Search

Background: This study's objective is to describe outcomes of adult patients who underwent thoracic stent graft placement treatment for primary or recurrent aortic coarctation., Methods: This is a retrospective study of 30 adult patients who underwent thoracic stent graft placement for aortic coarctation at our institution. Average age was 46.5 years, with 53.3% of patients presented with no prior treatment or repair for coarctation. Indications for repair included gradient ≥20 mm Hg with anatomic evidence of coarctation on imaging with left ventricular hypertrophy, pseudoaneurysm, aneurysm, refractory hypertension, or claudication. Stent grafts used for repair included MDT (Medtronic, Santa Rosa, CA) and GORE TAG (W. L. Gore & Associates, Flagstaff, AZ)., Results: Patients were observed for a median of 979 days, with one death during the study. All patients had complete resolution of symptoms with no recurrences. Thoracic endovascular aortic repair significantly reduced the gradient across the coarctation (P < 0.0001). Aortic coarctation diameter significantly increased at 30 days postoperatively and continued to increase up to 5 years posttreatment. At 3+ years, aortic remodeling was observed at the coarctation site and surrounding regions. At 30 days, systolic, diastolic, and mean arterial pressure were all reduced. Systolic and diastolic blood pressure and mean arterial pressure continued to significantly improve 1-year posttreatment., Conclusions: Stent grafts are a safe and effective treatment for aortic coarctation. We observed a clinically significant improvement in blood pressure and longitudinal aortic remodeling of the coarctation segment and the entire aorta that persisted more than more than 3 years., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Competing Interests: None.

Background: To evaluate differences in presentation and outcomes between sexes in patients who underwent thoracic endovascular aortic repair for type B aortic dissection (TBAD)., Methods: Between January 1, 2012 and January 1, 2017 186 patients underwent thoracic endovascular aortic repair for TBAD at a single institution. Men (n = 112) and women (n = 74) were compared based on presenting demographics, comorbidities, and postoperative complications. Primary outcomes were survival and need for reintervention., Results: Women were older (P = 0.04) and had a lower body mass index (P = 0.03). More women (F) presented with continued pain or refractory hypertension (51.0% F, 30.0% M), while more men (M) presented with acute complicated dissections (19.0% F, 39.0% M) (P = 0.008). At presentation, women had statistically higher relative rates of chronic obstructive pulmonary disease (P = 0.05), hyperlipidemia (P = 0.03), and smoking (P = 0.03). Significantly more women were on Medicare without Medicaid (55.0% F, 34.0% M), while men had private insurance (35.0% F, 13.0% M) (P = 0.005). There was no significant difference in blood pressure control at presentation, discharge, or at 30 days. When normalized by body surface area, women had larger ascending aortic diameters (19.2(3.10)F, 17.5(2.40)M, P = 0.0002), as well as proportionally larger true lumens at the left subclavian artery (14.9(2.90)F, 13.4(2.50)M, P = 0.0002), carina (12.6(5.80)F, 9.90(4.80)M, P = 0.0009), and celiac (10.5(4.50)F, 8.50(4.10)M, P = 0.006) levels, and at the largest point of dissection (11.6(6.50)F, 9.60(4.80)M, P = 0.04), as well as proportionately smaller false lumens at the carina (5.90(5.60)F, 9.30(6.10)M, P = 0.003). Despite not being statistically significant, women had lower rates of stroke (6.80% F, 8.00% M, P = 0.7) and acute kidney injury (5.40% F, 11.6% M, P = 0.2), as well fewer days in the intensive care unit (ICU) (3.20(4.30)F, 4.60(6.60)M, P = 0.2) and an overall shorter length of stay (6.80(6.70)F, 8.00(8.20)M, P = 0.5). Kaplan-Meier estimates for survival for women versus men were 96.0% vs. 92.0%, 90.0% vs. 79.0%, and 70.0% vs. 69.0% at 30 days, 1 year, and 3 years, respectively (P = 0.042). Kaplan-Meier estimates for freedom from reintervention for women versus men were 89.0% vs. 90.0%, 58.0% vs. 72.0%, and 48.0% vs. 58.0% at 30 days, 1 year, and 3 years, respectively (P = 0.13)., Conclusions: Women present with TBAD at an older age, have more comorbidities, lower socioeconomic status, and have larger ascending aortic diameters for their size. Despite having less severe dissections as evidenced by smaller false lumens and wider true lumens, it does not appear that this correlates with improved outcomes for women when compared to men. It appears that this is one of the few, if not only, aortic pathologies that result in comparable outcomes between sexes., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Hostile aortic neck anatomies such as proximal short necks are known to put patients at an increased risk for type IA endoleaks, migration, and need for reinterventions. The Heli-FX EndoAnchor System was designed to improve seal of aortic stent grafts. Endosuture aneurysm repair (ESAR) using EndoAnchors with the Endurant stent graft has been shown to be safe and effective for the treatment of patients with short necks through one year. This study reports the 5-year patient outcomes of the Aneurysm Treatment using the Heli-FX EndoAnchor System Global Registry (ANCHOR) short neck regulatory cohort., Methods: The 70 patients from the ANCHOR Registry were cohort submitted to regulators for approval of the Endurant short neck indication. Patients had an infrarenal neck length of ≥ 4 mm and <10 mm. At 5 years, this short neck cohort had clinical and imaging follow-up compliance rates of 85% (28/33) and 70% (23/33), respectively., Results: The short neck cohort had a mean age of 71.3±8.1 years and was 27.1% (19/70) female. Kaplan Meier freedom from all-cause mortality was 68.5 ± 6.2%, freedom from aneurysm-related mortality was 90.1 ± 4.5%, freedom from any endovascular or surgical secondary procedure was 76.9 ± 7.2%, and freedom from rupture was 95.6 ± 3.2%. Eight patients had a total of nine type IA endoleaks detected through 5 years, of which three resolved spontaneously by the next follow-up visit. There were two patients with renal complications who did not undergo reintervention and there were no device migrations reported through 5 years. After 5 years, 68.2% of patients (15/22) had sac regression, 13.6% (3/22) had stable sacs, and 18.2% (4/22) had increased sac diameter as compared with their 1-month measurements., Conclusions: After ESAR treatment using Heli-FX EndoAnchors with Endurant, the 5-year outcomes of the short neck cohort from the ANCHOR registry had encouraging results with regards to proximal neck-related complications, secondary procedures, and sac regression. This review of ESAR in patients with short proximal necks showed positive outcomes through 5 years although follow-up of a larger cohort is necessary., (Copyright © 2023. Published by Elsevier Inc.)

