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BACKGROUND Superior mesenteric venous thrombosis (SMVT) is a rare but fatal condition that is typically treated initially with anticoagulation therapy, and if this fails, with endovascular interventions. However, due to its rarity, there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT. AIM To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes. METHODS A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed. Technical success was defined as angiographic improvement in SMV flow after intervention. Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention. Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up. The adverse events were reported through Clavien-Dindo classification. RESULTS Twenty-four patients were included for analysis. The median age at intervention was 60 years (35-74 years) and 16 (67%) were men. Nineteen patients presented with acute thrombosis (79.2%) and 5 with chronic thrombosis with acute manifestations (20.8%). The most commonly used endovascular modalities were thrombectomy in 12 patients (50.0%) and catheter-directed thrombolysis in 10 patients (41.7%). Technical success was achieved in 18 patients (75%). The 14-d and 30-d primary patency rates were 88.9% and 83.3%, respectively. Adverse events were reported in two patients (8.3%), one marked as grade IIIB, and 1 death marked as grade V. Five-year overall survival rate was 82% (58%-100%). CONCLUSION Endovascular intervention with anticoagulation appears to be effective for managing SMVT. This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Background To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. Methods A review of our EVA database (1998–2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. Results 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46–018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69–0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. Conclusion Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

The adverse gender disparities for women after open abdominal aortic aneurysm (AAA) repair have been well documented. The purpose of this study is to review whether these disparities extend to elective endovascular aneurysm repair (EVAR).Nonruptured, elective AAA was identified from the American College of Surgeons' National Quality Improvement Program (NSQIP) Targeted Participant Use File for EVAR from 2012 to 2017. The primary outcome was mortality. Secondary outcomes included lower extremity ischemia requiring intervention (LEIRI) and prolonged operative time (120 min). Multivariable logistic regression models were used to assess the risk of mortality, LEIRI, and prolonged operative time among women compared with men.There were 14,019 EVAR procedures captured. A total of 3,367 were included for analysis after limiting to nonruptured, elective cases for diagnosis of AAA with a Current Procedural Terminology procedure code for EVAR. Of those, 2,764 (82.1%) were performed in men and 603 (17.9%) in women. Female patients were older (median [interquartile range (IQR)] 77 years [70-82] versus 74 years [68-80], P 0.001), more likely to smoke (35.5% versus 29.6%, P = 0.005), and less likely to have diabetes (12.4% versus 17.8%, P = 0.001). Women had slightly smaller AAA size (median [IQR] 5.4 cm [5.0-5.9] versus 5.5 cm [5.1-6.0], P 0.001) and were more likely to have prior abdominal operations (35.3% versus 23.1%, P 0.001). The operative time was longer among women (median 114 min. [85-150] versus 105 min. [82-140], P 0.001). Postoperatively, mortality was higher in female patients (1.8% versus 0.9%, P = 0.036), LEIRI occurred in higher proportion among female patients (2.7% versus 1.2%, P = 0.009), and their hospital stay was also longer (median 2 days [1-3] versus 1 day [1-2] days, P 0.001). On multivariable logistic regression analysis, hematocrit level30 vol% versus ≥30 vol% (odds ratio (OR) 5.5, 95% confidence interval (CI) 2.1-14.5, P 0.001) was associated with increased mortality. Although not statistically significant, there was also evidence that the odds of mortality were also greater among women (OR 2.0, 95% CI 0.98-4.2, P = 0.06). LEIRI was more likely among women (OR 2.1, 95% CI 1.2-3.9, P = 0.015) and patients with a smoking history (OR 1.8, 95% CI 1.0-3.2, P = 0.044). Finally, odds of prolonged operative time were higher among women (OR 1.4, 95% CI 1.2-1.7, P 0.001) and patients with chronic obstructive pulmonary disease (OR 1.2, 95% CI 1.0-1.5, P = 0.033) or partial/total dependent functional status (OR 2.2, 95% CI 1.3-3.7, P = 0.003).Although EVAR has improved overall surgical AAA outcomes, the NSQIP data in elective EVAR demonstrate continued sex disparities in morbidity and mortality after AAA surgical repair to the detriment of female patients.

Contained rupture of an aortic aneurysm is a high-mortality condition that requires immediate repair. Open repair has been the gold standard; however, endovascular and hybrid open-endovascular repair techniques have also emerged as less invasive solutions to this vascular emergency. Here. we present a patient with a giant 14.0 cm contained rupture of a Thoracic aortic aneurysm and 7.4 cm juxtarenal abdominal aortic aneurysm who was successfully treated with hybrid open-endovascular repair.

