic medicine degree. The majority (62.3%) had been a previous chief of a surgical subdivision with only 26% having been a previous chair/chief of the surgical department. The average chair had 72 peer-reviewed manuscripts with 28 published book chapters. Chair's at academic institutions with university affiliation had a significantly higher number of peer-reviewed manuscripts (P 0.0001) as well as were more likely to be trained at academic institutions (P = 0.013).There are no set characteristics that define the Chair of a Department of Surgery. By understanding a group of baseline characteristics that unify these surgical leaders, young faculty and trainees with leadership aspirations may begin to understand what is necessary to fill these roles in the future.

Coverage of one or both renal arteries may be required to facilitate endovascular aneurysm repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures.Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival.Overall, there were 2,278 patients presenting with ruptured aneurysms. Most patients had no renal artery coverage (n = 2,230; 98%), followed by single renal artery coverage (n = 30; 1.2%), and finally bilateral renal artery coverage (n = 18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR] = 5.7, ±4; P = 0.030), permanent dialysis/30-day death (OR = 9.5, ±7; P = 0.016), and permanent dialysis (OR = 47.5, ±47; P 0.001). Two patients with bilateral renal coverage did not suffer permanent dialysis/death. Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR = 2.8, ±1.6; P = 0.044) driven mainly by its effect on the outcome of permanent dialysis (OR = 12.3, ±6; P 0.001). Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR] = 3.4, P = 0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR = 3.5, P = 0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models.Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.

For the open treatment of juxtarenal aortic aneurysms (JRAAs), some argue for the removal of all proximal aneurysmal aortic tissue to prevent future degeneration, whereas others deem it unnecessary. This study sought to compare perioperative and long-term outcomes of two different approaches to treatment of JRAAs.Patients who underwent open JRAA repair from 2007 to 2015 at our institution were reviewed and stratified by operative technique: plication of the aneurysm cuff with graft sewn up to the renal arteries (PLI) vs a beveled anastomosis with left renal artery bypass (LRB). Patients who underwent additional mesenteric bypasses were excluded. Primary outcomes included death, anastomotic degeneration, and decline in renal function. Univariate and Kaplan-Meier analyses were performed.There were 199 patients identified, 56% PLI (n = 112) and 44% LRB (n = 87). The majority were male (68%), white (89%), and smokers (58%). Mean age was 71.5 ± 8.5 years. LRB patients were more likely to have chronic kidney disease (29% vs 13%; P = .01) and larger juxtarenal diameters (median, 25 mm vs 28 mm; P = .001). LRB patients had longer postoperative length of stay (median, 8 days vs 7 days; P = .003) and longer operative times (median, 4.7 hours vs 3.7 hours; P .001). Overall 30-day mortality was 2% (n = 4), with no difference between cohorts. There were no differences in perioperative complications except for the development of acute kidney injury, which was more common in LRB patients (47% vs 23%; P .001). During 3-year follow-up, there was no difference in anastomotic aneurysmal degeneration or sac growth. In the long term, LRB patients were more likely to develop an occluded left renal artery (20% vs 0%; P = .004) and right renal artery stenosis (29% vs 3%; P = .002). However, neither group was more likely to have a decline in renal function (PLI, 23%; LRB, 25%; P = .84). There was no difference in 5-year mortality (P = .72).The more complex technique involving LRB was not protective against long-term anastomotic degeneration, decline in renal function, or mortality. In addition, LRB led to longer length of stay and operative times, with increased risk of perioperative acute kidney injury. In an era when fewer open aortic repairs are being performed, it is reasonable to consider the PLI technique in the treatment of JRAAs, particularly in patients with baseline chronic kidney disease.

Background/Objective Open aortoiliac grafts have typically been constructed with a short aortic bifurcation sewn near or to the visceral vessels to avoid limb kinking. Similarly, the majority of endovascular bifurcated stent grafts have short aortic main body ranging from 3 to 5 cm. In these patients, endovascular salvage with fenestrated stent grafts is technically challenging because of the short distance between the renal arteries and the flow divider of the graft. Custom fenestrated stent grafts can be extended into the prior open surgical graft or stent graft using a short distal bifurcated stent graft with inverted iliac limb for the contralateral gate. The aim of this study was to evaluate outcomes of patients treated with fenestrated stent grafts coupled with inverted iliac limbs for salvage of failed open surgical and endovascular stent grafts. Methods The clinical data of three U.S. aortic centers that use fenestrated stent grafts was entered into prospectively maintained databases from 2011 to 2014. All patients received customized distal bifurcated devices constructed with a main body less than 70 mm and an inverted iliac limb to dock the contralateral gate. End points were technical success, 30-day mortality, type I or III endoleak, limb occlusion, and secondary reintervention. The Institutional Review Board of each institution approved the use of the modified graft, and each patient provided informed consent. Results There were 56 patients (41 male), with mean age of 75 years treated by fenestrated stent grafts using distal bifurcated devices with inverted iliac limbs. Forty-seven patients had a previous aortic repair with a short main body device, and nine had short distances between the native renal artery and aortic bifurcation requiring inverted limbs. A total of 184 visceral arteries were targeted by fenestrations. Technical success was 96.4% with no 30-day deaths. At a mean follow-up of 11 months, seven patients developed endoleaks, with one device migration, no occlusions, or other complications associated with the inverted limb. On the inverted iliac limb side, there were four complications. Two patients developed type Ib endoleaks treated by limb extension and angioplasty, and one patient developed distal limb ischemia secondary to embolization treated by thrombectomy. One additional patient developed a component separation of the inverted limb discovered with follow-up imaging treated with aortouni-iliac repair. Conclusions Patients with a short distance between the renal arteries and the aortic bifurcation can be challenging for endovascular treatment using currently available devices. The use of inverted limb custom devices avoids the need for aortouni-iliac repair with femoral-femoral bypass preserving antegrade perfusion. In the short term, rates of complication are similar to what has been reported for universal bifurcated devices with noninverted iliac limbs.

