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Purpose: To characterize extrahepatic pseudoaneurysm regarding incidence and etiology and determine the effectiveness of endovascular management. Methods: A retrospective audit of 1,857 liver transplants in two institutions was performed (1996-2009). Recipients' demographics, clinical presentation, transplant type, biliary anastomosis, and presence of biliary endoprostheses were noted. Pseudoaneurysms were classified into iatrogenic (associated with biliary endoprosthesis or angioplasty) or spontaneous extrahepatic pseudoaneurysms. Spontaneous and iatrogenic pseudoaneurysms were compared for time from transplant, presenting symptoms, location in the arterial anatomy, and 3-month graft survival. Arterial patency and 6-month graft survival were calculated. Results: Twenty pseudoaneurysms were found (1.1 %, 20/1,857): 9 (0.5 % of transplants, 9/1,857) were spontaneous and 11 (0.6 % of transplants, 11/1,857) were "iatrogenic" (due to minimally invasive procedures: 4 angioplasty and 7 biliary endoprostheses). Sixty percent (12/20) underwent endovascular management (4 coil embolization and 8 stent-grafts). Technical success was 83 % (10/12) with a mean arterial patency of 70 % (follow-up mean, 4.9; range, 0-18 months). The 1-, 3-, and 6-month graft survival was 70, 40, and 35 %, respectively. Conclusions: Due to minimally invasive procedures, posttransplant extrahepatic pseudoaneurysms are no longer an exclusive complication of the transplant surgery itself. Endovascular management is effective to stabilize patients but has not improved historic postsurgical graft survival. [ABSTRACT FROM AUTHOR]

Tracheoinnominate fistula is a rare but lethal condition that requires emergent surgical intervention to prevent ensuing exsanguinating hemorrhage. In clinical situations where the risk of open surgery is prohibitively high, endovascular repair may provide a life-saving alternative to control hemorrhage and serve as a temporizing or definitive solution based on a given clinical scenario. The authors report successful endovascular repair of the bleeding tracheoinnominate fistula with a stent in a liver transplant patient with high comorbidities and review the current literature. [ABSTRACT FROM AUTHOR]

Transcatheter embolization of arterioportal fistulae in liver transplant recipients is restricted to symptomatic arterioportal fistulae. Angiograms of liver transplant recipients from a single university medical center were retrospectively reviewed. Hemodynamically significant arterioportal fistulae were defined as those exhibiting opacification of the main portal vein of the transplanted hepatic graft or its first order branch with or without portal venous changes by Doppler ultrasound imaging. Six arterioportal fistulae were found. Doppler ultrasound imaging detected 50% of all arterioportal fistulae and all 3 hemodynamically significant arterioportal fistulae. Three successful embolizations were performed. Follow-up (37 to 67 months) demonstrated patent hepatic arteries and no parenchymal ischemic changes with graft preservation. High-throughput arterioportal fistulae may require larger intrahepatic artery branch embolization. There is a window of opportunity for embolizing significant arterioportal fistulae before their progression to large symptomatic, high through-put arterioportal fistulae with their added risk of ischemic changes before and after embolization. [ABSTRACT FROM AUTHOR]

There is reasonable evidence that the fluid layer of the airway epithelium is exposed to changes in tonicity. The inspiration of cool, dry air causes an increased tonicity, whereas this tonicity may be decreased by glandular secretions. We hypothesized that the cystic fibrosis transmembrane conductance regulator (CFTR) is involved in the responses to changes in tonicity and that these may be altered in cystic fibrosis (CF). Using nasal potential difference (PD) protocols in 8 subjects with CF and 10 subjects without CF, we investigated the effects of hyper- and hypotonicity on ion transport processes. We found significant differences between the two groups. In response to a hypertonic challenge (mannitol 500 mM), there was a decreased PD in both groups, suggesting decreased sodium absorption. However, after the prior inhibition of sodium transport using amiloride, there was an increased PD in the non-CF group alone, suggesting CFTR-mediated chloride secretion in response to luminal hypertonicity. For the hypotonic solution, we found that hypotonicity inhibited CFTR-mediated chloride secretion in the non-CF group. These data suggest that CFTR plays a role in the recognition and regulation of airway fluid tonicity. [ABSTRACT FROM AUTHOR]