To review the sex differences among symptomatic and asymptomatic patients treated with carotid endarterectomy (CEA) and carotid artery stenting (CAS) in the Southeastern Vascular Study Group (SEVSG), a regional quality group of the Vascular Quality Initiative (VQI).All cases reported by the SEVSG members of symptomatic and asymptomatic patients were included in this retrospective review of CEA and CAS. Primary end point was 3-year survival difference between male and female patients. Secondary end points included in-hospital myocardial infarction (MI), transient ischemic attack (TIA)/stroke, and mortality differences between symptomatic and asymptomatic male and female patients. Cox proportional hazard regression was used to assess 3-year survival differences.There were 8,303 CEA and 1,876 CAS procedures performed in 29 centers from January 2011 to December 2018. From those, 4,650 (56.0%) and 938 (50.1%) were asymptomatic CEA and CAS, respectively. There were 2,760 (59.4%) male patients in the asymptomatic CEA and 597 (63.9%) in the asymptomatic CAS groups. After CEA, the rates of in-hospital MI (P = 0.034), TIA/stroke (P 0.001), and death (P 0.001) were significantly higher in symptomatic patients. MIs were more frequent in females with asymptomatic disease (P = 0.041). After CAS, the rate of TIA/stroke was higher in symptomatic patients (P = 0.030). There were no differences according to sex in the CAS group. On follow-up, asymptomatic male patients treated with CAS had a higher 3-year all-cause mortality compared with their female counterparts (7.0% vs. 1.8%; P = 0.015). On multivariable Cox regression analysis, male sex (HR = 2.63 [95% CI = 1.058-6.536]; P = 0.038) and lower hemoglobin levels (HR = 0.72 [95% CI = 0.597-0.857]; P 0.001) were predictors of death in asymptomatic male patients treated with CAS.In our SEVSG region, postoperative MIs, TIA/stroke, and deaths were higher in symptomatic CEA patients. MIs were more frequent in asymptomatic CEA females. Postoperative TIA/stroke was more frequent in symptomatic CAS patients. After CAS, asymptomatic male patients had higher 3-year all-cause mortality than female patients. On multivariable Cox regression analysis, male sex and lower hemoglobin levels were predictors of death in these asymptomatic male patients treated with CAS. Long-term mortality risk in asymptomatic males should be considered before offering CAS. Further national VQI analysis of our asymptomatic and symptomatic male and female patients treated with CEA and CAS would be warranted.

Prior studies suggest high prevalence of intracranial aneurysms (IA) in patients with infrarenal abdominal aortic aneurysms (AAA). We reviewed our multicenter experience in clinical detection/treatment of IAs in AAA patients and estimated the risk of IA in patients with AAA relative to patients without AAA. We reviewed cases of vascular surgery infrarenal AAA repairs at three Mayo Clinic sites from January 1998 to December 2018. Concurrent controls were randomly matched in a 1:1 ratio by age, sex, smoking history, and head imaging characteristics. Conditional logistic regression was used to calculate odds ratios. We reviewed 2,300 infrarenal AAA repairs. Mean size of AAA at repair was 56.9 ± 11.4 mm; mean age at repair, 75.8 ± 8.0 years. 87.5% of the cases (n = 2014) were men. Head imaging was available in 421 patients. Thirty-seven patients were found to have 45 IAs for a prevalence of 8.8%. Mean size of IA was 4.6 ± 3.5 mm; mean age at IA detection, 72.0 ± 10.8 years. Thirty (81%) out of 37 patients were men. Six patients underwent treatment for IA: four for ruptured IAs and two for unruptured IAs. All were diagnosed before AAA repair. Treatment included five clippings and one coil-assisted stenting. Time from IA diagnosis to AAA repair was 16.4 ± 11.0 years. Two of these patients presented with ruptured AAA, one with successful repair and a second one that resulted in death. Odds of IA were higher for patients with AAA versus those without AAA (8.8% [37/421] vs. 3.1% [13/421]; OR 3.18; 95% confidence interval, 1.62–6.27, p

This case describes a 72-year-old woman with a history of chronic kidney disease stage III presented with bilateral renal artery stenosis with a progressively atrophied right kidney. At the time of surgery, the atrophied kidney was nonfunctional. Therefore, the patient underwent unilateral renal artery revascularization via the inferior mesenteric artery as an inflow. A 7-year follow-up revealed improvement in the kidney function and stabilization of blood pressure, which was controlled with less number of antihypertensive medications. In brief, open surgical correction of the renal artery stenosis using the inferior mesenteric artery as an inflow source can retrieve renal function in selected hypertensive patients with ischemic nephropathy.