Iliac injury is a devastating and potentially avoidable complication of endovascular aortic intervention. To our knowledge, this study is the first investigation of demographic, anatomic, and device factors related to injury in vascular surgery patients.We retrospectively examined 1859 endovascular aortic interventions and found 42 iliac injuries, including 21 ruptures. Demographic, anatomic, and device data were extracted from these patients and a cohort of 200 case-matched control patients derived from the group of uninjured patients. Anatomic data include centerline and straight distance measurement of the iliac system from the aortic bifurcation to the inguinal ligament. The ratio of the two ("tortuosity index") was calculated. Additional data include midpoint and narrowest diameters in the iliac system along with the most acute angle. Each measurement was taken on both limbs of each patient.Nonwhite race was the only demographic factor associated with injury (P = .028). None of the examined comorbidities were associated with iliac injury. Increasing sheath size was associated with injury (P .001), whereas abdominal aortic segment intervention was inversely correlated with injury (P = .017). Anatomic factors that correlated with injury were decreasing iliac midpoint (P .01), narrowest diameters (P .001), and a higher ratio of sheath size to midpoint diameter (P .001). Injury was associated with a longer hospital length of stay (P = .042) and inpatient death (P .001), with iliac rupture conferring an odds ratio of 15.3 (95% confidence interval, 3.74-62.7; P.001).Iliac injury is associated with an increased hospital length of stay and death on the index admission. Nonwhite race, nonabdominal aortic segment intervention, larger relative and absolute sheath sizes, and smaller iliac artery diameters are associated with iliac injury. These findings should be prospectively evaluated along with interventions to reduce injury.

Thoracoabdominal aortic aneurysm (TAAA) repair remains a challenging clinical pathology. Endovascular technology, in particular the evolution of fenestrated and branched (F/B) endografts used in endovascular aneurysm repair (EVAR) has provided a less invasive method of treating these complex aneurysms. This study evaluated the technical and clinical outcomes of F/B-EVAR for extensive type II and III TAAA.Data from 354 high-risk patients enrolled in a physician-sponsored investigational device exemption trial (2004-2013) undergoing F/B-EVAR for type II and III TAAA were evaluated. Technical success, perioperative clinical outcomes, and midterm outcomes (36 months) for branch patency, reintervention, aneurysm-related death, and all-cause mortality were analyzed. Data are presented as mean ± standard deviation and were assessed using Kaplan-Meier, univariate, and multivariate analysis.F/B-EVARs incorporating 1305 fenestration/branches were implanted with 96% of target vessels successfully stented. Completion aortography showed 2.8% patients had a type I or III endoleak. Procedure duration (6.0 ± 1.7 vs 5.5 ± 1.6 hours; P .01) and hospital stay (13.1 ± 10.1 vs 10.2 ± 7.4 days; P .01) were longer for type II TAAA. Perioperative mortality was greater in type II repairs (7.0% vs 3.5%; P .001). Permanent spinal cord ischemia occurred in 4% and renal failure requiring hemodialysis occurred in 2.8% of patients. Twenty-seven branches (7.6%) required reintervention for stenosis or occlusion; and celiac artery, superior mesenteric artery, and renal artery secondary patency at 36 months was 96% (95% confidence interval [CI], 0.93-0.99), 98% (95% CI, 0.97-1.0), and 98% (95% CI, 0.96-1.0), respectively. Eighty endoleak repairs were performed in 67 patients, including 55 branch-related endoleaks, 4 type Ia, 5 type Ib, and 15 type II endoleaks. At 36 months, freedom from aneurysm-related death was 91% (95% CI, 0.88-0.95), and freedom from all-cause mortality was 57% (95% CI, 0.50-0.63). The treatment of type II TAAA (P .01), age (P .01), and chronic obstructive pulmonary disease (P .05) negatively affected survival.F/B-EVAR is a robust treatment option for patients at increased risk for conventional repair of extensive TAAAs. Technical success and branch patency are excellent, but some patients will require reintervention for branch-related endoleak. Aneurysm extent portends a higher risk of perioperative and long-term morbidity and mortality. Additional efforts are needed to improve outcomes and understand the utility of this treatment option in the general TAAA population.

Background To evaluate the aneurysm-related complications and device issues in patients who underwent partial endograft explantation during late conversion of endovascular aneurysm repair (EVAR) to open repair. Methods A retrospective analysis was performed on patients who had partially explanted endografts during late conversion between 1999 and 2012. Medical records were reviewed for patient demographics, subsequent operations, and aneurysm-related complications. Postoperative abdominal X-ray films and computed tomography scans were analyzed for endograft migration, component separation, device fracture, and arterial growth or aneurysm issues. Results Between 1999 and 2012, 22 patients had late conversion after EVAR with portions of the device left in situ. Five of the partially removed devices were Zenith, 6 Talent, 5 Ancure, 3 AneuRx, 2 Excluder endografts, and 1 Cook Aorto uni-iliac (AUI) graft. There were 4 in hospital mortalities. There were no graft migrations, component separations, device fractures, new aneurysmal degeneration, or ruptures with a median follow-up of 26.5 months. Conclusions Partial endograft removal during late conversion is not associated with complications from the remaining device pieces during follow-up. We recommend further study of this patient population.

