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Presented is a patient with carotid artery stenosis resulting in crescendo anterior and posterior circulation transient ischemic attacks. Treatment was complicated by a rare persistent hypoglossal artery (HGA) arising from the left internal carotid artery in addition to severe contralateral carotid disease, hypoplastic vertebral arteries, and incomplete circle of Willis. A carotid endarterectomy with shunting was performed, maintaining perfusion of both the proper left internal carotid artery and HGA. This is a rare case of carotid stenosis in the setting of a persistent HGA with contralateral carotid disease and highlights the importance of planning intracranial perfusion before carotid surgery.

Objective Angioplasty is a fundamental treatment for atherosclerotic disease and may be performed as the sole therapy in small vessel disease. However, the ideal duration of balloon inflation has not yet been identified. Our study investigated whether prolonged inflation of at least 1-min duration, when compared with brief inflation, affects residual stenosis after arterial angioplasty. Data sources and methods Two independent reviewers conducted a systematic review of EMBASE, MEDLINE, CENTRAL, trial registries and grey literature, using pre-specified search syntax. Data abstraction and quantitative analysis was performed independently, according to pre-specified criteria. The primary outcome was residual stenosis after initial angioplasty, in addition to other pre-specific clinical and radiographic outcomes. All analyses were stratified by coronary, cerebrovascular, and peripheral territory. The study protocol is published and registered on PROSPERO (CRD42018092702). Results Six relevant articles were identified, of which one investigated peripheral vascular angioplasty and five investigated coronary artery angioplasty, encompassing 1496 procedures. The studies were at moderate risk of bias. Minimal heterogeneity within coronary studies allowed for subgroup meta-analysis. Prolonged inflation was significantly associated with lower risk of residual stenosis post-inflation in the pooled coronary trials (RR 1.76 [95% CI 1.46–2.12], I2 = 0%, p

Atherosclerosis remains a leading cause of morbidity and mortality, with revascularization remaining a cornerstone of management. Conventional revascularization modalities remain challenged by target vessel reocclusion-an event driven by mechanical, thrombotic, and proliferative processes. Despite considerable advancements, restenosis remains the focus of ongoing research. Adjunctive agents, including dipyridamole, offer a multitude of effects that may improve vascular homeostasis. We sought to quantify the potential therapeutic impact of dipyridamole on vascular occlusion. We performed a literature search (EMBASE and MEDLINE) examining studies that encompassed 3 areas: (1) one of the designated medical therapies applied in (2) the setting of a vascular intervention with (3) an outcome including vascular occlusion rates and/or quantification of neointimal proliferation/restenosis. The primary outcome was vascular occlusion rates. The secondary outcome was the degree of restenosis by neointimal quantification. Both human and animal studies were included in this translational analysis. There were 6,839 articles screened, from which 73 studies were included, encompassing 16,146 vessels followed up for a mean of 327.3 days (range 7-3650 days). Preclinical studies demonstrate that dipyridamole results in reduced vascular occlusion rates {24.9% vs. 48.8%, risk ratio 0.53 [95% confidence interval (CI) 0.40-0.70], I2 = 39%, P < 0.00001}, owing to diminished neointimal proliferation [standardized mean differences -1.13 (95% CI -1.74 to -0.53), I2 = 91%, P = 0.0002]. Clinical studies similarly demonstrated reduced occlusion rates with dipyridamole therapy [23.5% vs. 31.0%, risk ratio 0.77 (95% CI 0.67-0.88), I2 = 84%, P < 0.0001]. Dipyridamole may improve post-intervention vascular patency and mitigate restenosis. Dedicated studies are warranted to delineate its role as an adjunctive agent after revascularization.