Background Multiple studies have demonstrated the benefits of creating arteriovenous fistulas (AVFs) under regional anesthesia. This is most likely because of the avoidance of hemodynamic instability and stress response of general anesthesia, as well as the sympathectomy associated with brachial plexus blockade. As vein diameter is the major limiting factor for primary AVF creation and maturation, our aim is to investigate if the vasodilation that accompanies regional anesthesia leads to improved patency and maturation rate of autologous AVF and improved patency of arteriovenous graft (AVG) compared with those placed under general anesthesia. Methods This retrospective study was approved by the institutional review board. A total of 238 patients who had either an AVF or an AVG placed at the Mayo Clinic, Florida, between 2012 and 2017 were analyzed. Demographics, access type, preoperative vein diameter, anesthesia type, change of plan after regional versus general anesthesia, and outcomes were assessed. All statistical tests were 2 sided, with the alpha level set at 0.05 for statistical significance. Results Among 238 patients, 120 (50.4%) had regional anesthesia. Differences between the 2 groups in risk factors and 30-day or long-term outcomes (failure, abandonment, or reoperation) were not statistically significant. Of the accesses placed under general anesthesia, 58.5% were abandoned compared with 45.2% of those placed under regional anesthesia. Owing to loss of patency, 25.8% of accesses placed under general anesthesia were abandoned compared with 19.2% of those placed under regional anesthesia. Two-month failure was higher in the general anesthesia group than that in the regional anesthesia group (P = 0.076). After preoperative vein mapping, 22 patients were originally intended to have an AVG placed under regional anesthesia. After brachial plexus blockade, 9 of these patients (41%) were successfully switched to AVF, while the other 13 followed the original surgical plan and received an AVG. Of these, 0 failed and 0 were abandoned because of loss of patency. Conclusions This study showed possible improvements in failure rates for vascular accesses placed under regional anesthesia compared with those placed under general anesthesia. In addition, we showed an impact of regional anesthesia on the surgical plan by transitioning from a planned AVG to an AVF, intraoperatively. Giving patients with originally inadequate vein diameter the chance to have the preferred hemodialysis access method by simply switching anesthesia type could reduce the number of grafts placed in favor of fistulas.

A relationship between intracranial and abdominal aortic aneurysms (AAA) has been appreciated through genome-wide association studies suggesting a shared pathophysiology. However, the actual prevalence of AAA in patients presenting with ruptured intracranial aneurysms is not known. Our aim was to estimate the prevalence of previously undiagnosed AAA in patients presenting with aneurysmal subarachnoid hemorrhage (aSAH) to see if it may be high enough to justify formally testing the utility of screening. A prospective, observational inception cohort study of 81 consecutive patients presenting to Mayo Clinic Florida with aSAH was performed from August 14, 2011 to February 10, 2014. These individuals were then screened using an abdominal ultrasound technique for an AAA. Our primary end point was detection of AAA. Our secondary end points were 30-day good-to-fair functional status (modified Rankin scale