The traditional CIBSE Guide model for design heat flow calculations (e.g., Figure A5.1 in the 1986 Guide Book A) is based on ambient temperature t[sub ao], room air temperature t[sub ai] and room environmental temperature t[sub ei] which was taken to be representative of the room as a whole. The ventilation conductance Cρv or NV/3 linking t[sub ao] and t[sub ai] is physical in origin and the conduction conductance ΣAU linking t[sub ao] and t[sub ei] is largely physical. The t[sub ai]-to-t[sub ei] link, h[sub a]ΣA or 4.8ΣA, however is an equivalent construct having no physical meaning. The Guide combines NV/3 and h[sub a]ΣA into the single conductance C[sup *][sub v]. The article reviews the early derivations of the room index temperature t[sub ei] and of h[sub a]ΣA. It was based on exchange between the air, surface A and combined surface 5A of a cubic enclosure. The article shows that the Guide model follows exactly from a delta-to-star transformation of the two convective and one radiative links in the room model. If however the Guide argument is applied to a room with a very small window, it is found that t[sub ei] depends solely on the radiative and convective characteristics of the window and ignores the characteristics of the room as a whole. If separate emissivities and convection coefficients are assumed for the A and 5A surfaces of a cube, the values of the conductances conflict with standard heat flow theory. The concept of environmental temperature is fundamentally flawed; indeed, the CIBSE Guide arguments are based on a raft of shortcomings. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the incidence and diameter of the Arc of Buhler by power injection digital subtraction angiography in asymptomatic patients. A retrospective evaluation of 120 combined celiac (CAx) and superior mesenteric artery (SMA) angiograms was carried out on potential live related liver transplant donors (asymptomatic patients) performed from January 1999 to May 2002. The diameter of the Arc of Buhler was calculated with reference to the 5 French catheters used to perform the diagnostic angiograms. It was considered hemodynamically significant if it preferential filled the branches of the other visceral vessel. An Arc of Buhler was identified in 4 patients (3.3%). All 4 patients had a patent gastroduodenal artery (GDA) and none of the 4 had a hemodynamically significant stenosis of either the SMA or the CAx. All Arcs of Buhler found measured less than 2.5 mm in diameter and half of them (2 of the 4) filled the CAx when power injecting the SMA and/or vice versa. There is a low incidence of Arc of Buhler in asymptomatic patients; however, 50% of those encountered were hemodynamically significant. When evaluating the Arc of Buhler by angiography in the setting of pathology, it is important to have a reference diameter and hemodynamic reference in the normal setting, particularly when the prospect of GDA ligation or embolization is entertained in the presence of CAx or SMA occlusion. [ABSTRACT FROM AUTHOR]