Iliac conduits (ICs) are used for challenging iliac access during endovascular aortic aneurysm repair (EVAR) with contradictory reports of safety and increased surgical complications, morbidity, and mortality in national database reviews. The objective of this study was to examine outcomes related to IC placement before or concomitant with EVAR at a high-volume single center.A retrospective analysis of patients who underwent IC placement for endovascular aortic repair from 2006 to 2016 was conducted. Planned and unplanned, as well as staged and concomitant IC for EVAR, thoracic EVAR, and fenestrated/branched EVAR were included. Categorical factors were described using frequencies and percentages. Continuous measures were summarized in comparative tables. Comparisons between the planned and unplanned groups, concomitant and staged groups, and between those with and without a postoperative event were performed using Pearson χA total of 137 patients underwent IC placement, of which 9 were bilateral procedures, for a total of 144 IC placements. IC placement was necessary in 14 EVARs (9.7%), 38 thoracic EVARs (26.4%), and 92 fenestrated/branched EVARs (63.9%). The 30-day related mortality was 2.1% (n = 3). Perioperative morbidities included return to the operating room in five patients (5.6%) for bleeding (n = 4) and graft thrombosis (n = 1), 4 myocardial infarctions (2.8%), 5 episodes of respiratory failure (3.5%), 12 wound complications (8.3%), and 7 renal injuries (4.9%), of which 3 had progression to dialysis (2.1%). Other complications included return to the operating room for endoleak reintervention (n = 3) and late graft infection (n = 1 [0.7%]). There were 112 ICs (77.8%) planned and 65 (45.1%) were staged. Staged ICs were less likely to have postoperative complications (P .001), respiratory failure (P .05), infectious complications (P .05), and postoperative cerebrovascular accidents (P .05). ICs were done to accommodate 20F to 24F sheath sizes in 131 instances (91.0%). Factors associated with unplanned IC placement were iliac rupture and an inability to advance the endograft in arteries deemed size-appropriate preoperatively (P .001). Unplanned ICs were associated with higher estimated blood loss (P .001), operating room transfusion volume (P .001), and overall complication rates (P .05). Women (P .05), preoperative chronic kidney disease (P .05), and concomitant IC placement (P .001) were associated with higher overall complication rates. Operative time, estimated blood loss, and operating room transfusion volume were associated with increased rate of complications in comparison between all subgroups (P .05).ICs are a safe and viable option for high-risk patients with challenging iliac artery access for EVVAR. ICs are best performed in a planned fashion or in a staged manner, when feasible.

OBJECTIVE Our objective was to identify the postoperative risk associated with different timing intervals of repair. BACKGROUND Timing of carotid intervention in poststroke patients is widely debated with the scales balanced between increased periprocedural risk and recurrent neurologic event. National database reviews show increased risk to patients treated within the first 2 days of a neurologic event compared to those treated after 6 days. METHODS Utilizing Vascular Quality Initiative data, all carotid interventions performed on stroke patients between the years 2012 and 2017 were queried. Patients were then stratified based on the timing of surgery from their stroke ( 15 days). Major outcomes included postoperative stroke, death, and myocardial infarction. RESULTS A total of 8404 patients were included being predominantly men (5281, 62.8%), with an average age of 69 (±10). Patients treated at greater than 8 days showed significantly less risk of postoperative combined stroke/death and postoperative stroke. There were no significant differences in postoperative stroke or death between the 8 to 14 and greater than 15 days groups.Multivariate regression analysis showed that delayed timing of surgery between 3 and 7 days was protective for postoperative stroke/death (P = 0.003) and any postoperative complication (P = 0.028). Delaying surgery to more than 8 days after stroke was protective for postoperative stroke/death (P < 0.001), postoperative stroke (P < 0.001), and any postoperative complication (P < 0.001). CONCLUSIONS Carotid revascularization should occur no sooner than 48 hours after index stroke event. Surgeons should strive to operate between 8 and 14 days to protect against postoperative stroke/death.

Proteoglycan accumulation is a hallmark of medial degeneration in thoracic aortic aneurysm and dissection (TAAD). Here, we defined the aortic proteoglycanome using mass spectrometry, and based on the findings, investigated the large aggregating proteoglycans aggrecan and versican in human ascending TAAD and a mouse model of severe Marfan syndrome. The aortic proteoglycanome comprises 20 proteoglycans including aggrecan and versican. Antibodies against these proteoglycans intensely stained medial degeneration lesions in TAAD, contrasting with modest intralamellar staining in controls. Aggrecan, but not versican, was increased in longitudinal analysis of Fbn1mgR/mgR aortas. TAAD and Fbn1mgR/mgR aortas had increased aggrecan and versican mRNAs, and reduced expression of a key proteoglycanase gene, ADAMTS5, was seen in TAAD. Fbn1mgR/mgR mice with ascending aortic dissection and/or rupture had dramatically increased aggrecan staining compared with mice without these complications. Thus, aggrecan and versican accumulation in ascending TAAD occurs via increased synthesis and/or reduced proteolytic turnover, and correlates with aortic dissection/rupture in Fbn1mgR/mgR mice. Tissue swelling imposed by aggrecan and versican is proposed to be profoundly deleterious to aortic wall mechanics and smooth muscle cell homeostasis, predisposing to type-A dissections. These proteoglycans provide potential biomarkers for refined risk stratification and timing of elective aortic aneurysm repair.