Little is known about the surgical challenges and outcomes of kidney transplantation (KT) in the face of severe iliac occlusive disease (IOD). We aim to examine our institution's experience and outcomes compared with all KT patients. Retrospective review of our multi-institutional transplant database identified patients with IOD requiring vascular surgery involvement for iliac artery endarterectomy at time of KT from 2000 to 2018. Clinical data, imaging studies, and surgical outcomes of 22 consecutive patients were reviewed. Our primary end-point was allograft survival. Secondary end-points included mortality and perioperative complications. A total of 6,757 KT were performed at our three sites (Florida, Arizona, and Minnesota); there were 22 (0.32%) patients receiving a KT with concomitant IOD requiring iliac artery endarterectomy. Mean patient age was 61.45 ± 7 years. There were 13 (59.1%) male patients. The most common etiology of renal failure was diabetic nephropathy in 10 patients (45.5%) followed by a combination of hypertensive/diabetic nephropathy in five patients (22.7%), and hypertensive nephrosclerosis in three patients (13.6%). The majority (n = 16, 72.7%) of patients received renal allografts from deceased donors and six (27.3%) were recipients from living donors. Mean time from dialysis to transplantation was 2.9 ± 2.9 years. Mean follow-up was 3.5 ± 2.5 years. Mean length of hospital stay was 6.3 ± 4.3 days (range: 3–18 days). Graft loss within 90 days occurred in two (9.1%) patients, one due to renal vein thrombosis and another due to acute tubular necrosis. Overall allograft survival was 90.1% at 1-year and 86.4% at 3-year follow-up. Overall mortality occurred in 6 (27.3%) patients. Perioperative complications (Clavien-Dindo Grade 2–4) occurred in 13 (59.1%) patients, including 10 (45.5%) with acute blood loss anemia requiring transfusion, 2 (9.1%) reoperations for hematoma evacuation, 1 (4.5%) ischemic colitis requiring total abdominal colectomy, and 1 (4.5%) renal vein thrombosis requiring nephrectomy. IOD patients selected for KT are not common and although challenging, they have similar outcomes to our standard KT patients. The 1- and 3-year allograft survivals were 90.1 and 86.4% versus 96.0 and 90.3% in the general KT patient population. With these excellent outcomes, we recommend expanding the criteria for KT to include patients with IOD with prior vascular surgery consultation to prevent progression of IOD or prevention of wait list removal in select patients who are otherwise good candidates for KT.

OBJECTIVE: We assessed the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hospitalized patients with coronavirus disease 2019 (COVID-19) compared with that in a matched cohort with similar cardiovascular risk factors and the effects of DVT and PE on the hospital course. METHODS: We performed a retrospective review of prospectively collected data from COVID-19 patients who had been hospitalized from March 11, 2020 to September 4, 2020. The patients were randomly matched in a 1:1 ratio by age, sex, hospital of admission, smoking history, diabetes mellitus, and coronary artery disease with a cohort of patients without COVID-19. The primary endpoint was the incidence of DVT/PE and the odds of developing DVT/PE using a conditional logistic regression model. The secondary endpoint was the hospitalization outcomes for COVID-19 patients with and without DVT/PE, including mortality, intensive care unit (ICU) admission, ICU stay, and length of hospitalization (LOH). Multivariable regression analysis was performed to identify the variables associated with mortality, ICU admission, discharge disposition, ICU duration, and LOH. RESULTS: A total of 13,310 patients had tested positive for COVID-19, 915 of whom (6.9%) had been hospitalized across our multisite health care system. The mean age of the hospitalized patients was 60.8 ± 17.0 years, and 396 (43.3%) were women. Of the 915 patients, 82 (9.0%) had had a diagnosis of DVT/PE confirmed by ultrasound examination of the extremities and/or computed tomography angiography of the chest. The odds of presenting with DVT/PE in the setting of COVID-19 infection was greater than that without COVID-19 infection (0.6% [5 of 915] vs 9.0% [82 of 915]; odds ratio [OR], 18; 95% confidence interval [CI], 8.0-51.2; P < .001). The vascular risk factors were not different between the COVID-19 patients with and without DVT/PE. Mortality (P = .02), the need for ICU stay (P < .001), duration of ICU stay (P < .001), and LOH (P < .001) were greater in the DVT/PE cohort than in the cohort without DVT/PE. On multivariable logistic regression analysis, the hemoglobin (OR, 0.71; 95% CI, 0.46-0.95; P = .04) and D-dimer (OR, 1.0; 95% CI, 0.33-1.56; P = .03) levels were associated with higher mortality. Higher activated partial thromboplastin times (OR, 1.1; 95% CI, 1.00-1.12; P = .03) and higher interleukin-6 (IL-6) levels (OR, 1.0; 95% CI, 1.01-1.07; P = .05) were associated with a greater risk of ICU admission. IL-6 (OR, 1.0; 95% CI, 1.00-1.02; P = .05) was associated with a greater risk of rehabilitation placement after discharge. On multivariable gamma regression analysis, hemoglobin (coefficient, -3.0; 95% CI, 0.03-0.08; P = .005) was associated with a prolonged ICU stay, and the activated partial thromboplastin time (coefficient, 2.0; 95% CI, 0.003-0.006; P = .05), international normalized ratio (coefficient, -3.2; 95% CI, 0.06-0.19; P = .002) and IL-6 (coefficient, 2.4; 95% CI, 0.0011-0.0027; P = .02) were associated with a prolonged LOH. CONCLUSIONS: A significantly greater incidence of DVT/PE occurred in hospitalized COVID-19-positive patients compared with a non-COVID-19 cohort matched for cardiovascular risk factors. Patients affected by DVT/PE were more likely to experience greater mortality, to require ICU admission, and experience prolonged ICU stays and LOH compared with COVID-19-positive patients without DVT/PE. Advancements in DVT/PE prevention are needed for patients hospitalized for COVID-19 infection.