Objective: Inframalleolar disease is present in most diabetic patients presenting with tissue loss. Inframalleolar (pedal) artery disease and pedal medial arterial calcification (pMAC) are associated with major amputation in patients with chronic limb-threatening ischemia (CLTI). This study aimed to examine the impact of pMAC on the outcomes after isolated inframalleolar (pedal artery) interventions., Methods: A database of lower extremity endovascular intervention for patients with tissue loss between 2007 and 2022 was retrospectively queried. Patients with CLTI were selected, and those undergoing isolated inframalleolar intervention on the dorsalis pedis and medial and lateral tarsal arteries and who had foot x-rays were identified. X-rays were assessed blindly for pMAC and scored on a scale of 0 to 5. Patients with concomitant superficial femoral artery and tibial interventions were excluded. Intention to treat analysis by the patient was performed. Amputation-free survival (survival without major amputation) was evaluated., Results: A total of 223 patients (51% female; 87% Hispanic; average age, 66 years; 323 vessels) underwent isolated infra-malleolar intervention for tissue loss. All patients had diabetes, 96% had hypertension, 79% had hyperlipidemia, and 63% had chronic renal insufficiency (55% of these were on hemodialysis). Most of the patients had Wound, Ischemia, and foot Infection (WIfI) stage 3 disease and had various stages of pMAC: severe (score = 5) in 48%, moderate (score = 2-4) in 31%, and mild (score = 0-1) in 21% of the patients. Technical success was 94%, with a median of one vessel treated per patient. All failures were in severe pMAC. Overall, major adverse cardiovascular events was 0.9% at 90 days after the procedure. Following the intervention, most patients underwent a planned forefoot amputation (single digit, multiple digits, ray amputation, or trans-metatarsal amputation). WIfI ischemic grade was improved by 51%. Wound healing at 3 months was 69%. Those not healing underwent below-knee amputations. The overall 5-year amputation-free survival rate was 35% ± 9%. The severity of pMAC was associated with decreased AFS., Conclusions: Increasing severity of pMAC influences the technical and long-term outcomes of infra-malleolar intervention in diabetes. Severe pMAC is associated with amputation and should be considered as a variable in the shared decision-making of diabetic patients with CLTI., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Infra-popliteal interventions for chronic limb-threatening ischemia (CLTI) can be impacted by the morphology of the tibial vessels. The aim of this study was to examine the impact of a novel morphology-driven classification on the outcomes of isolated tibial intervention for CLTI., Methods: A database of patients undergoing isolated tibial interventions for CLTI at a single center between 2010 and 2020 was retrospectively queried. Patients with isolated infra-popliteal disease were identified, and their anatomy was scored as present or absent for lesion calcification (1 point), target vessel diameter<3.0 mm (1 point), lesion length>300 mm (1 point), and poor pedal runoff score (1 point). Patients were then divided into 3 groups: low risk (0 or 1 points), moderate risk (2 points), and high risk (3 or 4 points). Intention to treat analysis by the patient was performed. Limb-based patency (the absence of reintervention, occlusion, critical stenosis [>70%], or hemodynamic compromise with ongoing symptoms of CLTI as it related to the patency of the preoperatively determined target artery pathway) was assessed. Patient-oriented outcomes of amputation-free survival (AFS; survival without major amputation) and freedom from major adverse limb events (MALE; above ankle amputation of the index limb or major reintervention: new bypass graft, jump/interposition graft revision) were evaluated., Results: 1,607 patients (55% male, average age 60 years, 3,846 vessels) underwent tibial intervention for CLTI. The majority of the patients were diabetic and of Hispanic origin. Morphologically, 27%, 31%, and 42% of the vessels were categorized as low risk, moderate risk, and high risk, respectively. There was a significant worsening of the infra-popliteal Global Limb Anatomic Staging System (GLASS) grading as the morphological risk increased. The 30-day major adverse cardiac events (MACE) were equivalent across the groups and were under the stated objective performance goal (OPG) of ≤10%. In contrast, both the 30-day MALE and the 30-day major amputations were significantly different across the groups, with the low-risk group remaining under the OPG of ≤9% and ≤4%, respectively, while the moderate risk and high risk exceeded the goal threshold. For the OPG, freedom from MALE was 60 ± 5%, 46 ± 5%, and 22 ± 9% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.008). Overall AFS was 55 ± 5%, 37 ± 6%, and 18 ± 7% at 5 years for low-, moderate-, and high-risk groups, respectively (mean ± standard error of the mean; P = 0.003)., Conclusions: Tibial anatomic morphology impacts isolated tibial endovascular intervention with adverse morphology associated with poorer short- and long-term outcomes. Risk stratification based on anatomic predictors should be an additional consideration as one intervenes on infra-popliteal vessels for CLTI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The establishment of a peripheral ECMO circuit can lead to significant arterial and venous complications in 10-30% of patients. Vascular complications, particularly acute limb ischemia, are associated with worsening overall outcomes. Limb ischemia occurs significantly more frequently in the early stages of VA ECMO than in VV ECMO. Mechanisms of limb ischemia include arterial obstruction, cannulation injury, loss of pulsatile flow, thromboembolism, venous stasis from compressive obstruction with large venous cannulas, and systemic vasoconstriction due to shock and pharmacologic vasoconstriction. The care team may use several mitigation strategies to prevent limb ischemia. Arterial and venous complications can be mitigated by careful access site selection, minimizing cannula size, placement of distal perfusion and/or outflow catheter(s), and continuous NIRS monitoring. Rapid intervention, when ischemia or compartment syndrome occurs, can reduce limb loss but may not affect the mortality and morbidity of the ECMO patient in the long term due to their underlying conditions and the etiology of the ECMO need.