Objective: Patients with peripheral arterial disease (PAD) have a significant risk of myocardial infarction and death secondary to concomitant coronary artery disease (CAD). This is particularly true in patients with critical limb-threatening ischemia (CLTI) who exceed a 20% mortality rate at 6 months despite standard treatment with risk factor modification. Although systematic preoperative coronary testing is not recommended for patients with PAD without cardiac symptoms, the clinical manifestations of CAD are often muted in patients with CLTI due to poor mobility and activity intolerance. Thus, the true incidence and impact of "silent" CAD in a CLTI cohort is unknown. This study aims to determine the prevalence of ischemia-producing coronary artery stenosis in a CLTI cohort using coronary computed tomography angiography (cCTA) and computed tomography (CT)-derived fractional flow reserve (FFR CT ), a noninvasive imaging modality that has shown significant correlation to cardiac catheterization in the detection of clinically relevant coronary ischemia., Methods: Patients presenting with newly diagnosed CLTI at our institution from May 2020 to April 2021 were screened for underlying CAD. Included subjects had no known history of CAD, no cardiac symptoms, and no anginal equivalent complaints at presentation. Patients underwent cCTA and FFR CT evaluation and were classified by the anatomic location and severity of CAD. Significant coronary ischemia was defined as FFR CT ≤0.80 distal to a >30% coronary stenosis, and severe coronary ischemia was documented at FFR CT ≤0.75, consistent with established guidelines., Results: A total of 170 patients with CLTI were screened; 65 patients (38.2%) had no coronary symptoms and met all inclusion/exclusion criteria. Twenty-four patients (31.2%) completed cCTA and FFR CT evaluation. Forty-one patients have yet to complete testing secondary to socioeconomic factors (insurance denial, transportation inaccessibility, testing availability, etc). The mean age of included subjects was 65.4 ± 7.0 years, and 15 (62.5%) were male. Patients presented with ischemic rest pain (n = 7; 29.1%), minor tissue loss (n = 14; 58.3%) or major tissue loss (n = 3; 12.5%). Significant (≥50%) coronary artery stenosis was noted on cCTA in 19 of 24 patients (79%). Significant left main coronary artery stenosis was identified in two patients (10%). When analyzed with FFR CT , 17 patients (71%) had hemodynamically significant coronary ischemia (FFR CT ≤0.8), and 54% (n = 13) had lesion-specific severe coronary ischemia (FFR CT ≤0.75). The mean FFR CT in patients with coronary ischemia was 0.70 ± 0.07. Multi-vessel disease pattern was present in 53% (n = 9) of patients with significant coronary stenosis., Conclusions: The use of cCTA-derived fractional flow reserve demonstrates a significant percentage of patients with CLTI have silent (asymptomatic) coronary ischemia. More than one-half of these patients have lesion-specific severe ischemia, which may be associated with increased mortality when treated solely with risk factor modification. cCTA and FFR CT diagnosis of significant coronary ischemia has the potential to improve cardiac care, perioperative morbidity, and long-term survival curves of patients with CLTI. Systemic improvements in access to care will be needed to allow for broad application of these imaging assessments should they prove universally valuable. Additional study is required to determine the benefit of selective coronary revascularization in patients with CLTI., (© 2023 The Author(s).)

Case: An 18-year-old woman with a history of congenital pseudarthrosis of the clavicle (CPC) presented with episodes of right upper extremity ischemia. Vascular studies demonstrated an extensive thrombus with complete occlusion of the brachial artery. She underwent urgent thrombectomy. Subsequently, she underwent first rib resection and scalenectomy as well as pseudarthrosis takedown and fixation. Postoperatively, she returned to Division I collegiate soccer with complete symptomatic resolution., Conclusion: We report a case of arterial thoracic outlet syndrome secondary to CPC., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B968)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Authors' Note: On February 17, 2021, Medtronic Incorporated issued a global voluntary recall of the Valiant Navion Thoracic Stent Graft System (the device under study in the Valiant Evo Global Clinical Program that is the subject of this publication), and instructed physicians to immediately cease use of the Valiant Navion system and return any unused product. Medtronic initiated the recall in response to three clinical trial subjects recently observed with stent fractures, two of whom have confirmed type IIIb endoleaks. The data collection, analysis, and manuscript submission occurred before the notice of this recall, and, specifically, the 100 procedures reviewed for this series were free of events at 1 year related to the reason for this device recall. The authors of this article and the manufacturer were unaware of the recently detected adverse events at the time of the preparation of the manuscript, and the 1-year trial results, and imaging-based analyses described are unchanged. Management of thoracic aortic aneurysms continues to be a challenging problem and outcomes are dependent on patient anatomy. The present publication focuses on the importance of achieving proximal and distal seals and the consideration of the temporal changes of the aortic morphology as a part of the TEVAR planning process. The authors believe there is still scientific merit in disclosing this information, despite the current nonavailability of the Valiant Navion system., Objective: The Valiant Navion stent graft system (Medtronic Inc, Santa Rosa, Calif) is a third-generation device with improved conformability. We have reported the 1-year clinical trial outcomes, with a focus on an imaging-based analysis of the aortic morphology. We assessed the effects of graft implantation on the native anatomy and the effects of the 1-year changes in thoracic aorta morphology on the original seal zones of the stent graft., Methods: A total of 100 subjects were enrolled in a prospective single-arm clinical trial investigating the Valiant Navion stent graft system. An independent core laboratory (Syntactx, New York, NY) assessed the anatomic characteristics and performance outcomes., Results: Through 1 year of follow-up, the freedom from all-cause mortality, aneurysm-related mortality, and secondary procedures was 89.8%, 97.0%, and 94.8% respectively. Of the 100 patients, 5 had undergone a total of six secondary procedures, and 9 patients had developed an endoleak (type Ia and Ib in 1, type Ia in 1, type Ib in 3, and type II in 4 patients) within the first year. After 1 year, 2 of 76 patients (2.6%) had had an increase in their maximum aneurysm diameter of ≥5 mm, 62 (81.6%) had had stable sacs, and 12 (15.8%) had experienced sac shrinkage. Although no deployment failures had occurred, 36 of the 100 proximal (36%) and 31 of the 100 distal (31%) attachment zones were considered short according to our definitions. The stent graft had conformed to the native anatomy at implantation, because the preprocedural thoracic aorta tortuosity (1.45 ± 0.02) had not significantly changed at 1 month after implantation (1.46 ± 0.02). Despite a natural increase in thoracic tortuosity after 1 year (1.49 ± 0.02), wall apposition had been maintained over time, as evidenced by the low endoleak rates. Aortic elongation and dilation had occurred at the proximal end of the graft by an average of 1.2 mm and 1.6 mm, respectively. Aortic remodeling was more pronounced at the distal end, with an average increase of 4.2 mm in length and 2.8 mm in diameter., Conclusions: The included patients had had positive 1-year outcomes with high freedom from mortality, endoleak development, and secondary procedures. Aortic elongation and dilation were more prevalent at the distal end, emphasizing the importance of distal attachment zone consideration as part of preoperative planning. Because aortic remodeling can be expected to continue over time, additional follow-up and imaging analysis in the trial will be necessary to assess the aortic morphology and its effects on stent graft performance., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Transcarotid artery revascularization (TCAR) is comprised of carotid artery stent placement with cerebral protection via proximal carotid artery clamping and reversal of cerebral arterial flow. The aim of the present study was to evaluate the safety and efficacy of TCAR performed by a broad group of physicians with variable TCAR experience., Methods: The ROADSTER 2 study is a prospective, open label, single arm, multicenter, postapproval registry for patients undergoing TCAR. Patients considered at high risk for complications from carotid endarterectomy with symptomatic stenosis ≥50% or asymptomatic stenosis ≥80% were included. The primary end point was procedural success, which encompassed technical success plus the absence of stroke, myocardial infarction, or death within the 30-day postoperative period. Secondary end points included technical success and individual/composite rates of stroke, death, and myocardial infarction (MI). All patients underwent independent neurological assessments before the procedure, within 24 hours, and at 30 days after TCAR. An independent clinical events committee adjudicated all major adverse events., Results: Between 2015 and 2019, 692 patients (Intent to Treat Population) were enrolled at 43 sites. Sixty cases had major protocol violations, leaving 632 patients adhering to the Food and Drug Administration-approved protocol (per-protocol population). The majority (81.2%) of operators were TCAR naïve before study initiation. Patients underwent TCAR for neurological symptoms in 26% of cases, and all patients had high-risk factors for carotid endarterectomy (anatomic-related 44%; physiological 32%; both 24%). Technical success occurred in 99.7% of all cases. The primary end point of procedural success rate in the Intent to Treat population was 96.5% (per-protocol 97.9%). The early postoperative outcomes in the Intent to Treat population included stroke in 13 patients (1.9%), death in 3 patients (0.4%), and MI in 6 patients (0.9%). The composite 30-day stroke/death rate was 2.3%, and stroke/death/MI rate was 3.2%. In the per-protocol population, there were strokes in 4 patients (0.6%), death in one patient (0.2%), and MI in 6 patients (0.9%) leading to a composite 30-day stroke/death rate of 0.8% and stroke/death/MI rate of 1.7%., Conclusions: TCAR results in excellent early outcomes with high technical success combined with low rates of postprocedure stroke and death. These results were achieved by a majority of operators new to this technology at the start of the trial. Adherence to the study protocol and peri-procedural antiplatelet therapy optimizes outcomes. Longer-term follow-up data are needed to confirm these early outcomes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02536378.