Objectives Stress and strain measurements have been used in clinical settings to predict and describe functions of the human body. However, the role of this modality in the analysis of the vascular system, for both pathologies and physiology, has not been heavily studied. Yet, stress and strain measurements may potentially be a more sensitive modality to evaluate the vascular system. In this abstract, we highlight the concept of utilizing wall biomechanical for enhanced characterization of targeted vascular physiology and pathology. Methods This abstract highlights three studies approved by the Institutional Review Board. Various components of the vascular system were analyzed. These included pathological (aneurysmal aorta vs non-aneurysmal aorta), reaction of normal physiology (carotid artery strain pre-and post-exercise) and change in physiology to stress (concomitant carotid and left ventricular strain pre- and post-major surgical intervention). Longitudinal and circumferential strain on the vessel wall was obtained by using two-dimension (2D) speckle tracking ultrasonography. All analysis was electrocardiogram (ECG)-gated as well. Strain patterns for each region of the targeted components of the vascular system were analyzed. Results For normal responses to the physiology of the carotid following exercise, there was a marked increase in the percent change of strain in response to small change in the conventional hemodynamic measurements. Consistency strain curves obtained at baseline compared to variable dispersion of strain curves obtained immediately following exercise was noted and had higher sensitivity in detecting changes to physiology compared to conventional methods ( Figure 1 Download : Download high-res image (306KB) Download : Download full-size image Figure 1 . Biomechanical analysis of the carotid artery before exercise (A, C) and after exercise(B, D). , Table 1 Table 1 . Volunteer demographics, conventional hemodynamic and strain measurements. ). Additionally, there were consistent strain patterns noted of the carotid and left ventricle at the various time points pre- and post- stress following major surgery ( Figure 2 Download : Download high-res image (388KB) Download : Download full-size image Figure 2 . Biomechanical analysis of the left ventricle pre-operatively (A), immediate post- operatively (B), immediately after extubation (C), and at least 6 hours post-extubation (D). ). Similarly, consistent strain patterns were noted in aneurysmal aorta segments compared to non- aneurysmal segments ( Figure 3 Download : Download high-res image (391KB) Download : Download full-size image Figure 3 . Biomechanical analysis of aneurysmal (A) vs non-aneurysmal (B) aorta with circumferential strain curve patterns. ). Table 1 . Table 1 Volunteer demographics, conventional hemodynamic and strain measurements. Conclusion The concept of utilizing 2D speckle tracking ultrasonography to characterize the wall biomechanics within vascular system (aorta, carotid artery, and left ventricle) may be a feasible new modality for evaluating pathology, normal physiology, and the impact of surgical stress on the vascular system. Consistent patterns of stress and strain curves, which were more sensitive in change following pathological/physiological stress compared to conventional measures, were noted in each setting. Future research evaluating the specific strain patterns and their clinical implications is warranted.

Acute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4–3.2], p = 0.0005) and moderate (HR: 1.5 [1.03–2.13], p = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2–1.9], p = 0.0007), and longer index hospitalization (HR: 1.02 [1.01–1.02], p

The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39–0.87]; p = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p