Fenestrated and branched endografts allow for proximal sealing zone extension into or above the visceral aorta to optimize landing in healthy aorta. We describe the incidence, causes, and implications of proximal endoleak development in patients undergoing complex endovascular aortic aneurysm repair.All patients undergoing a fenestrated/branched repair were entered onto a prospective database, and this analysis included all those with at least one postoperative contrast computed tomography scan. Preoperative and postoperative three-dimensional imaging was reanalyzed to characterize morphology and identify endoleak. A blinded assessor used the preoperative imaging to resize the repairs in the endoleak group and a matched cohort of patients without endoleak. The outcome measures were proximal endoleak development, mortality, and component stability, and a comparison was made with all patients undergoing complex aortic repair.From 2001 to July 2013, 969 patients underwent repair in a physician-sponsored investigational device exemption trial. Excluded were 24 emergency patients and 21 patients without requisite imaging, leaving 924 available for analysis. A proximal type Ia endoleak developed in 26 patients (2.8%). Poor choice of landing zone was implicated in most cases, with an area of sealing in the visceral aorta, compared with the thoracic aorta, being significantly associated with endoleak development (P .01). Aortic-related mortality was significantly higher in the endoleak group (26.9%) than in the group without endoleak (6.2%; P = .001). These patients also experienced a higher incidence of component instability of 30.8% compared with 9.6% in patients without type Ia endoleak (P .01).Fenestrated/branched endovascular repair has a low incidence of sealing zone failure despite the increased complexity. However, development of a proximal endoleak destabilizes the repair and leads to increased mortality. Increasing complexity of design seems to improve the long-term outcome for patients requiring complex aortic repair.

ObjectiveThe practice of using fenestrated endografts to treat juxtarenal and group IV thoracoabdominal aortic aneurysms (TAAAs) has become more accepted, but long-term outcomes are still unknown. We report long-term survival, complications, and branch-related outcomes from a single-center experience.MethodsThe study included consecutive patients enrolled prospectively into a physician-sponsored investigational device exemption classified as undergoing group IV TAAA or juxtarenal aneurysm repair by the treating surgeon using fenestrated endografts. Device morphology was used to subclassify this group of patients. Long-term survival and a composite outcome of secondary intervention, branch occlusion, stent migration, endoleak, aneurysm growth, or spinal cord injury were calculated. Descriptive analysis of branch-related outcomes and need for any reintervention was performed. Univariate and multivariate analysis of mortality and the composite outcome was performed to determine associative risks.ResultsLong-term survival for patients with juxtarenal and group IV TAAA aneurysms treated with fenestrated stent grafts was 20% at 8 years. Multivariate analysis showed long-term survival for this patient population was negatively associated with increasing age, congestive heart failure, cancer, and previous aneurysm repair. The risk of spinal cord ischemia (SCI) in this group was 1.2% and of aortic-related mortality was 2%. The risk of a spinal event increased with coverage above the celiac artery (52 mm of coverage above the celiac artery in patients with SCI vs 33 mm without SCI; P = .099). More complex device configurations were more likely to require an increased rate of reinterventions, and patients with celiac fenestrations were more likely to experience celiac occlusion over time (3.5% vs 0.5%; P = .019). However, less complex designs were complicated by an increased risk of type I endoleak over time (10.4% for renal fenestrations only vs 1.9% for others; P < .01). As experience evolved, there was a trend to increase the number of fenestrations in devices treating the same anatomy.ConclusionsThe use of fenestrated devices to treat juxtarenal and group IV TAAA is safe and effective in long-term follow-up. Mortality in this patient population is largely not aortic-related. Devices designed for fenestrated repair of juxtarenal and group IV thoracoabdominal aneurysms within a physician sponsored investigational device exemption have changed over time. Further research is needed to determine the best configuration to treat aneurysms requiring coverage proximal to the celiac artery.

Objective Endovascular stent-grafting provides an alternative treatment option for high-risk patients with ascending aortic disease. The feasibility of this approach has been demonstrated before. We assess the updated experience with ascending thoracic endovascular aortic repair and propose a modification of the landing zone classification based on the outcomes. Methods From 2006 to 2016, 39 patients deemed very high risk for open replacement underwent endovascular repair of ascending aorta for acute type A dissection (12, 31%), intramural hematoma (2, 5%), pseudoaneurysm (22, 56%), and chronic dissection suture line entry tear (3, 8%). Ascending thoracic endovascular aortic repair was performed in 36 patients. In 3 patients with pseudoaneurysm, occluder devices were used. Computed tomography imaging analysis was performed, and the extent of aortic pathology was designated by segmental proximity to the left ventricle. Segmental anatomy of the proximal aorta was designed as zone 0A from the annulus to the distal margin of highest coronary, 0B extends from above the coronary to the distal margin of right pulmonary artery, and 0C extends from the right pulmonary artery border to the innominate artery. Multivariable time to event Cox regression analysis was performed to predict mortality, and long-term survival was estimated using the Kaplan–Meier method. Results Operative mortality was 13%; all 5 deaths occurred after emergency ascending thoracic endovascular aortic repair for type A dissection. Other complications included stroke in 4 patients (10%), myocardial infarction in 2 patients (5%), tracheostomy in 2 patients (5%), and dialysis in 2 patients (5%). In patients with acute type A dissection, the ascending pathology extended into zone 0A in 10 (71%) and 0B in 4 (29%). Among those with pseudoaneurysm, the location of the defect was in 0B in 11 (50%), 0C in 10 (45%), and 0A in 1. Among the patients with chronic dissection, the defect was located in 0C in all 3 (100%). After multivariable adjustment, Cox regression predicted significantly higher hazard of mortality with disease involving zone 0A versus 0C ( P = .020) and older age ( P = .026). Kaplan–Meier estimate of survival was also significantly worse in patients with disease extension into 0A versus 0C ( P = .0018). At 30 days, 1 year, and 5 years, the overall survival was 81%, 74%, and 64% and freedom from reintervention was 85%, 77%, and 68%, respectively. Conclusions The modified zone zero classification is useful for characterizing extent of ascending aortic pathology and assessing prognosis. Location of the defect varies by pathology, and the presence of 0A disease predicts worse outcomes. Design of endovascular devices should be tailored to the aortic pathology and zone characteristics.