Objective: The Valiant Navion stent graft system (Medtronic, Santa Rosa, Calif) is a new iteration of a thoracic endograft for the treatment of descending thoracic aortic aneurysms. Herein, the 30-day primary safety and efficacy outcomes and secondary end points are presented., Methods: The Valiant EVO global clinical trial is a prospective, nonrandomized, single-arm trial. Patient enrollment occurred from April 2016 to October 2017. The primary end point was defined as access and/or deployment failure and/or a major device effect (MDE), including device-related secondary procedures, device-related mortality, conversion to open surgery, or thoracic aortic aneurysm rupture within 30 days of the index procedure. Other measures of stent graft performance including procedural data, rates of secondary procedures, and frequency of endoleaks are also reported., Results: Of the 87 consecutive patients undergoing thoracic endovascular aneurysm repair who were enrolled, 33 (37.9%) were female with 61 (70.9%) presenting with severe access artery tortuosity and 66 (85.7%) with high thoracic aortic tortuosity per core laboratory evaluation. The mean procedure duration was 88.7 ± 53.4 minutes and geographical differences existed such as percutaneous access (37/52 [71.2%]) in the United States and surgical cut down in the outside of the U.S. sites (28/35 [80.0%]). There were no access or deployment failures and only 2.3% of the patients (2/87; P < .0001; performance goal of 16%) experienced a MDE within 30 days of the index procedure. Two secondary procedures (n = 1 retrograde type A dissection; n = 1 aortic arch rupture) were required, and in the first 30 days, two patients died leading to a freedom from all-cause mortality of 97.7%. Endoleaks at 1 month were reported in 2.5% of patients (n = 1 type Ia; n = 1 type II)., Conclusions: Access/deployment failures, MDEs, and endoleaks were rare in the first 30 days of the Valiant Evo clinical trial. The Valiant Navion thoracic stent graft system has shown encouraging 30-day results in this challenging cohort and trial patients will continue to be followed through 5 years., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Endovascular repair of abdominal aortic aneurysm (AAA) remains a challenging clinical scenario when there is a short or nonexistent segment of healthy infrarenal aorta. This study sought to determine the safety and effectiveness of endosuture aneurysm repair (ESAR) using the Endurant II/IIs endograft (Medtronic Vascular, Santa Rosa, Calif) in conjunction with Heli-FX EndoAnchors (Medtronic Vascular) in the treatment of short-neck AAA., Methods: In this subgroup analysis, 70 patients were identified from the Aneurysm Treatment Using the Heli-FX EndoAnchor System Global Registry (ANCHOR) who had an infrarenal neck length <10 mm down to 4 mm based on core laboratory measurements. Primary outcomes included technical success of the index procedure, rate of type IA endoleak at 1 month and 12 months, and rate of secondary procedures at 12 months., Results: In this short-neck cohort (n = 70), the average neck length and diameter were 6.9 ± 1.6 mm and 25.7 ± 4.0 mm, respectively. Investigators reported an overall procedural success rate of 97.1% and a technical success rate of 88.6%. The duration of the implant procedure, EndoAnchor implantation, and total fluoroscopy time was 148.0 ± 80.0 minutes, 17.1 ± 11.5 minutes, and 35.3 ± 22.0 minutes, respectively, and an average of 5.5 ± 2.1 EndoAnchors were implanted per patient. Through the 30-day follow-up, type IA endoleaks were reported in four patients, of which three resolved spontaneously by the 12-month follow-up. There was an additional type IA endoleak through the 12-month follow-up that has not resulted in AAA enlargement or required a secondary procedure. The Kaplan-Meier estimate for freedom from secondary endovascular procedures and all-cause mortality is 95.4% and 92.7% through 365 days, respectively. No patient in the short-neck cohort experienced main body stent migration, increase in maximum aneurysm diameter, or aneurysm rupture or required conversion to open surgical repair through 12 months., Conclusions: In this analysis of the short-neck cohort from ANCHOR, the Endurant II/IIs endograft in conjunction with Heli-FX EndoAnchor implants (ESAR) appears to be a safe and effective treatment option with a high technical success rate and low incidence of type IA endoleaks and secondary interventions. Despite the complex and hostile anatomies, the ESAR method required short procedure and fluoroscopy times. These short-term outcomes suggest that ESAR could be complementary to therapies currently available for treatment of hostile AAA anatomy and a viable off-the-shelf endovascular treatment option for patients with short-neck AAAs, although long-term follow-up is critically important., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To describe and compare the clinical and anatomical characteristics and outcomes of patients with and without known cocaine use who underwent thoracic endovascular repair for type B aortic dissections., Methods: Between January 2012 and January 2017, 186 patients underwent thoracic endovascular repair for type B aortic dissection at our institution. Clinical data and anatomical characteristics were collected under an institutional review board-approved protocol. Survival, reintervention, complications, and characteristics of dissection were compared between patients with cocaine use (C+; n = 14) and those with no known cocaine use (C-; n = 172)., Results: Cocaine users were more likely to be young African American males who smoked. They tended to present with more extensive dissections as evidenced by larger false lumen diameters. They also had higher rates of endoleaks and more reinterventions., Conclusions: These results suggest that special care should be taken to provide close follow-up for these patients., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate outcomes of endovascular treatment of aortic coarctation in adults., Methods: Clinical data and imaging studies of 93 consecutive patients treated at nine institutions from 1999 to 2015 were reviewed. We included newly diagnosed aortic coarctation (NCO), recurrent coarctation, and aneurysmal/pseudoaneurysmal degeneration (ANE) after prior open surgical repair (OSR) of coarctation. Primary end points were morbidity and mortality. Secondary end points were stent patency and freedom from reintervention., Results: There were 54 (58%) male and 39 (42%) female patients with a mean age of 44 ± 17 years. Thirty-two patients had NCO (mean age, 48 ± 16 years) and 61 had endovascular reinterventions after prior OSR during childhood (mean, 30 ± 17 years after initial repair), including 50 patients (54%) with recurrent coarctation and 11 (12%) with ANE. Clinical presentation included asymptomatic in 31 patients (33%), difficult to control hypertension in 42 (45%), and lower extremity claudication in 20 (22%). Endovascular treatment was performed using balloon-expandable covered stents in 47 (51%) patients, stent grafts in 36 (39%) patients, balloon-expandable uncovered stents in 9 (10%) patients, and primary angioplasty in 1 (1%) patient. Mean lesion length and diameter were 64.5 ± 50.6 mm and 19.5 ± 6.7 mm, respectively. Mean systolic pressure gradient decreased from 24.0 ± 17.5 mm Hg to 4.4 ± 7.4 mm Hg after treatment (P < .001). Complications occurred in nine (10%) patients, including aortic dissections in three (3%) patients and intraoperative ruptures in two patients; type IA endoleak, renal embolus, spinal headache, and access site hemorrhage occurred in one patient each. The aortic dissections and ruptures were treated successfully by deploying an additional covered stent proximal to the site of dissection or rupture. Two patients died within 30 days of the index procedure. After a mean follow-up of 3.2 ± 3.1 years, nearly all patients (98%) were clinically improved and all stents were patent. Reintervention was needed in 10 (11%) patients. Freedom from reintervention at 5 years was 85%. Two additional patients died during follow-up of coarctation-related causes, including rupture of an infected graft and visceral ischemia. Patient survival at 5 years was 89%., Conclusions: Endovascular repair is effective with an acceptable safety profile in the treatment of NCO and postsurgical complications of coarctation after initial OSR. Aortic rupture is an infrequent (2%) but devastating complication with high mortality. Balloon-expandable covered stents are preferred for NCO, whereas stent grafts are used for ANE. The rate of reinterventions is acceptable, with high procedural and long-term clinical success., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate clinical, anatomic, and procedural characteristics of patients who developed retrograde type A dissection (RTAD) after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD)., Methods: Between January 2012 and January 2017, there were 186 patients who underwent TEVAR for TBAD at a multidisciplinary aortic center. Patients who developed RTAD after TEVAR (n = 15) were compared with those who did not (no-RTAD group, n = 171). Primary outcomes were survival and need for reintervention., Results: The incidence of RTAD in our sample was 8% (n = 15). Kaplan-Meier estimates found that no-RTAD patients had better survival (P = .04). Survival rates at 30 days, 1 year, and 3 years were 93%, 60%, and 60% for RTAD patients and 94%, 87%, and 80% for no-RTAD patients. One RTAD was diagnosed intraoperatively, 5 were diagnosed within 30 days of the index procedure, 6 were diagnosed within 1 year, and 3 were diagnosed after 1 year. Reintervention for RTAD was undertaken in 10 of 15 patients, with a 50% survival rate after reintervention. Partial or complete false lumen thrombosis was more frequently present in RTAD patients (P = .03). RTAD patients more frequently presented with renal ischemia (P = .04). Most RTAD patients (93%, RTAD patients; 64%, no-RTAD patients; P = .02) had a proximal landing zone in zone 0, 1, or 2. Aortic diameter was more frequently ≥40 mm in the RTAD group (47%, RTAD patients; 21%, no-RTAD patients; P = .05). Patients with RTAD had stent grafts placed in the renovisceral arteries for complicated dissections, and this approached significance (P = .05). Three RTAD patients had a type II arch (20%) compared with 53 no-RTAD patients (31%; P = .6), but a comparison of type II arch with type I or type III found no statistical significance (P = .6). No correlations were found between ratio of descending to ascending diameters, average aortic sizing, graft size, or bare-metal struts at proximal attachment zone and development of RTAD. We found no statistically significant differences in demographics, genetic disease, comorbidities, or previous repairs., Conclusions: The development of RTAD after TEVAR for TBAD does not appear to be correlated with any easily identifiable demographic feature but appears to be correlated with proximal landing zones in zone 1 and 2 and an ascending diameter >4 cm. Furthermore, the presence of partial or complete false lumen thrombosis as well as more complicated presentation with renal ischemia was significantly more frequent in patients with RTAD. TBAD patients should be observed long term, as type A dissections in our patients occurred even after 1 year., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Endovascular aneurysm repair (EVAR) has been shown to reduce mortality in the emergent repair of ruptured abdominal aortic aneurysms (AAAs). However, long-term survival data for this group of patients are lacking with contemporary endovascular endografts. The purpose of this study was to evaluate both 30-day mortality rates and 1-year survival in patients undergoing emergent EVAR in a 43-facility hospital system with a quaternary referral center with an established ruptured aneurysm protocol., Methods: Retrospective analysis of patients captured prospectively in an Institutional Review Board-approved registry for patients treated emergently for AAA were reviewed between 2012 and 2017 was conducted. Primary outcome measures were 30-day mortality and 1-year survival for the entire group as well as for symptomatic and ruptured aneurysms. Data were analyzed using logistic regression survival curves, and a log-rank test was performed to compare survival between open and endovascular repair. Patients were evaluated on an intent-to-treat basis, and outcomes were evaluated in a multivariate model., Results: A total of 249 patients were referred as part of the protocol. Of these, 102 (41%) were treated emergently. Kaplan-Meier estimates of 30-day and 1-year survival were 64% and 53% for all patients, 58% and 46% for ruptured patients, and 86% and 81% for symptomatic patients. EVAR resulted in improved 30-day survival (64% vs 31%; odds ratio, 4.0; P = .03) and 1-year survival (40% vs 23%; odds ratio, 2.3; P = .4) over open repair. Significant predictors for 30-day mortality included hypotension (P = .0003), blood transfusion (P < .0001), length of stay (P = .0005), extravasation (P = .01), preoperative cardiopulmonary resuscitation (P = .04), open repair (P = .007), aortouni-iliac reconstruction (P = .008), and abdominal compartment syndrome (P = .007). Significant predictors for 1-year mortality included advanced age (P = .04), hypotension (P = .01), blood transfusion (P = .006), extravasation (P = .03), reintubation (P = .03), and abdominal compartment syndrome (P = .03). There were no differences in outcomes based on race, gender, or outside transfer. Peripheral arterial disease (P = .04), hypertension (P = .04), coronary artery disease (P = .03), and familial history of aneurysms (P = .05) were related to increased 30-day mortality. Peripheral arterial disease (P = .06) and coronary artery disease (P = .07) were nearly significant, with increased 1-year mortality., Conclusions: EVAR is associated with improved survival compared with open repair in patients requiring emergent AAA repair. However, in the first year, there is a significant risk of death based on initial presentation as well as underlying comorbidities. To improve long-term survival, aggressive medical management and medical surveillance are warranted., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the difference in outcomes after endovascular intervention in patients with complicated type B aortic dissection (TBAD) based on ethnicity and blood pressure control., Methods: Between 2012 and 2016, there were 126 patients who underwent endovascular procedures for complicated TBAD at a single-institution quaternary referral center. Patients self-identified as African American (n = 53), white (n = 70), and Asian (n = 3). African American and white patients were compared on a number of variables, including age, ethnicity, insurance type, blood pressure, comorbidities, number of previous interventions, and number of antihypertension medications they were taking before intervention. Primary outcomes were survival and need for reintervention., Results: Kaplan-Meier estimates for survival for African Americans vs whites were 94% vs 89%, 91% vs 83%, 89% vs 79%, and 89% vs 76% at 30 days, 1 year, 3 years, and 5 years, respectively (P = .05). African Americans were younger overall (52.5 ± 11 years) vs whites (63.7 ± 14.7 years; P < .0001). African Americans required a significantly greater number of reinterventions (P = .007). They also had higher rates of chronic kidney disease (P = .01), smoking (P = .03), and cocaine use (P = .02) and were more likely to be on Medicaid (P = .02). Hypertension was poorly controlled in both groups, with the percentage of patients with uncontrolled hypertension (systolic >140 mm Hg) preoperatively, postoperatively, and 30 days after intervention at 32%, 32%, and 39%. There was no significant difference between the cohorts in uncontrolled hypertension preoperatively (P = .39) or postoperatively (P = .63). However, more African Americans had uncontrolled hypertension at 30 days (African Americans, 49%; whites, 31%; odds ratio, 2.1; P = .09). African Americans were taking a greater number of antihypertension medications at presentation than whites (P = .01) and specifically had higher use rates of beta blockers (P = .02), diuretics (P = .02), and angiotensin-converting enzyme inhibitors (P = .04)., Conclusions: African Americans with TBAD present at a younger age than their white counterparts do and have a survival advantage up to at least 5 years. However, African Americans have a higher rate of reintervention that is probably associated with poor blood pressure control despite taking more antihypertension medications both before and after the repair. It appears that optimal medical therapy is difficult to achieve in all groups. More aggressive medical management is needed, particularly more so in African Americans, which may in turn decrease the number of interventions and potentially improve long-term survival., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Stent graft coverage of the left subclavian artery (LSA) may be required to achieve an adequate landing zone in up to 40% of descending thoracic aneurysms (DTAs). The Valiant Mona LSA Thoracic Stent Graft System (Medtronic, Santa Rosa, Calif) consists of a main stent graft and a branch stent graft designed to maintain LSA patency while diverting circulation through the