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Progressive peripheral artery disease, especially in the tibial and pedal vessels, can severely limit the interventions that vascular surgeons and interventionalists can provide to patients. End-stage peripheral arterial disease is often described as a disease where there are no distal targets available in the foot. Traditionally, amputation has been the only option for these patients. However with advancements in surgical and endovascular technology, surgical and now peripheral deep vein arterialization (pDVA) can be utilized. In pDVA, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts in order to increase distal limb perfusion and improve amputation-free survival. Many techniques have been described, but currently the only formal device marketed and under investigation for pDVA is the LimFlow System (LimFlow SA, Paris, France). Our institution has performed pDVA for multiple vascular patients with no other available surgical interventions. We describe the technique, postoperative care, and outcomes for these patients. Additionally, we will explore updated outcomes and applicability of the LimFlow System in the current vascular practice today.

Background: Tandem lesions of the proximal aortic branch vessels and carotid bifurcation are uncommon. While management strategies vary, a hybrid approach of carotid endarterectomy with retrograde common carotid artery (CCA) or innominate artery (IA) stenting has become a mainstay of treatment. The purpose of this article was to provide a review of the literature, discuss alternative treatment modalities, and highlight technical considerations of the hybrid approach., Methods: We performed a systematic review of the literature by searching relevant key words in the Cochrane Library, PubMed/Medline, and Embase. The primary endpoints of this study were stroke and all-cause mortality at 30 days. Secondary outcomes included rate of technical success, re-stenosis and need for re-intervention, and stroke and all-cause mortality at 1 year., Results: We identified 15 retrospective cohort studies with a cumulative 242 patients who underwent hybrid repair. The average technical success rate of hybrid repair for the management of tandem carotid lesions was high (98.8%). Multiple studies reported zero events. The average 30-day mortality rate across all studies was 0.6% (pooled: 3/242, 1.2%) and average 30-day stroke rate across all studies was 0.9% (pooled: 7/242, 2.9%). Of the studies that reported rates of re-stenosis and need for re-intervention, the average re-stenosis rate was 9.6% (pooled 34/209; 16.3%). The most common area of re-stenosis was the proximal carotid CCA/IA (61.7%). The average reintervention rate across all studies was 4.5% (pooled 13/209; 6.2%)., Conclusions: A hybrid approach of carotid endarterectomy with retrograde CCA/IA stenting is a safe and effective treatment modality for tandem carotid disease. However, there remains a paucity of high-level data as single-center studies are subject to publication bias. This study highlights the critical need for a prospective registry to prognosticate the risk of stroke and mortality for patients with asymptomatic versus symptomatic tandem carotid lesions., (Copyright © 2024. Published by Elsevier Inc.)

Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Vascular surgeons have the ability to manage and intervene on numerous vascular diseases of both the arterial and venous systems. With the growing number of interventions available as endovascular technology evolves, it is important to determine when a procedure is safely indicated for a vascular surgery patient. Appropriate Use Criteria (AUC) offer synthesized clinical information and practice standards that can aid clinicians in making these management decisions. Professional societies, such as the Society for Vascular Surgery, bring experts in the field together to collaborate and create AUC for various vascular diseases and interventions. It is essential to publish these criteria in peer-reviewed journals, as well as make them available on public websites so the information is available to vascular surgeons and interventionalists from other specialties who also treat patients with vascular disease. Cardiology, interventional radiology, and interventional nephrology are some other specialties that perform procedures for vascular disease, and vascular interventions by nonsurgeon specialists continue to increase. The Society for Vascular Surgery has published AUC on intermittent claudication, carotid disease, and abdominal aneurysm management. These are intended to guide practice, but also have highlighted areas for improvement that would allow for more universal implementation of AUC in vascular patient care across medical specialties. Increased intersocietal participation and perhaps inclusion of government and other payer participation will allow professional society-sponsored AUC to evolve, resulting in coordinated, appropriate care for vascular surgery patients., Competing Interests: Declaration of competing interest The authors have no relevant financial disclosures or conflicts of interest for this manuscript., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Subclavian and thyrocervical trunk pseudoaneurysms are rare pathologies and even more so when they occur simultaneously. Treatment of these vascular injuries can be done endovascularly or with open surgery. We present a novel two-stage, hybrid open and endovascular approach to the management of a healthy 41-year-old man with no personal or family history of connective tissue disorders, who presented with subclavian branch and thyrocervical trunk pseudoaneurysms complicated by brachial artery occlusion. The pseudoaneurysms were treated with microvascular plug deployment, followed by subclavian artery covered stenting, with treatment of the brachial occlusion via open thrombectomy with patch angioplasty. The patient recovered without any complications., Competing Interests: None., (© 2024 Published by Elsevier Inc. on behalf of Society for Vascular Surgery.)