Background Endovascular repair of a proximal anastomotic pseudoaneurysm (APSA) of an end-to-side aortobifemoral bypass (ABF) can lead to pelvic ischemia. We present a novel application of branched aortic endograft to repair such pseudoaneurysm while preserving flow into the ABF and native aortoiliac system. Methods A 71-year-old male with history of aortoiliac occlusive disease resulting in lifestyle limiting claudication was treated with an aortobifemoral bypass in 1999. The patient developed an 8.8 cm pseudoaneurysm at the aortic anastomosis. CTA demonstrated patent right common and internal iliac arteries with an occluded right external iliac artery and occluded left common and external iliac arteries. Results A 24 × 80 mm endograft with an 8 × 15 mm posterior branch based on the Cook Zenith device (Bloomington, IN) was delivered via a right femoral artery exposure. The preloaded wire of the main body was snared via left brachial access. A 10F sheath was advanced into the side branch of the graft to deliver a 10 × 10-mm Bard Fluency (Covington, Georgia) stent graft into the right common iliac artery. The branch was reinforced proximally with an 8 × 17 mm Boston Scientific Express (Marlborough, MA) stent. The patient was discharged after 5 days. At 1 month, CTA demonstrated patent ABF, patent branch graft into the pelvis, and exclusion of the pseudoaneurysm. Conclusions Branch grafts can provide minimally invasive revision of a failing ABF, in this case an APSA, while preserving pelvic circulation and lower extremity perfusion.

Objective With more than a decade of use of endovascular aneurysm repair (EVAR), we expect to see a rise in the number of failing endografts. We review a single-center experience with EVAR explants to identify patterns of presentation and understand operative outcomes that may alter clinical management. Methods A retrospective analysis of EVARs requiring late explants, >1 month after implant, was performed. Patient demographics, type of graft, duration of implant, reason for removal, operative technique, length of stay, complications, and in-hospital and late mortality were reviewed. Results During 1999 to 2012, 100 patients (91% men) required EVAR explant, of which 61 were placed at another institution. The average age was 75 years (range, 50-93 years). The median length of time since implantation was 41 months (range, 1-144 months). Explanted grafts included 25 AneuRx (Medtronic, Minneapolis, Minn), 25 Excluder (W. L. Gore & Associates, Flagstaff, Ariz), 17 Zenith (Cook Medical, Bloomington, Ind), 15 Talent (Medtronic), 10 Ancure (Guidant, Indianapolis, Ind), 4 Powerlink (Endologix, Irvine, Calif), 1 Endurant (Medtronic), 1 Quantum LP (Cordis, Miami Lakes, Fla), 1 Aorta Uni Iliac Rupture Graft (Cook Medical, Bloomington, Ind), and 1 homemade tube graft. Overall 30-day mortality was 17%, with an elective case mortality of 9.9%, nonelective case mortality of 37%, and 56% mortality for ruptures. Endoleak was the most common indication for explant, with one or more endoleaks present in 82% (type I, 40%; II, 30%; III, 22%; endotension, 6%; multiple, 16%). Other reasons for explant included infection (13%), acute thrombosis (4%), and claudication (1%). In the first 12 months, 23 patients required explants, with type I endoleak (48%) and infection (35%) the most frequent indication. Conversely, 22 patients required explants after 5 years, with type I (36%) and type III (32%) endoleak responsible for most indications. Conclusions The rate of EVAR late explants has increased during the past decade at our institution. Survival is higher when the explant is done electively compared with emergent repair. Difficulty in obtaining a seal at the initial EVAR often leads to failure ≤1 year, whereas progression of aneurysmal disease is the primary reason for failure >5 years.

Objective This study assessed preliminary results of the Ventana Fenestrated System (Endologix, Irvine, Calif) as an off-the-shelf integrated device for juxtarenal aortic aneurysm (JAA) or pararenal aortic aneurysm (PAA) endovascular repair. Methods From November 2010 to April 2012, seven centers enrolled 31 patients with JAAs or PAAs in an international clinical trial of the Ventana Fenestrated System. Clinical and laboratory evaluations were done predischarge and at 1 month, with continuing follow-up through 5 years. Core laboratory computed tomography imaging assessments were performed at 1 month and at each subsequent follow-up. Results Patients (mean age, 73 years; 90% male) presented with mean aneurysm sac diameter of 6.0 cm. One patient with a short, reversed tapered infra-superior mesenteric artery (SMA) neck was enrolled under a protocol waiver. Among the 31 patients, one of five Ventana device models was used to preserve main renal arteries, the SMA, and celiac arteries; 20 patients (65%) received the same Ventana device (aligned fenestrations, 28-mm diameter). Median fluoroscopy and procedure times were 49 and 197 minutes, respectively; median hospital length of stay was 3.0 days. The 1-month clinical success rate was 94% (29 of 31), with no perioperative mortality. One intervention on day 26 was done to resolve limb kink/occlusion. A type IA endoleak and renal occlusion secondary to procedural device damage led to a reintervention on day 52 and dialysis at 5 months. During follow-up to 23 months, three non-aneurysm-related deaths occurred. No aneurysm rupture or conversion to open repair has occurred. One late migration with endoleak and covered renal stent fracture/occlusion occurred at 8 months in the patient with a short, reverse tapered infra-SMA neck performed under a protocol waiver, which was managed successfully with bilateral renal bypasses and endovascular repair of the endoleak. Another patient underwent late endovascular interventions to resolve bilateral renal stenosis. Conclusions The multicenter experience of the Ventana Fenestrated System supports its safety and early-term to midterm effectiveness for the endovascular repair of JAAs and PAAs. This off-the-shelf integrated system permits endovascular treatment of JAAs or PAAs; however, further expanded clinical experience and longer-term follow-up are needed to more fully assess this device system.