Purpose: Percutaneous renal artery revascularization for hypertension and renal dysfunction remains common. The frequency, cause, and outcomes of anatomic injury associated with renal intervention are poorly delineated. This study aims to determine the frequency of acute anatomic renal injury after renal artery interventions, identify factors associated with anatomic renal injury, and determine whether anatomic renal injury related to renal intervention is associated with late adverse clinical events., Methods: A retrospective analysis of patients undergoing renal artery interventions for atherosclerotic renal artery disease between 2002 and 2022 was performed. Acute anatomic renal injury encompassed renal artery dissection, renal artery perforation, acute occlusion, renal parenchymal infarction, and renal parenchymal perforation. Freedom from renal-related morbidity (increase in persistent creatinine >20% of baseline, progression to hemodialysis, death from renal-related causes) and patient survival were measured., Results: A total of 968 patients underwent 1309 renal artery interventions: 47% for hypertension, 25% for hypertension associated with chronic renal dysfunction, and 28% for chronic renal dysfunction. An acute anatomic renal injury occurred in 5.9% of the patients. The occurrence of an anatomic injury was associated with a significant decrement in freedom from renal-related morbidity (79±2% vs 55±8%, no-injury vs injury group, mean±standard error of the mean; p=0.003) and markedly decreased survival at 5 year follow-up (78±3% vs 48±8%; p=0.002). No factor was identified that predicted anatomic injury. In those patients with anatomic injury, perforation was associated with decreased survival, while estimated glomerular filtration rate <60, resistive index >0.8, and dissection were associated with a lack of retained renal benefit., Conclusion: Acute anatomic renal injury occurs in approximately 6% of patients undergoing percutaneous renal artery intervention and is a negative predictor of survival and is associated with subsequent renal failure, need for dialysis, and death from renal-related causes., Clinical Impact: Acute anatomic renal injury occurs in approximately 5% of patients undergoing percutaneous renal artery intervention. Modern endovascular interventions allow for the control and remediation of injuries in the majority of cases with an overall low mortality and morbidity. There is a significant early occlusion of renal arteries following the injury within 1 month. In the long term, the occurrence of injury is a negative predictor of survival and is associated with subsequent renal failure, the need for dialysis, and death from renal-related causes., 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.

Objective: Failure to achieve timely arteriovenous fistulae (AVFs) utilization due to excessive depth (>6 mm) remains an ongoing concern for dialysis access. This study evaluates the outcomes of radiocephalic (RCF) and brachiocephalic (BCF) fistula elevation required for access utilization., Methods: A retrospective review of all patients undergoing first-time autologous access over 10 years was undertaken. RCF and BCF were analyzed, and cases of initial access failure due to depth alone were selected for study. Primary and staged brachio-basilic AVF were excluded. Outcomes of early thrombosis, line placement, maturation (successful progression to hemodialysis [HD), reintervention, and functional dialysis (continuous HD for 3 consecutive months) were examined., Results: From January 2012 to December 2022, 1733 patients (67% female; mean age, 61 ± 14 years) underwent autologous AVF placement. Of these, 298 patients (17%) had depth-related AVF access issues (BCF, 71% and RCF, 29%). Nineteen percent of these AVFs underwent a primary balloon-assisted maturation (BAM), and 2% had side branch coil embolization before consideration for elevation. The average time to intervention for depth was 11 ± 4 weeks after primary creation. During elevation, side branch ligation occurred in 38% of cases, and 15% underwent intraoperative BAM, The pre-elevation depth was 8.2 ± 3.1 mm, and the mean post-elevation depth was 4.7 ± 2.9 mm (P = .002). Early thrombosis (<18 days) occurred in 4% of cases. There was no mortality, and the 30-day major adverse cardiac event rate was 2%, with a 30-day morbidity of 5%, which was driven by wound issues. Six percent of the AVFs underwent follow-up BAM within 3 months. Mean maturation of the AVFs was 74% ± 3% vs 72% ± 3% (P = .58) for the elevation vs no-elevation groups at 24 weeks, respectively. However, there was an increase in tunneled central line placement in pre-emptive fistula patients due to the delay in maturation (elevation, 17% vs no-elevation, 8%; P = .008). There was a mean successful access time of 6 ± 3 weeks after elevation (16 ± 4 weeks after access creation). There was a median of 2.4 secondary interventions per year after elevation compared with a median of 2.7 secondary interventions per year without elevation. Mean access functionality was 68% ± 8% vs 75% ± 8% at 3 years for the elevation vs no-elevation groups, respectively (P = .25)., Conclusions: Elevation of deep BCF and RCF occurs late after placement but can be successfully achieved with low morbidity and satisfactory long-term functionality. It results in an increase in tunneled central line placement in pre-emptive fistula patients. Elevation is a valuable adjunct to AVF maturation and enhances an autologous access policy., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE., Methods: A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE., Results: In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes., Conclusions: The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Several methods exist to reduce the number of arterial blood gases (ABGs). One method, Roche v-TAC, has been evaluated in different patient groups. This paper aggregates data from these studies, in different patient categories using common analysis criteria., Research Design and Methods: We included studies evaluating v-TAC based on paired arterial and peripheral venous blood samples. Bland-Altman analysis compared measured and calculated arterial values of pH, PCO 2 , and PO 2 . Subgroup analyses were performed for normal, chronic hypercapnia and chronic base excess, acute hyper- and hypocapnia, and acute and chronic base deficits., Results: 811 samples from 12 studies were included. Bias and limits of agreement for measured and calculated values: pH 0.001 (-0.029 to 0.031), PCO 2 -0.08 (-0.65 to 0.49) kPa, and PO 2 0.04 (-1.71 to 1.78) kPa, with similar values for all sub-group analyses., Conclusion: These data suggest that v-TAC analysis may have a role in replacing ABGs, avoiding arterial puncture. Substantial data exist in patients with chronic hypercapnia and chronic base excess, acute hyper- and hypocapnia, and in patients with relatively normal acid-base status, with similar bias and precision across groups and across study data. Limited data exist for patients with acute and chronic base deficits.