Background Endovascular therapy is a fundamental treatment for peripheral arterial disease. However, the success rate of endovascular therapy remains poor, as a third of patients with critical limb ischemia ultimately require a major amputation for gangrene despite endovascular treatment. This failure rate has prompted investigation into methods of determining physiologic procedural success before and after treatment, before clinically apparent outcomes occur such as gangrene. The aim of this systematic review is to evaluate if in patients undergoing endovascular surgery for lower extremity atherosclerotic peripheral arterial disease, do changes in physiologic measures of perfusion during surgery correlate with clinical outcomes. Methods We registered and designed a study protocol for a systematic review. Literature searches will be conducted in MEDLINE, EMBASE, and CENTRAL (from January 1977 onwards). Grey literature will be identified through OpenGrey and clinical trial registries, and supplemented by citation searches. We will include randomized controlled trials, quasi-experimental trials, and observational (cohort, case-control) studies conducted in human adults (age 18 or older) who received elective arterial angioplasty for atherosclerotic peripheral vascular disease. The primary outcome of interest will be major adverse limb events. Two investigators will independently screen all citation, full-text articles, and abstract data. The study quality (risk of bias) will be appraised appropriate tools. Data analysis and synthesis will be qualitative; no meta-analysis is planned, as the anticipated homogeneity of measurement and outcome reporting standardization is low. Discussion The treatment of peripheral arterial disease is unique in that the tissue of the ischemic leg is easily accessible for direct monitoring during procedures. This is contrasted with cardiac and neurologic monitoring during cardiac and cerebral procedures, where indirect or invasive measures are required to monitor organ perfusion. Currently synthesized evidence describing limb perfusion focuses on static states of ischemia, and does not evaluate the value of change in perfusion measurement as an indicator of endovascular treatment success. These methods could potentially be applied to optimize procedural outcomes by guiding perfusion-based decision-making during surgery. Systematic review registration PROSPERO CRD42019138192

We investigated the yield of ultrasound surveillance for small abdominal aortic aneurysms (AAAs) in patients older than 80 years compared with a younger population for detecting AAA growth reaching the threshold size for repair. Secondary objectives included analysis of the incidence of AAA repair and the cost-benefit of surveillance.A retrospective cohort study was performed of all patients undergoing AAA surveillance in Ottawa between 2007 and 2015. Patients were dichotomized by enrollment age (80 years vs ≥80 years) and stratified by enrollment AAA size. Cohorts were cross-referenced with the Ottawa surgical database, leveraging the common health region to ensure complete data capture. The threshold size for repair was sex specific (female, 5.0 cm; male, 5.5 cm). Factors influencing AAA growth rate were assessed with a general linear multiple mixed model. Analyses with Cox proportional hazards models with competing risk for mortality assessed aorta-related events, and cost-benefit was analyzed by referencing Ontario billing codes.A total of 1231 patients underwent serial ultrasound surveillance, of whom 500 were older than 80 years at some point during the study period. The mean AAA growth rate was 1.63 mm/y (95% confidence interval [CI], 1.54-1.71). Old age and small enrollment aneurysm size were significantly protective against AAA growth. Overall, 357 (29%) patients reached the AAA size threshold for repair, and 272 (22%) underwent AAA repair. Patients older than 80 years were less likely to reach the AAA threshold size for repair compared with their younger counterparts (adjusted hazard ratio, 0.77; 95% CI, 0.61-0.97). Of the 357 patients whose AAA reached the threshold size for repair, octogenarians were substantially less likely to undergo elective AAA repair (adjusted hazard ratio, 0.34; 95% CI, 0.24-0.47). Repair of ruptured AAA was rare (0.8%), and age differences were insignificant. For every octogenarian with an enrollment AAA size between 3.0 and 3.9 cm who ultimately received elective AAA repair, 51 patients were enrolled in surveillance without elective repair. This corresponded to an estimated $33,139 in ultrasound fees.Surveillance of most patients with small AAA is appropriate. However, patients older than 80 years were significantly less likely than their younger counterparts to experience aortic growth reaching the threshold size for repair. Furthermore, in the unlikely event of AAA growth, patients older than 80 years were substantially less likely to undergo repair. These results suggest that in the context of patient-specific health and wishes, surveillance of AAAs 4 cm in octogenarians is costly and unlikely to be beneficial.

Inpatient treatment of peripheral artery disease (PAD) is more than six times as costly as that of the general inpatient population. Our objective was to describe factors associated with hospital cost for patients admitted for PAD, the characteristics of high-cost patients, and their outcomes including amputations and death.We performed a retrospective cohort study of admitted patients receiving a procedure for PAD at The Ottawa Hospital between 2007 and 2016. Demographics, comorbidity, inpatient events, and hospital cost data during the index admission were collected. We defined high-cost patients as those whose total costs of index admission were in the tenth percentile and above. Features associated with high-cost status were examined using logistic regression with elastic net regularization. We used generalized linear models to examine overall drivers of cost.We identified 3084 eligible patients, incurring $72.2 million in hospital costs. The mean cost of the most expensive 10% of patients was $88,076 (standard deviation, $54,720), more than five times the mean cost of $16,217 (standard deviation, $10,322) for nonhigh-cost patients. High-cost patients were more likely to present urgently (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.16-2.25; P .01). After adjustment for preadmission factors, high-cost patients were more likely to have experienced an adverse patient safety incident (OR, 13.49; 95% CI, 6.97-24.8; P .01), amputation (OR, 2.79; 95% CI, 1.68-4.49; P .01), intensive care unit admission (OR, 6.42; 95% CI, 3.62-10.2; P .01), and disposition barriers requiring alternate level of care status (OR, 10.44; 95% CI, 6.42-15.2; P .01). The high-cost group was more likely to have received hybrid revascularization (OR, 7.07; 95% CI, 3.34-13.6; P .01). High-cost patients had higher than predicted in-hospital mortality (18% vs 9.2% predicted) compared with the low-cost group (3.0% vs 2.7%; P .001), and fewer than half of high-cost patients were discharged home.Providing hospital care for the top 10% most expensive patients in our cohort was more than five times as costly per patient than providing care for the nonhigh-cost patients. Whereas pre-existing factors may predispose a patient to require expensive care, there are potentially modifiable factors during the admission that could reduce costs of these patients.