Objective Malperfusion syndrome is a known predictor of poor outcomes in acute type B dissection. We describe our experience with revascularization in the acute setting. Methods Patients undergoing intervention for ischemia complicated acute type B dissection between November 1999 and March 2011 were reviewed. Details of presenting condition, surgical intervention, and postoperative course were collected. Descriptive and inferential statistical analyses included survival and freedom from reintervention using Cox proportional hazards models. Results A total of 61 patients were identified with malperfusion in at least one territory, including spinal cord 7/61 (12%), mesenteric 37/61 (61%), renal 45/61 (73%), and lower extremity 38/61 (62%). Thoracic stent grafts were placed in all patients, and 41% of patients required adjunctive branch vessel stenting. After intervention, resolution of the ischemia was reported in 57/61 (93%) of patients. The 30-day/in-hospital mortality was 21.3%. The 6-month, 1-year, and 5-year survival was 75% (95% CI, 65%-87%), 71% (95% CI, 61%-84%), and 56% (95% CI, 43%-74%), respectively. The 6-month, 1-year, and 5-year freedom from reintervention was 84% (95% CI, 75%-95%), 76% (95% CI, 65%-90%), and 42% (95% CI, 24%-76%), respectively. Territory of ischemia was not independently associated with mortality, but placement of a stent graft proximal to the subclavian artery was associated with poor outcome hazard ratio 2.91 (95% CI, 1.09-8.11; P = .034). Conclusions Malperfusion in any territory at the time of presentation in patients with type B dissections can be treated with endovascular intervention with acceptable outcomes. Opposed to branch vessel intervention alone, increased aortic intervention with regard to proximal coverage may signify more serious disease is associated with worse outcome.

The generation of vascular grafts by recruiting autologous cells within the peritoneal cavity has shown promise. However, the microenvironment affects cell differentiation and elastic matrix production. Therefore, this study determined the impact of systematic changes in the average fiber diameter of electrospun poly(ɛ-caprolactone) conduits, and the pore size of pouches used to enclose the conduits, on recruited cells. After 2 weeks in the peritoneal cavity, fibrous capsules formed containing macrophages, α-smooth muscle actin (α-SMA)(+) and SM22α(+) myofibroblastic or smooth muscle like-cells, and what appeared to be mesothelial cells on the outer surfaces. These cells infiltrated and deposited matrix (e.g., collagen, hyaluoronan, and limited elastin) within conduit walls. Constructs enclosed within the largest pore pouches exhibited significantly better tissue generation responses (e.g., better cell infiltration, elongation, and matrix deposition). Additionally, the healing response was impacted by the conduit average fiber diameter, and consequently, the effective pore diameter, with the largest diameter fibers promoting the most positive healing response (e.g., greater total cellularity, extracellular matrix deposition, and α-SMA(+) cells). Six weeks post-intra-aortal grafting, constructs were occluded, but significant remodeling also occurred in the arterial microenvironment. Overall, these results demonstrate the importance of microenvironmental cues on recruited peritoneal cells and the necessity of developing strategies to further improve elastic matrix synthesis.

The aim of this study was to evaluate alterations in Th1 and Th2 cytokines during experimental abdominal aortic aneurysm (AAA) formation.AAAs were induced in apolipoprotein E null mice by infusing angiotensin II (Ang II, 1000 ng/kg/min). Aortic homogenates were assessed at 0, 7, 14, and 28 d (n = 11/time point) for select Th1 and Th2 cytokines by ELISA. Additional mice had co-administration of anti-IgG (n = 20) or anti-IL-5 (n = 20) and were assessed at 28 d for AAA. Aortic homogenates were assessed for MMP-2 and MMP-9 expression. Mouse aortic SMC (MASMC) and peritoneal-derived macrophages were treated with IL-5 (0-40 ng/mL), and cell extracts and media (0-48 h) were assessed for MMP-2 and MMP-9 expression.Ang II infusion was associated with a 3.4-fold (P0.01) and 3.6-fold (P0.01) increase in IL-5 and IL-10 (respectively), and a 0.6-fold reduction in IL-6, by 7 d. Anti-IL-5, but not anti-IgG, ameliorated Ang II-induced AAA formation. Up-regulation of MMP-2 and MMP-9 was observed in aneurysmal aortas, but not in the aortas obtained from mice treated with anti-IL-5. IL-5 stimulation of MASMC increased MMP-2 and MMP-9 mRNA (2.1-fold and 2.7-fold, respectively, P0.01) and protein (1.6-fold and 1.9-fold, respectively, P0.01) by 24 h. IL-5 stimulation of macrophages did not alter MMP expression.Ang II induces increased Th2 cytokines IL-5 and IL-10 early in the course of experimental AAA formation, and inhibition of IL-5 prevents AAA formation suggesting an important role. While IL-5 is capable of up-regulating MMP-2 and MMP-9 expression in MASMC, investigations into alternate roles in AAA formation is warranted.