Background This study aimed to review short- and long-term outcomes of all carotid artery stenting (CAS) in patients with radiation-induced (RI) internal carotid artery (ICA) stenosis compared with patients with atherosclerotic stenosis (AS). Methods We performed a single-center, multisite case–control study of transfemoral carotid artery intervention in patients stented for RI or AS. Cases of stented RI carotid arteries were identified using a CAS database covering January 2000 to December 2019. These patients were randomly matched 2:1 with stented patients because of AS by age, sex, and year of CAS. A conditional logistic regression model was performed to estimate the odds of reintervention in the RI group. Finally, a systematic review was performed to assess the outcomes of RI stenosis treated with CAS. Results There were 120 CAS in 113 patients because of RI ICA stenosis. Eighty-nine patients (78.8%) were male, and 68 patients (60.2%) were symptomatic. The reasons for radiation included most commonly treatment for diverse malignancies of the head and neck in 109 patients (96.5%). The mean radiation dose was 58.9 ± 15.6 Gy, and the time from radiation to CAS was 175.3 ± 140.4 months. Symptoms included 31 transient ischemic attacks (TIAs), 21 strokes (7 acute and 14 subacute), and 17 amaurosis fugax. The mean National Institutes of Health Stroke Scale in acute strokes was 8.7 ± 11.2. In asymptomatic patients, the indication for CAS was high-grade stenosis determined by duplex ultrasound. All CAS were successfully completed. Reinterventions were more frequent in the RI ICA stenosis cohort compared with the AS cohort (10.1% vs. 1.4%). Reinterventions occurred in 14 vessels, and causes for reintervention were restenosis in 12 followed by TIA/stroke in two vessels. On conditional regression modeling, patients with RI ICA stenosis were at a higher risk for reintervention (odds ratio = 7.1, 95% confidence interval = 2.1–32.8; P = 0.004). The mean follow-up was 33.7 ± 36.9 months, and the mortality across groups was no different (P = 0.12). Conclusions In our single-center, multisite cohort study, patients who underwent CAS for RI ICA stenosis experienced a higher rate of restenosis and a higher number of reinterventions compared with CAS for AS. Although CAS is safe and effective for this RI ICA stenosis cohort, further data are needed to reduce the risk of restenosis, and close patient surveillance is warranted. In our systematic review, CAS was considered an excellent alternative option for the treatment of patients with RI ICA stenosis. However, careful patient selection is warranted because of the increased risk of restenosis on long-term follow-up.

Objective Sex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes. Methods All elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications. Results There were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P Conclusions Our three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.

BACKGROUND: Major vascular reconstruction during a pancreaticoduodenectomy (PD), also known as a Whipple procedure, leads to controversial postoperative outcomes compared to conventional Whipple. Discussion with the patient regarding postoperative expectations is a crucial component of holistic surgical healthcare. The aim of this study was to report our 8-year experience of Whipple procedures involving vascular reconstruction and to review relevant literature to further evaluate expectant outcomes, therefore leading to more accurate discussion. METHODS: A retrospective review of patients undergoing Whipple procedures from January 2010, through December 2017 was performed. Patch, graft, and primary anastomosis during Whipple procedures were considered major vascular reconstruction. Literature on the current understanding of the outcomes associated with vascular reconstruction during Whipple procedures was reviewed. RESULTS: Twenty-nine from a total of 405 patients that met inclusion criteria had a Whipple procedure that involved major vascular reconstruction. Twelve patients were male and 17 were female (mean age, 65.2 years). Median hospital and intensive care unit (ICU) stay [range] of patients with vascular reconstruction was 12 [5–92] days and 3 [0–59] days, respectively. Thirty-day survival and 1-year survival of patients with vascular reconstruction was 93.1% and 55.2%, respectively, compared to non-vascular reconstruction patients 96.0% and 83.5%, respectively (P=0.35, P

Aneurysms of the internal mammary artery are extremely rare. Immediate treatment is necessary because of the high risk of rupture that can be life-threatening. Here we describe a case of idiopathic internal mammary artery aneurysm in a 54-year-old woman in the setting of aberrant right subclavian artery. The aneurysm was successfully treated with coil embolization without complications.

Overprescription of postoperative opioid medication is a major contributor to the opioid abuse epidemic in the United States. Research into prescribing practices has suggested that patients be limited to 7 days or 200 morphine milligram equivalents (MME) after surgical procedures. Our aim was to identify patient or institutional factors associated with increased opioid prescriptions.Opioid naive patients from an integrated health system undergoing one of nine surgical and endovascular procedures tracked within the Vascular Quality Initiative from 2015 to 2017 were identified and matched to their discharge and refill opioid prescriptions. Discharge opioid prescriptions were converted to MME. The primary outcome was discharge MME200, and secondary outcomes were procedure-specific top-quartile opioid prescription and medication refills. Multivariable logistic regression was used to assess patient and perioperative factors associated with each outcome.Among 1546 opioid naive patients, 739 (48%) received a discharge opioid prescription; median MME was 0 (interquartile range, 0-150), and 349 (23%) had200 MME. Among those with a discharge prescription, median MME was 180 (interquartile range, 150-300). MME varied by procedure (P .001), with highest MME after suprainguinal bypass (median, 225) and infrainguinal bypass (200) and lowest MME after carotid artery stenting, carotid endarterectomy, and percutaneous peripheral vascular intervention (all medians of 0). On multivariable analysis, factors associated with MME200 included younger patient age (65 vs ≥ 80 years; odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.6; P .001), treating institution B vs A (OR, 3.50; 95% CI, 2.42-5.07; P .001) and C vs A (OR, 3.90; 95% CI, 2.66-5.74; P .001), procedure-specific top-quartile length of stay (OR, 1.45; 95% CI, 1.01-2.08; P = .047), and prior tobacco use (OR, 1.60; 95% CI, 1.07-2.37; P = .02). The same variables along with current tobacco use and lack of preoperative aspirin were associated with procedure-specific top-quartile MME at discharge. Chronic beta-blocker use was protective of top-quartile MME. Based on the observed variability, an institutional standard for opioid prescribing has been developed for standardization.Opioid prescriptions at discharge vary with the invasiveness of vascular surgical procedures. Less than 25% of patients receive200 MME. Variation by center represents a lack of standardization in prescribing practices and an opportunity for further improvement based on developed guidelines. Patient factors and procedure type can alert clinicians to patients at risk of higher than recommended MME.