encroaching aneurysm. Participating in the United States Food and Drug Administration's new Innovation Pathway, this first-in-human, early feasibility study evaluates early clinical experience of the Valiant Mona LSA Stent Graft System in patients with DTAs where the proximal landing zone necessitates LSA coverage., Methods: This premarket, nonrandomized, single-arm prospective study recruited nine patients (age 72.9 ± 7.6 years). Primary end points were aneurysm-related mortality, stroke, paraplegia, left arm/hand ischemia, and treatment success. Neurologic events were assessed by imaging and by independent neurologists. Inclusion criteria required patients with a DTA or penetrating aortic ulcer to have a distance of ≥10 mm between the left common carotid artery and the LSA. Mean aneurysm diameter was 53.7 ± 10.0 mm. The indication for repair was for saccular DTA in five patients or fusiform DTA in four. Seven patients were at American Society of Anesthesiologists Physical Status Classification III/IV., Results: All nine patients received one main stent graft (diameter 28 to 42 mm) and one branch stent graft (diameter 10 to 14 mm). To extend device coverage distally, a commercial Valiant Captivia device was implanted in seven patients. No uncorrected endoleaks were observed at the end of the implant procedure. Four endoleaks developed before discharge in four of eight evaluable patients. Two were identified as type II and two were of undetermined type. No endoleak resulted in a secondary intervention. Technical success, defined by the clinical investigational plan, was achieved in all nine patients intraoperatively, and treatment success was achieved in all eight evaluable patients at 1 month. There were no major, disabling strokes. Four minor nondisabling strokes were reported in three patients ≤30 days (days 1, 1, 5, and 24). To date, there have been no reports of death, left arm ischemia, paraplegia, rupture, conversion to open surgery, or secondary endovascular procedure. No patients required surgical LSA revascularization., Conclusions: The Valiant Mona LSA system demonstrates technical and treatment success, relative safety, and early durability in its initial use in DTA patients. Midterm results are expected as patients are monitored at regular intervals to 5 years., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Mortality and complication rates for open thoracic aortic aneurysm repair have declined but remain high. The purpose of this study is to determine the influence of ethnicity and insurance type on procedure selection and outcome after open thoracic aneurysm repair., Methods: Using the Nationwide Inpatient Sample database, ethnicity and insurance type were evaluated against the outcome variables of mortality and major complications associated with open thoracic aneurysm repair. The potential cofounders of age, gender, urgency of operation, and Deyo index of comorbidities were controlled., Results: Between 2001 and 2005, a total of 10,557 patients were identified who underwent elective open thoracic aneurysm repair, with a significantly greater proportion of white patients (n = 8524) compared with black patients (n = 819), Hispanic patients (n = 556), and patients categorized as other (n = 658). Most patients (67%) were male. Almost half (45%) of the procedures were performed for urgent/emergent indications. Overall mortality was 10.7% (n = 1126) and the rate of spinal cord ischemia was 0.4% (n = 43). Univariate analysis revealed significant differences among race with regard to surgery type, income, hospital region, hospital bed size, and insurance type (P < 0.0001). Differences between insurance coverage were significant for gender, surgery type, income, hospital region, and race (P < 0.0001). Bivariate analysis by race revealed differences for death (P < 0.0001), pneumonia (P < 0.0001), renal complications (P = 0.011), implant complications (P < 0.0001), temporary tracheostomy (P = 0.004), transfusion (P < 0.0001), and intubation (P < 0.0001). In terms of payer status, bivariate analysis by insurance coverage revealed differences in death (P < 0.0001), central nervous system complications (P = 0.008), pneumonia (P < 0.0001), myocardial infarction (P = 0.001), infection (P < 0.0001), renal complications (P < 0.0001), malnutrition (P < 0.0001), temporary tracheostomy (P < 0.0001), spinal cord ischemia (P = 0.001), transfusion (P < 0.0001), and intubation (P < 0.0001)., Conclusions: A high percentage of open thoracic procedures (45%) are performed urgently or emergently in the United States, which is associated with increased morbidity and mortality. Both ethnicity and payer status were associated with significant differences in surgical outcomes, including mortality and frequency of complications after open thoracic aortic aneurysm repair., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Treatment of deep venous thrombosis (DVT) with therapeutic anticoagulation has been increasingly challenged by aggressive percutaneous treatment using ultrasound-accelerated catheter-directed thrombolysis (US-CDT) or percutaneous pharmacomechanical thrombectomy (PMT). These techniques have been promoted to improve thrombus removal, prolong venous patency, prevent venous insufficiency, and reduce postthrombotic syndrome. This study reviews midterm results using these endovascular techniques for both acute and chronic DVT., Methods: A retrospective chart review was performed on patients treated for acute or chronic DVT with US-CDT and/or PMT. Charts were reviewed for patient demographics, medical history and treatment, operative details, and postoperative outcomes. Intraoperative venography and intravascular ultrasound quantified clot response to therapy. Duplex ultrasound defined the pre- and postoperative extent of venous thrombosis, venous patency, and valvular function., Results: Between October 1, 2002 and September 30, 2010, 80 patients were treated for iliofemoral (n = 48), iliofemoropopliteal (n = 15), or femoropopliteal (n = 17) venous thrombosis. Mean age was 45.8 years (range, 15-78 years), and 24 patients (30%) had a documented history of hypercoagulable state. Intravascular ultrasound confirmed May-Thurner syndrome in 34 patients (42.5%). Fifty-two patients (65%) were treated for acute DVT; the mean time to intervention from symptom onset was 8.7 ± 4.5 days (range, 1-14 days). The remaining 28 patients (35%) had chronic symptoms and were treated at a mean of 8.6 ± 10.9 months (range, 1.5-36 months) after DVT diagnosis was made. Patients were treated with PMT (n = 43, 53.8%), US-CDT (n = 14, 17.5%), or both (n = 32, 28.7%). Clot lysis (>90%) was achieved in 72 of 80 patients (90%). Tenecteplase was used for all cases, and the mean dose was 8.6 ± 4.3 mg. Adjunctive procedures, including angioplasty with or without stent placement, were required in 90% (n = 47) of acute patients and in 96% (n = 27) of chronic patients (P = .33). Three patients (3.8%) had postoperative bleeding events requiring blood transfusion; there were no occurrences of intracranial hemorrhage or clinically significant pulmonary embolism. At a mean follow-up of 3.8 years (range, 1-8.9 years), venous patency was present in 49 of 52 acute patients (94%) and in 23 of 28 chronic patients (82%) (P = .12). Valve function was preserved in 41 of 52 (79%) acute patients vs 11 of 28 (39%) chronic patients (P < .001)., Conclusions: US-CDT and PMT can effectively remove acute and chronic thrombus in the lower extremity deep venous system. Vein patency and valvular function is better preserved at midterm follow-up after treatment for acute DVT, however intervention should be considered in patients with chronic DVT as well., (Copyright © 2013 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Parodi first introduced endovascular aneurysm repair (EVAR) in 1991 and since that time it has been shown to have a lower 30-day morbididty and mortality compared to open surgery. Anatomic constraints governed by the need for adequate access vessels, and sufficient proximal and distal landing zones, as well as the need for long-term surveillance, have been the main limitations of this technology. Anatomic factors were initially estimated to exclude 40% of patients with abdominal aortic aneurysm (AAA). The rapid extension of EVAR technology has been complimented by improved access to both high-quality imaging modalities and a variety of endografts. These developments have led EVAR to become a more practical alternative for patients with ruptured AAA. Early data in this setting is encouraging with even more profound reductions in morbidity and mortality than seen in the elective repair., (Copyright © 2012 Elsevier Inc. All rights reserved.)