Background Advances in endovascular aneurysm repair now allow surgeons to treat high-risk patients with complex aortic aneurysms. Stringent selection criteria for repair exist from an anatomic and technical perspective; however, there is a paucity of literature examining frailty in patients being evaluated for fenestrated and branched endovascular aortic repair (FEVAR). As a marker of frailty well supported in the literature, we hypothesized that preoperative hypoalbuminemia would increase risk for short-term mortality after endovascular juxtarenal and thoracoabdominal aortic aneurysm repair. Methods One thousand eighty nine consecutive patients with juxtarenal and thoracoabdominal aortic aneurysms considered high risk for open surgery from a single institution who underwent FEVAR from 2001 to 2014 were included in the study. Risk factors for all-cause mortality were identified via a Cox regression model on time to death. Results The patients with severe hypoalbuminemia (albumin P = 0.025, odds ratio [OR]: 4.967 (95% CI: 1.385–17.814, normal versus severe) and 2-year mortality P = 0.006, OR: 2.4, 95% CI: 1.05–5.73, normal versus severe), as well as increased 30-day complication rates P = 0.026, OR: 1.91, 95% CI: 0.9–4.17, normal versus severe). A univariate analysis for 30-day mortality revealed no significant difference in median age: 75.1 vs. 72.5 years (alive at 30 days (Q1, Q3: 69.8, 80.1) versus expired (Q1, Q3: 69.3, 77.8), P = 0.24. Conclusions Patients with hypoalbuminemia have significantly increased mortality risk. Albumin level is regulated by nutritional intake and inflammation due to chronic disease, which make it a useful part of a preoperative frailty assessment. Further studies are needed to identify whether optimizing nutrition status will affect albumin levels or decrease mortality.

Introduction Successful endovascular exclusion of abdominal aortic aneurysms is largely dependent on adequate apposition of the stent graft to the aortic wall. Proximal endoleaks at the time of stent graft placement are uncommon but are more prevalent in patients with challenging neck anatomy. If these initial leaks do not respond to simple balloon angioplasty, Palmaz stents (Cordis Endovascular, Warren, NJ) and covered stent graft cuffs both have been used to seal the endoleak. Long-term data regarding the efficacy of one method over the other, however, is lacking. Methods We retrospectively reviewed a database of all infrarenal aortic aneurysm repairs with an intraoperatively diagnosed type Ia endoleak requiring Palmaz stent or covered stent graft cuff placement. Fenestrated and branch grafts were excluded. All records and appropriate imaging studies were reviewed. The primary end points were technical success of aneurysm exclusion, recurrence of a type Ia leak, and need for reintervention. Results At the time of the initial aneurysm repair, 72 patients required an adjunctive covered extension or Palmaz stent; of these, 24 (33%) underwent sole placement of a Palmaz stent, 45 (62.5%) underwent placement of a covered stent graft cuff, and 3 required both a cuff and a Palmaz stent. Aneurysmal exclusion was successful in all patients before leaving the operating room. No recurrent type Ia endoleak developed in patients who underwent Palmaz stent placement. Of the 45 patients who underwent cuff placement, proximal leaks developed in 3 that required reintervention: 1 was managed with a Palmaz stent and the other 2 required open surgical revision. Conclusions Palmaz stent placement and stent graft cuff placement are frequently used to seal immediate proximal endoleaks that do not resolve with balloon angioplasty. Both methods appear to be durable long-term options to facilitate endovascular exclusion of abdominal aortic aneurysms.

ObjectivesTo evaluate the use of intraoperative guidance by means of C-arm cone-beam computed tomography (CT) (cone-beam computed tomography [CBCT]) and the use of postoperative CBCT to assess for successful aneurysm exclusion in fenestrated branched endovascular aneurysm repair (FEVAR).MethodsPatients with FEVAR who underwent CBCT were retrospectively evaluated and categorized into one of two groups. The CBCT-fusion group was comprised of patients who underwent preprocedural CBCT to guide FEVAR using fusion imaging with multidetector computed tomography (MDCT). The postprocedure CBCT group consisted of patients undergoing CBCT following deployment of the endograft. Outcomes from the CBCT-fusion group were compared with historical controls. These controls were patients who underwent FEVAR for similar groups of abdominal and thoracoabdominal aortic aneurysms in the 12 months preceding the initiation of a CBCT program. The findings on postprocedural CBCT were compared with those on predischarge MDCT. Results are expressed as mean ±standard error of the mean, or as median and interquartile range.ResultsForty patients were included in the “CBCT-fusion” group and compared with the historical cohort. The use of perioperative guidance of FEVAR by means of CBCT resulted in a significantly lower contrast dose (94 cc [72-131] vs 136 cc [96-199]; P = .001). While there was a trend toward lower operative (330 minutes [273-522] vs 387 minutes [290-477]; P = .651) and fluoroscopy times (81 min [54-118] vs 90 minutes (46-128), P = .932); this difference did not reach statistical significance. Nineteen patients were included in the “postprocedural CBCT” group and compared with predischarge MDCT. Postoperative CBCT identified eight endoleaks. Type I and III (n = 6) endoleaks were identified and treated during the primary procedure. When CBCT did not show an endoleak, this was confirmed by MDCT. The use of CBCT required significantly less contrast compared to MDCT (50 cc [set amount] vs 100 cc [80-125]; P < .0001). Mean skin dose was 0.27 (0.011) Gy for preoperative CBCT and 0.552 (0.036) Gy for postoperative CBCT.ConclusionsCBCT is a valuable addition to complicated aortic interventions such as FEVAR. Intraoperative use utilizing fusion imaging limits contrast dosage and postdeployment CBCT is of sufficient quality to evaluate successful aneurysm exclusion and for detection of early complications after FEVAR. With the information we are able to obtain from the CBCT at the completion of the FEVAR, we can intervene on problems earlier and potentially decrease the subsequent need for reintervention.