Recently, there has been a major shift in the concept of resident autonomy in the operating room. As a result, surgical residents' independence has decreased during their training years. This change has been secondary to multiple factors, including fragmented attending resident interactions, hospital demands for productivity, operating room efficiency, and the public's perception of resident participation in surgery. Multiple gender, personality, and racial biases have also influenced the autonomy of surgical residents. In this paper, we have analyzed the impact of all these factors on the current state of resident autonomy after reviewing relevant literature. We have proposed a strategy to increase resident autonomy via increased resident and faculty interactions, case planning, and encouraged recruitment of diverse vascular surgery trainees and faculty., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

There have been significant technologic advances in endovascular aortic therapies since the introduction of conventional infrarenal endovascular aortic aneurysm repair (EVAR). These advances have sought to address the weaknesses of conventional EVAR- particularly the difficult or "hostile" infrarenal aortic aneurysm neck. We review anatomical features that create a hostile neck and the most recent advancements to overcome these limitations. EndoAnchors replicate open suture fixation to seal endograft to aortic tissue and have been shown to be useful as a prophylactic measure in short, angulated necks as well as therapeutic for type Ia endoleaks. Fenestrated EVAR (FEVAR) devices such as the Z-fen (Cook Medical, Bloomington, IN, USA) raises the seal zone to the suprarenal segment while maintaining renal perfusion. Finally, multibranch aortic grafts such as the Thoracoabdominal Branch Endoprosthesis (Tambe; W. L. Gore & Associates, Flagstaff, AZ, USA) raise the seal zone above the visceral segment and can be used off the shelf with promising results., Competing Interests: The authors declare no conflicts of interest., (Copyright: © 2023 The Author(s). Published by IMR Press.)

Peripheral artery disease (PAD) can often present with chronic limb threatening ischemia (CLTI), including ischemic rest pain and severe tissue loss. Progression of PAD can lead to "no option" or end-stage disease in which there are no traditional open or endovascular interventions available for revascularization. This cohort of patients have a poor prognosis, with a major amputation rate of 40% and mortality of up to 20% at six months. For this patient population, surgical deep vein arterialization (DVA) is offered as an attempt to provide blood flow to the distal preserved venous bed and reverse the ischemic process. Surgical DVA has traditionally been offered as an option and was pioneered by Herb Dardik. The evolution of endovascular technology has allowed for percutaneous DVA (pDVA). Using ultrasound and fluoroscopic guidance, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts to increase distal limb perfusion with the goals of improving wound healing and amputation-free survival. Lysis of venous valves with a valvulotome also aids with reversal of flow into the distal venous system. Investigations of percutaneous deep vein arterialization are underway with one device, the LimFlow System (LimFlow SA, Paris, France), which is undergoing feasibility trials. Here we present the current clinical indications, feasibility, results, and our institutional experience with the use of percutaneous deep vein arterialization.

Dialysis is the preferred treatment for patients with end-stage renal disease (ESRD) for the removal of accumulated toxins secondary to compromised renal function. Hemodialysis has traditionally been performed via a surgically created arteriovenous fistula (AVF) or arteriovenous graft (AVG). Novel endovascular techniques have allowed for the creation of percutaneous arteriovenous fistulas for hemodialysis access. Two devices, the Ellipsys® Vascular Access System (Avenu Medical, Inc., San Juan Capistrano, California) and the WavelinQ EndoAVF System (C.R. Bard, Inc., Murray Hill, New Jersey), are currently available for percutaneous AVF creation and investigation of their utility is ongoing. This paper describes the current utilization, differences, and results thus far with these devices and, additionally, investigates the contemporary advantages, disadvantages, and selection criteria for percutaneous AVFs overall.

Introduction: Thoracic endovascular aortic repair (TEVAR) has become first-line therapy for a wide range of thoracic aortic pathologies including traumatic thoracic aortic injury, type B aortic dissection, intramural thoracic aortic hematoma, and penetrating aortic ulcers. This study aims to analyze the progress made of thoracic stent graft devices, review the current Food and Drug Administration (FDA)-approved devices, and discuss the future technological advances., Materials and Methods: In this paper, we will review the history of TEVAR and the development of the first iteration of devices. We will discuss the four currently available TEVAR devices, the GORE® TAG® (W. L. Gore and Associates, Flagstaff, Arizona), Medtronic Navion™ (Medtronic plc, Santa Rosa, California), Bolton RELAY® (Terumo Aortic, Sunrise, Florida), and the Zenith® Alpha™ Thoracic and the Zenith® Dissection Stent Graft (Cook Medical, Bloomington, Indiana), and the features and applications of each. Finally, future advancements in TEVAR technology and grafts currently under trial will be reviewed., Results: The first generation of TEVAR grafts had several limitations including large delivery systems, the need for rapid pacing for accurate deployment, wind socking during deployment, and graft migration. The current available TEVAR grafts have novel features to address these prior pitfalls. The GORE® TAG® is initially deployed 50% with subsequent room for adjustment to increase accuracy; the Medtronic Navion™ and Bolton RELAY® are available in low-profile delivery systems; and the Cook Zenith® Alpha™ now has an open cell petticoat specific for use in dissections extending to the visceral abdominal aorta. The current generation of TEVAR devices have broadened the application of TEVAR and reduced the anatomic limitations previously encountered., Conclusion: TEVAR has evolved to overcome technical challenges and offer expanded applicability to different types of thoracic aortic pathologies and enhanced accuracy of deployment.

Decomposition of N-tosyl-1,2,3-triazoles with rhodium(II) acetate dimer in the presence of alcohols forms synthetically versatile N-(2-alkoxyvinyl)sulfonamides, which react under a variety of conditions to afford useful N- and O-containing compounds. Acid-catalyzed addition of alcohols or thiols to N-(2-alkoxyvinyl)sulfonamide-containing phthalans provides access to ketals and thioketals, respectively. Selective reduction of the vinyl group in N-(2-alkoxyvinyl)sulfonamide-containing phthalans via hydrogenation yields the corresponding phthalan in good yield, whereas reduction with sodium bis(2-methoxyethoxy)aluminumhydride generates a ring-opened phenethylamine analogue. Because the N-(2-alkoxyvinyl)sulfonamide functional group is synthetically versatile, but often hydrolytically unstable, this protocol emphasizes key techniques in preparing, handling, and reacting these pivotal substrates in several useful transformations.