We report the case of a 26-year-old female patient with Marfan syndrome and an aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum. The patient presented with spontaneous acute dissection of the ARSA that showed fusiform dilation to 4 cm in diameter. Definitive treatment was performed using a two-stage hybrid endovascular technique, including extrathoracic bilateral upper extremity bypass and thoracic endovascular aortic repair with debranching of the right and left subclavian arteries. This was followed by coil and plug embolization to exclude the dissection and prevent subsequent endoleak., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Conventional repair of aortic arch pathology is associated with significant mortality and stroke rates of 6-20% and 12%, respectively. Because endografting has excellent results for descending thoracic aortic disease, extension of thoracic endovascular repair (TEVAR) to the arch is a consideration., Methods: Records of patients with aortic arch pathology treated with TEVAR were reviewed. Branch vessels were (1) covered without revascularization, (2) surgically bypassed, (3) stented, or (4) fenestrated. Technical success was defined both by accurate endograft deployment with disease exclusion and by target vessel revascularization. Patient postoperative outcomes, complications, and follow-up are reported., Results: Between March 2006 and January 2010, 58 patients with arch pathology were treated with TEVAR. Indications included aneurysm (n = 19, 32.8%), dissection (type A: n = 3, 5.2%; type B: n = 18, 31.0%), transection (n = 8, 13.8%), pseudoaneurysm (n = 6, 10.3%), or other (n = 4, 6.9%). Pathology was zone 0 (n = 1, 1.7%), zone 1 (n = 10, 17.2%), zone 2 (n = 45, 77.6%), or zone 3 (n = 2, 3.4%). Interventions were emergent in 44.8% and elective in 55.2%. The left subclavian (LSA) was covered in all and revascularized (n = 23, 39.7%) via bypass (n = 13, 22.4%), stenting (n = 4, 6.9%), or fenestration (n = 6, 10.3%). The carotid was revascularized (n = 11, 19.0%) with bypass (n = 7, 12.1%) or stenting (n = 4, 6.9%). One patient (1.7%) underwent innominate revascularization with a homemade branched endograft. Technical success was 100% for endograft deployment and 97.1% for revascularization. Thirty-day mortality was 3.4% (2 of 58). ICU and hospital stays were 5.8 ± 6.8 (range: 0-34; median 4) and 10.9 ± 8.0 (range: 1-40; median: 9) days, respectively. Morbidities included renal failure (n = 3, 5.2%), respiratory (n = 2, 3.4%), myocardial infarction (n = 1, 1.7%), stroke (n = 6, 10.3%), and spinal cord ischemia (SCI) (n = 2, 3.4%). SCI (p < 0.001), but not stroke (p = 0.33), was associated with LSA sacrifice. Stroke was associated with underlying pathology and graft selection (p = 0.01). During follow-up of 10.6 ± 9.1 (range: 0-43) months, 17 patients (29.3%) required 20 reinterventions for endoleak (n = 8, 13.8%), disease extension (n = 5, 8.6%), steal (n = 4, 6.9%), or other reasons (n = 3, 5.2%). Dissection patients had a higher rate of reintervention (p = 0.01). All patients with steal had LSA sacrifice and were left-hand dominant., Conclusions: TEVAR can effectively treat aortic arch pathology in high-risk patients with low morbidity and mortality. TEVAR and branch vessel revascularization techniques may be extended to the more proximal arch without increased complications compared with patients with subclavian only involvement. Stroke remains the most significant drawback of arch interventions. Indications for intervention, graft selection, and revascularization choices may all affect outcome. LSA sacrifice is associated with increased SCI and may predispose left-handed patients to symptomatic weakness., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Prior studies have reported improved clinical outcomes with higher surgeon volume, which is assumed to be a product of the surgeon's experience with the index operation. We hypothesized that composite surgeon volume is an important determinant of outcome. We tested this hypothesis by comparing the impact of operation-specific surgeon volume versus composite surgeon volume on surgical outcomes, using open abdominal aortic aneurysm (AAA) repair as the index operation., Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing open AAA repairs for 2000 to 2008. Surgeons were stratified into deciles based on annual volume of open AAA repairs ("operation-specific volume") and overall volume of open vascular operations ("composite volume"). Composite volume was defined by the sum of several open vascular operations: carotid endarterectomy, aortobifemoral bypass, femoral-popliteal bypass, and femoral-tibial bypass. Multiple logistic regression analyses were used to examine the relationship between surgeon volume and in-hospital mortality for open AAA repair, adjusting for both patient and hospital characteristics., Results: Between 2000 and 2008, an estimated 111,533 (95% confidence interval [CI], 102,296-121,232) elective open AAA repairs were performed nationwide by 6,857 surgeons. The crude in-hospital mortality rate over the study period was 6.1% (95% CI, 5.6%-6.5%). The mean number of open AAA repairs performed annually was 2.4 operations per surgeon. The mean composite volume was 5.3 operations annually. As expected, in-hospital mortality for open AAA repair decreased with increasing volume of open AAA repairs performed by a surgeon. Mortality rates for the lowest and highest deciles of surgeon volume were 10.2% and 4.5%, respectively (P < .0001). A similar pattern was observed for composite surgeon volume, as the mortality rates for the lowest and highest deciles of composite volume were 9.8% and 4.8%, respectively (P < .0001). After adjusting for patient and hospital characteristics, increasing composite surgeon volume remained a significant predictor of lower in-hospital mortality for open AAA repair (odds ratio, 0.994; 95% CI, .992-.996; P < .0001), whereas increasing volume of AAA repairs per surgeon did not predict in-hospital deaths., Conclusions: The current study suggests that composite surgeon volume-not operation-specific volume-is a key determinant of in-hospital mortality for open AAA repair. This finding needs to be considered for future credentialing of surgeons., (Published by Mosby, Inc.)