ObjectiveIn contrast to endovascular repair (EVAR), the absence of rigorous imaging follow-up after open surgical repair (OSR) has rendered the perception that late failure (LF) is rare. Better understanding of associated factors with LF will help define OSR follow-up paradigms and perhaps alter initial repair strategy to facilitate treatment of LF. The aim of this study is to evaluate aspects of LF requiring intervention after OSR.MethodsFrom 1998 to 2008, data were collected prospectively on 1097 patients who underwent an aortic endovascular repair. Patients undergoing intervention for LF contiguous with prior OSR were subjected to further analysis. The indication for reintervention was a maximal diameter >60 mm. Univariable and multivariable linear regression models were used to compare patients and disease variables (18 variables regarding age, comorbidities, family history, etiology, and extent) with time to LF.ResultsLF of open surgical aneurysm repair was identified in 104 (9.5%) patients. Mean aneurysm diameter was 72 ± 12 mm. Mean age at first repair and time between the two repairs were 61.4 ± 10.0 and 10.8 ± 6.0 years, respectively. When compared with the 993 other patients whose EVAR was their primary repair, LF patients were significantly younger at the time of their first repair (61.4 ± 10.0 vs 74.1 ± 9.6 years; P < .00001) and more frequently had a family history of aneurysms (20% vs 7%; P = .001). They were also more likely to have presented with dissection, renal insufficiency, and manifestations of atherosclerosis. On multivariable analysis, patients with an initial incomplete OSR (aneurysm located in another aortic segment but not treated at the time of the primary repair), more extensive aneurysms (those involving the descending thoracic or the thoracoabdominal aorta), and older patients experienced earlier LF (P < .00001, .002, and .001, respectively). Although we were incapable of determining the incidence of LF after OSR, 34% of patients presenting with LF were regional to our center.ConclusionAneurysmal disease is an ongoing process potentially involving the entire aorta. Segments that appear normal prior to OSR of EVAR may be vulnerable to LF. We identified several groups of patients following OSR who mandate more aggressive follow-up given their propensity to present with LF. The threshold and strategies guiding reintervention in the setting of LF is dependent upon many factors relating to the structure and the morphology of the aorta and implanted graft, the type of anastomosis, and patient comorbidities. Therefore, surgeons should consider LF treatment options when planning an aneurysm repair in an effort to optimize any later interventions, and have specifically tailored follow-up paradigms.

BackgroundTranscription factor signal transducer and activator of transcription (STAT) 1 has been linked to a variety of pathologic states involved with matrix remodeling, but its role in aortic pathology has not been previously described. The current study hypothesized that STAT1 regulates aneurysmal degeneration and its role was evaluated in human abdominal aortic aneurysm (AAA) and in a mouse model of aortic dissection.MethodsApolipoprotein E knockout mice (ApoE-/-) or ApoE/STAT1 double knockout mice (ApoE/STAT1-/-) were infused with 1000 ng/kg/min of angiotensin II. Systolic blood pressure (SBP) was measured in the rodent tail. At sacrifice, aortic diameters and extent of aneurysm formation were measured by digital microscopy. STAT1 and phosphorylated-STAT1 protein levels were assessed in ApoE-/- mice at 0, 7, 14, and 28 days (n = 8/time point) by enzyme-linked immunosorbent assay. Histology was performed using hematoxylin and eosin (H&E) and Movat stains. Statistical analyses included χ2 test, t test, and analysis of variance.ResultsSTAT1 messenger RNA and total protein were greater in human AAA vs non-AAA controls. In addition, aneurysms occurred in 8%, 50%, and 80% of ApoE-/- mice at 7, 14, and 28 days, respectively. Total STAT1 levels were not altered during the course of angiotensin II infusion. Phosphorylated STAT1 levels peaked at 7 days with a 1.4-fold increase over baseline (P < .05). Aneurysms occurred in 0%, 100%, and 100% of ApoE/STAT1-/- mice at 3, 5, and 28 days. In mice infused with angiotensin II for >3 days, aortic rupture occurred more frequently in ApoE/STAT-/- mice (53% vs 19%, P < .05) and at earlier time points (4.0 ± 0.5 vs 9.2 ± 0.77 days, P < .05) vs ApoE-/- mice. SBP did not differ between the groups during angiotensin II infusion. By 28 days, aneurysms were larger in ApoE/STAT1-/- mice compared with ApoE-/- mice (2.7 ± 0.4 vs 1.9 ± 0.1 mm, P < .05) and were more extensive. H&E and Movat stain did not reveal differences in aortic wall structural content at baseline between ApoE-/- and ApoE/STAT1-/- mice. Both groups demonstrated equal disorganization in the aneurysmal state.ConclusionsPhosphorylated STAT1 is elevated during aneurysmal degeneration. Its loss is associated with a higher rate of acute aortic rupture and more extensive aneurysms in a mouse model of aortic dissection. Further investigation is necessary to determine whether these observations are secondary to an underlying aortic wall abnormality or alterations in vessel wall matrix remodeling.Clinical RelevanceAbdominal aortic aneurysms (AAA) are a major health concern. Age, smoking, hypercholesterolemia, family history of AAA, and atherosclerotic disease all correlate with an increased risk for the development of aortic aneurysms. Most AAAs remain undetected until the aneurysm presents with a rupture or is identified incidentally. Currently, the only mode of treatment is operative intervention by conventional or endovascular surgery before significant aneurysm expansion and rupture. Future improvement in outcomes for patients with aneurysmal disease will involve the early identification of patients prone to develop AAA and those with small, low-risk aneurysms. Pharmacologic therapy to prevent aortic wall deterioration and subsequent aneurysm formation in this group would prove extraordinarily beneficial. A better understanding of the sequence of biochemical and cellular events that lead to AAA formation would allow the development of pharmacotherapies targeted at preventing aneurysm development and expansion.