Hybrid repair involves both open and endovascular interventions. This technique has been increasingly used in treating complex aortic aneurysms as an alternative to conventional open repairs, mainly because of the avoidance of aortic cross-clamping and the associated increased ischemia time to the viscera. We report a hybrid repair of a juxtarenal abdominal aortic aneurysm complicated by a nonstandard right renal artery originating just proximal to the aortic bifurcation in the setting of a nonfunctional left kidney.

Introduction: To report a successful unilateral renal revascularization via an inferior mesenteric artery to left renal artery bypass with return of renal function to baseline postoperatively. Methods: A 73-year-old female presented with rapidly deteriorating renal function and uncontrolled hypertension secondary to ischemic nephropathy due to chronic renovascular occlusive disease. The patient had failed prior Percutaneous Transluminal Angioplasty (PTA) attempts. Preoperative evaluation showed the right kidney to be atrophied and normal size left kidney. Intraoperative exploration revealed porcelain abdominal aorta and both common and external iliac arteries were heavily calcified and were not suitable for appropriate clamping or to be used as an inflow for renal revascularization. Although the patient was asymptomatic, both celiac artery and Superior Mesenteric Artery (SMA) were nearly occluded and severely stenosed, respectively, at their origins. Therefore, the splenic artery and SMA were not used for reconstruction. Further exploration revealed a minimally diseased and widely patent Inferior Mesenteric Artery (IMA). A unilateral renal revascularization was performed via an IMA to left renal artery bypass using PTFE graft via a midline laparotomy. Results: The patient was discharged on postoperative day 8 in good condition. Glomerular Filtration Rate (GFR) and blood pressure returned to baseline within 6 weeks postoperatively. CT angiogram undertaken 24 months postoperatively revealed a patent renal bypass. The patient maintained normal renal function and adequately controlled blood pressure 24 months postoperatively. Conclusion: Open surgical correction of atherosclerotic renovascular disease can retrieve renal function in selected hypertensive patients with ischemic nephropathy. In the absence of other suitable inflow sources, the inferior mesenteric artery can be used as an alternative with acceptable outcomes.

Although endoleaks have been well described after endovascular abdominal aortic aneurysm (AAA) repair, their occurrence after open repair is much less common. This case report describes a patient who had a leak at the proximal anastomotic site of the graft after open AAA repair. The patient was a 78 year old male patient who presented to our facility with bright red blood from the rectum at approximately 3 months after an open AAA repair at an outside facility. On computed tomographic angiography, a leak was detected at the proximal anastomotic site and resembled a type I endoleak that may occur after endovascular repair. The patient was treated through endovascular technique with the placement of two proximal extension cuffs. The endoleak was not observed on follow-up imaging, and the patient has been asymptomatic since treatment. Endoleaks after open AAA repair are rare, but they can be treated through an endovascular approach, with proximal extension cuff placement to seal the leak.