Purpose: To determine the risk of aneurysm rupture in patients with persisting proximal type Ia endoleaks following endovascular aneurysm repair (EVAR) in comparison to the risk of rupture of untreated abdominal aortic aneurysms (AAA) of similar size., Methods: Among 400 patients who where treated with EVAR from 1996 to 2003 at a single center, 21 (5.3%) patients (13 men; mean age 78.0±5.0 years, range 67-86) with large (≥5.5 cm) aneurysms had imaging evidence of type Ia endoleaks that persisted >10 months (type Ia group) despite secondary endovascular treatment. These patients were compared to 24 untreated AAA patients (17 men; mean age 73.8±5.2 years, range 64-88) with large aneurysms from a separate geographic region with a well-established aneurysm treatment program before EVAR became available (1990-1998)., Results: There were no significant differences between the type Ia and the untreated AAA patients with regard to age (79±8 vs. 74±5 years), gender (38% vs. 29% women), baseline aneurysm diameter (6.1±0.7 vs. 6.4±0.9 cm), or length of follow-up (32±23 vs. 29±40 months). During the follow-up period, the rate of aneurysm enlargement was significantly lower in type Ia patients (0.19 cm/y) than in untreated AAA patients (0.54 cm/y, p = 0.03). One (4.8%) patient with a persisting type Ia endoleak and 2-cm aneurysm enlargement (0.8 cm/y) had aneurysm rupture after 2.5 years, while 12 (50%) of the 24 untreated aneurysms ruptured (p = 0.001), which was the primary cause of death in this group. The rupture rate was 1.8 per 100 patient-years in the type Ia group and 20.7 per 100 patient-years in the untreated AAA group. Aneurysm-related mortality was significantly reduced in the type Ia group compared to the untreated AAA group at 36 months (11% vs. 52%, p = 0.004). In the multivariate analysis, factors associated with death were an untreated AAA (odds ratio 97, p = 0.004), female gender (odds ratio 9.7, p = 0.02), and baseline aneurysm size (odds ratio 4.7/cm, p = 0.03)., Conclusion: This study suggests that EVAR may reduce the risk of rupture and aneurysm-related death despite the presence of a persisting type Ia endoleak. This finding is limited to patients with aortic endografts that are in good position. The mechanism of protection from rupture is unclear but may be related to reducing the rate of aneurysm enlargement.

Background: Type B aortic dissections are being successfully treated by thoracic endovascular aortic repair (TEVAR). Postoperative false lumen patency has been associated with aneurysmal dilatation and rupture of the thoracic aorta, necessitating further intervention. This is the first volumetric analysis of type B aortic dissections comparing patients with and without false lumen thrombosis (FLT) after TEVAR. We hypothesized that a greater increase in postoperative true lumen volume will lead to FLT, and without this change, false lumen patency will result., Methods: Preoperative and postoperative computed tomography angiography (CTA) imaging was analyzed using three-dimensional reconstruction to measure the short- and long-axis diameter and cross-sectional area of the true lumen, false lumen, and total aorta. Measurements were taken at 5-cm intervals from the left subclavian artery to the aortic bifurcation. Pre- and postoperative volumetric data were calculated and compared in patients with and without postoperative FLT., Results: Between 2006 and 2010, 132 patients underwent thoracic aortic stent grafting. Of these, 31 (23%) had thoracic endografting for type B aortic dissection. Pre- and postoperative CTA images were available for analysis in 23 patients with a mean age of 59 ± 14 years treated for acute, complicated (n = 8, 35%), and chronic (n = 15, 65%) indications. Mean follow-up imaging was 9 months (range, 1-39 months). Thirteen patients (56%) had postoperative FLT and 10 (43%) had persistent false lumen patency. The dissections involved the left subclavian artery (n = 12), visceral arteries (n = 14), renal arteries (n = 16), and iliac arteries (n = 15). The left subclavian artery was intentionally covered in 15 patients (65%). There were no significant differences in age, acute vs chronic dissection, branch vessel involvement, coverage of the left subclavian artery, or distal extent of the endograft between patients with and without postoperative FLT. Patients with postoperative FLT had a significantly smaller preoperative maximum thoracic aortic diameter (5.05 ± 1.0 vs 6.30 ± 1.4 cm; P = .02). Volumetric analysis demonstrated significantly smaller preoperative true lumen volume (141.3 ± 68 vs 230.5 ± 92 cm(3); P = .01) in patients with FLT, but no difference in preoperative false lumen volume. Patients with FLT had a significant increase in the volume percentage of the true lumen from 42.7% to 61.7% (P = .02) after stent graft repair, compared with an increase from 46.7% to 47.7% (P = .75) in patients with persistent false lumen patency., Conclusions: This volumetric study of type B aortic dissection treated with TEVAR suggests that the ability of the endograft to significantly increase the true lumen volume as a percent of the total aorta most accurately predicts postoperative FLT. This is best demonstrated in a nonaneurysmal dissection regardless of timing since dissection., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Endovascular repair for complex thoracic aortic pathology has emerged over the past decade as an alternative to open surgical repair. Reports suggest lower morbidity and mortality rates associated with endovascular interventions. The purpose of this report was to analyze a large single institution experience in endovascular thoracic aortic repair based on clinical presentation as well as within and outside specific instructions for use., Methods: Records of all patients undergoing thoracic aortic endografting at our institution were retrospectively reviewed for demographics, interventional indications and acuity, operative details, and clinical outcomes. Study outcomes were analyzed by clinical presentation (urgent/emergent vs elective) and aneurysm morphology that was within and outside specific instructions for use as recommended by the manufacturer., Results: Between March 2006 and October 2009, 96 patients underwent thoracic endografting for aneurysm (n = 43), transection (n = 7), penetrating ulcer (n = 11), dissection (n = 19; acute = 9, chronic = 10), pseudoaneurysm (n = 11), or miscellaneous indications (n = 5). Endografting was performed with various endografts (Gore TAG: 59; Medtrontic Talent: 26; Zenith-TX2: 7; Combination: 4.Involvement of the arch (n = 42, 43.75%) was treated with subclavian artery coverage without revascularization in 13 (13.5%), debranching in 20 (20.8%), and fenestration/stenting in 9 (9.38%). Involvement of the visceral vessels (n = 24, 25%) was treated with debranching in 15 (15.6%) or fenestration/stenting in 9 (9.4%). Patients had a mean follow-up of 11.5 ± 10.96 (range: 0-38) months. Overall mortality was 6.25% (n = 6). Mean intensive care unit stay was 6.26 ± 8.55 (range: 1-63, median: 4) days, and hospital stay was 9.97 ± 10.31 (range: 1-65, median: 65) days. Major complications were infrequent and included: spinal cord ischemia (n = 6, 6.25%), stroke (n = 6, 6.25%), myocardial infarction (n = 3, 3.15%), renal failure (n = 6, 6.25%), and wound complications (n = 9, 9.38%). Reoperation was required in 13 (13.54%), with early intervention in 2 (2.1%). The vast majority of patients were discharged directly to home (n = 66, 68.8%). There were no significant differences between death (1/49 [2%] vs 5/47 [10.6%], P = .07), stroke (3/49 [6%] vs 3/47 [6%], P = 1.0), or spinal cord ischemia (3/49 [6%] vs 3/47 [6%], P = 1.0) when comparing urgent/emergent presentation to elective cases, respectively. However, there were significant differences in death (6/58 [10.5%] vs 0/38 [0%], P = .04) and spinal cord ischemia (6/58 [10.5%] vs 0/38 [0%], P = .04) but not stroke (5/58 [8.8%] vs 1/38 [2.5%], P = .24] when procedures were performed outside the specific instructions for use., Conclusions: Results of this single-institution report suggest that endovascular thoracic aortic repair is a safe and effective treatment option for a variety of thoracic pathology including both elective and emergent cases. However, off-label usage of the devices is associated with a significantly higher risk of mortality and spinal cord ischemia, but the risk still appears acceptable given the majority of cases were emergent., (Copyright © 2011 Society for Vascular Surgery. All rights reserved.)