Background Angioplasty is a fundamental treatment for atherosclerotic disease in the cardiac, cerebrovascular, and peripheral vascular beds. However, the optimal duration of balloon inflation has not been identified. Our study will investigate whether prolonged angioplasty balloon inflation of at least 1 min duration, when compared with brief inflation, affects residual stenosis after arterial angioplasty. Methods In compliance with PRISMA, two independent reviewers will conduct a systematic review of EMBASE, MEDLINE, CENTRAL, trial registries, grey literature, and ancestry and citation search. Data abstraction, quantitative, and quantitative meta-analysis will be performed according to pre-specified criteria. The primary outcome is residual stenosis immediately after initial angioplasty; however, secondary outcomes will include multiple short and long term pre-specific clinical and radiographic outcomes. Risk of bias, subgroup analyses, and sensitivity analyses are planned. Discussion Despite the ubiquitous use of angioplasty in atherosclerotic disease and multiple trials investigating the ideal balloon inflation duration, there are no systematic reviews evaluating prolonged angioplasty balloon inflation. Currently synthesized evidence is insufficient to confidently direct clinical decision-making, and the current variation in operator preference of balloon angioplasty duration suggests ongoing clinical equipoise. Given the known availability of current primary evidence, our study intends to synthesize the evidence and guide future clinical decision making and investigation. Systematic review registration PROSPERO CRD42018092702 Electronic supplementary material The online version of this article (10.1186/s13643-019-0955-2) contains supplementary material, which is available to authorized users.

Objective Infrarenal aortic neck angulation is one of the most powerful predictors of endovascular aneurysm repair failure. Whereas the “gold standard” to measure this angle is three-dimensional (3D) reconstruction and centerline measurement, many surgeons rely on estimations of angulation based on two-dimensional (2D) views of computed tomography imaging. Unfortunately, these views do not accurately represent the true angle, particularly if aortic angulation is oblique to the standard views. In response to this issue, our group has developed a novel trigonometric formula that uses coronal and sagittal measured angles to calculate the true angle. The purpose of this study was to compare the paired angle formula with 3D centerline measurements for estimating true aortic neck angulation. Methods Fifty randomly selected patients treated by endovascular aneurysm repair at The Ottawa Hospital between 2010 and 2015 were studied. The 3D centerline aortic neck angle measurements were made by a radiology staff physician. The paired angle formula was applied by a vascular surgeon, resident, and student using 2D coronal and sagittal angles from computed tomography imaging to estimate the true angle. Results The average age was 78 years; 74% of patients were male, and average preoperative aneurysm diameter was 5.7 cm. The mean neck length was 1.9 cm (1.1-3.2 cm), and mean neck angulation calculated by the gold standard measurements was 39 degrees (2-84 degrees). Linear regression demonstrated strong association between 3D measurements and the paired angle formula, with correlations comparable to the intraobserver variability (intraclass correlation coefficient values range, 0.74-0.87). The average user estimates deviated minimally from the gold standard (absolute difference, 6 degrees; 95% confidence interval, 4-8 degrees) without systemic bias. The paired angle formula accurately ruled out severe angulation >60 degrees with an overall negative predictive value of >99%. Compared with isolated 2D measurements, application of the paired angle formula significantly decreased the false-negative rate of unappreciated severe angulation >60 degrees from 4.8% to 0.7% (P = .032). Conclusions The paired angle formula detects significantly more severe angles than isolated 2D measurements and can accurately rule out severe angulation >60 degrees compared with the 3D measurements. The implementation of this angle estimation method is a useful adjunct in the measurement of aortic neck angulation, especially if 3D reconstruction software is not readily available. Furthermore, the importance of accurate angle measurement is not limited to vascular surgery and has direct relevance to any procedural specialty that relies on preoperative angle measurements.