Aortic disease becomes more prevalent with age and can result in acute aortic conditions including aneurysm, dissection, intramural hematoma and penetrating ulcers. Repair techniques for these conditions remain controversial due to the varying outcomes of studies. This retrospective study collected and analyzed data from twenty-three (23) patients with complex aortic aneurysms repaired using hybrid open-endovascular techniques. A high percentage of patients (82.6%) suffered from multiple comorbidities, including hypertension, hyperlipidemia, renal disease, coronary artery disease, congestive heart failure and prior aortic procedures. All patients presented with ASA scores 3 or 4. Eleven patients (47.8%) presented with aneurysms of the ascending, transverse and descending arch, and seven patients (30.4%) with thoracoabdominal aneurysm. 78.3% of patients underwent thoracic vessel debranching, while the remainder underwent visceral vessel debranching (13.0%) or thoracic and visceral debranching (8.7%). No patients suffered visceral ischemia, spinal cord injury, extremity amputation or reoperation for bleeding post-operatively. Two patients suffered minor stroke (8.7%) and one patient (4.3%) had major stroke. Three patients (13.0%) suffered temporary kidney injury and one patient (4.3%) developed renal failure requiring dialysis. Four patients (17.4%) developed Type II stent graft endoleaks. All patients had patent grafts. Reintervention occurred in two patients (8.7%). Thirty-day mortality occurred in three patients (13.0%). These results are within the range reported in other studies involving hybrid repair of aortic conditions, and show that hybrid open-endovascular repair is a feasible alternative in high-risk patients.

Background Multiple studies have shown that patch angioplasty after carotid endarterectomy (CEA) reduces the risk of stroke and restenosis when compared with primary closure. Biological, synthetic, or vein patches have been traditionally used in CEA. This article reports the early and long-term outcomes of bovine pericardium (BP) for patch angioplasty in CEA. Methods A retrospective, consecutive analysis of 874 patients who underwent CEA during the past 17 years at Mayo Clinic, Florida, was performed. BP patch (BPP) was used in 680 patients. Other CEA techniques were used in 194 patients (standard without patch, 78; standard with Dacron, 74; standard with vein patch, 16; and other techniques: bypasses, 26). We defined group 1 as those who underwent BPP angioplasty and group 2 as those who underwent all other techniques. Early and late clinical outcomes and patch-related complications (restenosis, infection, and hematoma) were recorded and analyzed. Results Median follow-up for the entire series was 39.6 months. There were no statistically significant differences in 30-day mortality and morbidity between the 2 groups, except that BP group has less 30-day stroke (0.1%, 1 of 680) versus other techniques (1.5%, 3 of 194, P = 0.03). Thirty-day postoperative mortality rate was 0.1% (1 of 680) in BPP group and 1.0% (2 of 194) in other technique group (P = 0.13). No statistically significant difference was noted in 30-day postoperative major complications (transient ischemic attack [TIA], wound infection, hematoma requiring surgical evacuation, and nerve injury) between the 2 groups. Ten-year freedom from stroke/TIA were 97.8% in the BP group compared with 98.5% in the other group (P = 0.86). Ten-year freedom from restenosis was also similar between groups (89.0% BP vs. 90.4% others, P = 0.69). Ten-year survival rate was 38.4% in BP group and 45.0% in other technique group, and this was statistically significant on univariate analysis only. Conclusions CEA with BP angioplasty has excellent early and late outcomes with minor morbidity and mortality.

This study examines whether surgical resection of carotid body tumors (CBTs) is acceptable in light of potential significant neurologic complications. This IRB-approved retrospective study analyzed data from 24 patients undergoing surgical treatment for CBTs between April 1998 and April 2017 at Mayo Clinic (Florida campus only). For patients who underwent multiple CBT resections, only data from the first surgery was used in this analysis. CBT resection occurred in 24 patients with the following demographics: fourteen patients (58.3%) were female, median age was 56.5 years, median BMI was 29. A prior history of neoplasm was found in ten patients (41.7%). A known family history of paraganglioma was present in five patients (20.8%). Two patients were positive for succinate dehydrogenase mutation (8.3%). Multiple paragangliomas were present in seven patients (29.2%). There was nerve sacrifice in three patients (12.5%) during resection. Carotid artery reconstruction and patch angioplasty occurred in one patient (4.2%). Complete resection occurred in 24 patients (100.0%). Postoperatively, one patient (4.2%) suffered stroke. No mortalities occurred within or beyond 30 days of surgery. Persistent cranial nerve injury occurred in two patients (8.3%) with vocal cord paralysis. There was no recurrence of CBT through last follow-up. Five patients (20.8%) were diagnosed with other neoplasms after resection, including basal cell carcinoma, contralateral carotid body tumor, glomus vagale, and glomus jugulare. There was 100% survival at 1 year in patients followed for that time ( n = 17). Surgical treatment remains the first-line curative treatment to relieve symptoms and ensure non-recurrence. While acceptable, neurologic complications are significant and therefore detailed preoperative informed consent is mandatory.

Purpose: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. Case report: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. Conclusion: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.