Purpose: To determine the most accurate method of assessing clot lysis after percutaneous mechanical thrombectomy for iliofemoral deep vein thrombosis (DVT) and to evaluate the effectiveness of two different pharmacomechanical thrombectomy devices., Methods: Between 2004 and 2009, 33 patients (18 women; mean age 47 years) with iliofemoral DVT underwent pharmacomechanical thrombectomy using the AngioJet (n = 18) or Trellis (n = 15) devices with 10 mg of tenecteplase. Intravascular ultrasound (IVUS) and venography were performed over the iliofemoral segments before and after treatment. Cross-sectional vessel and lumen diameters were measured from the IVUS scans and the post-procedure anteroposterior and lateral venograms at 3 points (proximal, mid-section, and distal) along each iliofemoral vein by 2 independent observers blinded to the treatment method. Volumes of the recanalized segments were calculated and compared to volumes of the original venous segments to assess clot lysis with each PMT device. IVUS scans and venograms were also compared for their ability to identify residual lesions or clot in need of treatment. Repeatability between and among observers was analyzed using the Bland and Altman method., Results: All procedures were successfully completed; there were only 2 minor bleeding complications. The mean volume of the recanalized segment was 2255+/-66 mm(3) by IVUS, representing 80% lysis of the clot compared to what was perceived as >90% lysis with venography (p<0.05). IVUS was able to delineate significant residual thrombus, stenosis, or May-Thurner anatomy requiring ancillary interventions in 100% of patients versus 48% (16/33) on the venograms (p<0.01). Quantitative assessments of the diameters of the involved venous segments from the venograms and IVUS were consistent between and among observers. Comparing the similar patient subgroups, AngioJet resulted in greater clot lysis (88%) versus the Trellis device (72%; p<0.01), corresponding to recanalized venous segment volumes of 2486+/-74 and 2025+/-57 mm(3) and total venous segment volumes of 2826+/-84 and 2813+/-79 mm(3), respectively., Conclusion: IVUS is superior to venography for detection of residual thrombus and underlying venous pathology after pharmacomechanical thrombectomy. While greater clot lysis was seen with the AngioJet system, both the AngioJet and Trellis devices resulted in excellent clinical clot lysis.

An 82-year-old female with a history of right carotid endarterectomy with patch closure 12 years prior presents with a pulsatile right neck mass with skin erosion and bleeding. The patient had been previously evaluated but refused the surgical intervention because a median sternotomy was recommended to obtain adequate proximal control. Her aneurysm was successfully repaired using a combination of open and endovascular method. The repair was performed through a right-hand side anterior sternocleidomastoid neck incision, and proximal vascular control was obtained with an 8.5-mm balloon positioned under fluoroscopic guidance via a femoral puncture.

Background: A recent report determined that the nationwide mortality for renal artery bypass (RAB) is surprisingly high-10%. We hypothesized that operative mortality for RAB is related to the volume of such operations performed in each center., Methods: The Nationwide Inpatient Sample was analyzed to identify patients undergoing RAB for the years 2000-2005. In-hospital mortality for RAB was compared between hospitals., Results: During the study period, RAB was performed on 7413 patients with an overall in-hospital mortality of 9.6%. The multivariate logistic regression analyses revealed that after adjusting for surgical risk, increasing hospital volume was significantly associated with decreased in-hospital mortality for RAB (odds ratio 0.98; 95% confidence interval, 0.96-0.99; P=.015)., Conclusions: Patient risk profile and hospital volume are critical determinants of in-hospital mortality for RAB, which should be factored into decision making for patients requiring intervention for renovascular disease.

Background: The mortality rate for renal artery bypass grafting (RABG) is reported to be 0% to 4% for patients with renovascular hypertension and 4% to 7% for patients with ischemic nephropathy. However, these data come from high-volume referral centers known for their expertise in treating these conditions. Because of the relative infrequency of these operations in most vascular surgery practices, the nationwide outcomes for RABG are not known. The purpose of this study was to define the operative mortality rate for RABG in the United States and to identify risk factors for perioperative mortality., Methods: The National Inpatient Sample was analyzed to identify patients undergoing RABG for the years 2000 to 2004. Categoric data were analyzed using chi(2) and the Cochran-Armitage trend tests. Multivariate logistic regression analyses were performed to identify risk factors for perioperative mortality after RABG., Results: During the study period, 6608 patients underwent RABG, representing a frequency of 3.51 operations per 100,000 discharges. More than two-thirds were performed at teaching hospitals (4564 vs 2,044; P < .0001). The frequency of RABG decreased by 30.7% between 2000 and 2004 (4.28 vs 2.96 RABGs per 100,000 discharges; P for trend < .0001). The in-hospital mortality for RABG was 10.0%. On univariate analysis, in-hospital mortality after RABG varied with increasing age, race, region of the country, and a preoperative history of chronic renal failure, congestive heart failure, or chronic lung disease. Logistic regression models identified advanced age (odds ratio [OR] 1.57; 95% confidence interval [CI], 1.44-1.72], female gender (OR, 1.20; 95% CI, 1.02-1.41), and a history of chronic renal failure (OR, 2.21; 95% CI, 1.75-2.78), congestive heart failure (OR, 1.94; 95% CI, 1.44-2.62), or chronic lung disease (OR, 1.40; 95% CI, 1.18-1.67) as independent markers of risk-adjusted, in-hospital mortality (P < .0001 for each of these five variables)., Conclusions: Nationwide in-hospital mortality after RABG is higher than predicted by prior reports from high-volume referral centers. Advanced age, female gender, and a history of chronic renal failure, congestive heart failure, or chronic lung disease were predictive of perioperative death. For the typical vascular practice, these data may provide a rationale for lower risk alternatives, such as renal artery stenting or referral to high-volume referral centers for RABG.

Background: The deep veins (DV) of the thigh have proven to be versatile autogenous conduits for arterial reconstruction. Harvesting DV poses a theoretical risk of compromising venous outflow of the limb, which could predispose to chronic venous morbidity. The purpose of this study was to define the late incidence of chronic venous insufficiency (CVI) and to characterize the long-term alterations in venous physiology after DV harvest., Methods: Since 1991, 269 patients have undergone arterial reconstructions using DV at our facility. Patients with DV harvest at least 43 months prior to the study (n = 151) were eligible for inclusion. Eighty-nine patients were excluded (deceased = 70; lost to follow-up = 19). Forty-six patients who declined formal testing were queried by phone for signs and symptoms of CVI. The current study presents a case-control series of 16 patients (27 limbs) after DV harvest and six age- and gender-matched control patients (12 limbs) who underwent examination and venous testing., Results: At a mean follow-up of 70.1 +/- 5.6 months, 23 of 27 limbs (85.2%) had no significant CVI (CEAP C(0) to C(2)). Four limbs (14.8%) had significant venous morbidity (C(3) to C(6)), including edema alone (C(3); n = 2 limbs), edema with skin changes (C(4); n = 1 limb), and a healed venous ulceration (C(5); n = 1 limb). APG testing confirmed relative venous outflow obstruction after DV harvest (mean outflow fraction: harvested limbs = 38.4 +/- 3.9% vs control limbs = 51.7 +/- 4.3%; P = .04). Despite the relative outflow obstruction, the mean VFI was not significantly different between harvested and control limbs (harvested limbs = 1.08 +/- 0.15% vs control limbs = 0.77 +/- 0.16%; P = .19). DV harvest resulted in no significant changes in calf ejection fraction (harvested limbs = 67.4 +/- 6.4% vs control limbs = 86.8 +/- 9.5%; P = .09) or residual volume fraction measured (harvested limbs = 32.3 +/- 6.4% vs control limbs = 47.7 +/- 11.6%; P = .22). Of the 46 patients interviewed by phone, five (10.9%) reported bilateral amputations, seven (15.2%) reported chronic edema in their harvested limbs (C(3)), and 34 (73.9%) reported no signs of CVI in their harvested limbs (C(0))., Conclusions: Deep vein harvest produces few symptoms of chronic venous insufficiency, and venous ulceration is infrequent. Despite relative venous outflow obstruction, noninvasive indices of chronic venous insufficiency on APG are often normal, suggesting that the risk of developing venous ulceration is low in the majority of patients after DV harvest.