Background: One-third of American adults encompassed by current colorectal cancer screening guidelines fail to obtain recommended screening evaluations. Educational videos are a valuable medium through which to educate and encourage recommended health behaviors in patients., Methods: A cross-sectional study reviewing the quality of patient education videos addressing colorectal cancer screening. Video quality was assessed in 3 domains: accountability, content, and production., Results: Forty-four videos met inclusion criteria. Out of 33 possible points, videos scored a median of 15.0 (interquartile range 12.9-16.6). Videos scored 1.0 (interquartile range .8-1.0) out of 4.0 for accountability, 6.0 (interquartile range 4.4-8.0) out of 20 for content, and 8.0 (interquartile range 7.4-8.0) out of 9.0 for production. Colonoscopy was the most frequently discussed method of screening (38, 86%). While 13 (34%) videos discussed the risk of colorectal cancer in the general population and 15 (32%) discussed the risk in those with a family history, few videos addressed those with other risk factors. Most (31, 70%) videos discussed the medical consequences of not receiving screening, but only 1 (2%) video discussed the social consequences. Similarly, medical benefits were discussed in 34 (77%) videos while other benefits were not discussed by any video. Only one-fifth of the videos address three or more barriers to screening., Conclusions: Videos on colorectal cancer screening have excellent production quality but need improvement in the domains of accountability and content. The videos included in this analysis did not adequately address the concerns of viewers nor the benefits of colorectal cancer screening., 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.

Objective: Maintenance of long-term arteriovenous access is important in long-term care for patients with end-stage renal disease. Arteriovenous access is associated in the long term with the development of fistula aneurysms (FAs). This study aims to evaluate the outcomes of staged FA treatment in dialysis access arteriovenous fistulae (AVF)., Methods: A retrospective review of all patients over a 12-year period with primary autogenous AVF was undertaken at a single center. Patients undergoing elective open aneurysm repair were identified and were categorized into three groups: single FA repair (single, control group) and staged and unstaged repair of two FAs (staged and unstaged). A staged repair was a procedure in which the initial intent was to treat both aneurysms in the AVF and in which the most symptomatic aneurysm was treated first. When the incision from the first surgery had healed, the second symptomatic aneurysm in the AVF was treated. An unstaged repair was a procedure in which the initial intent was to repair both symptomatic aneurysms simultaneously. All patients had a fistulogram before the FA repair. Thirty-day outcomes, cannulation failure, line placement, reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined., Results: Five hundred twenty-seven patients presented with FA that met requirements for open intervention; 44% underwent single FA repair, whereas the remaining 34% and 22% underwent staged and unstaged repair of two FAs, respectively. The majority of patients were diabetic and Hispanic. Ninety-one percent of the patients required percutaneous interventions of the outflow tract (37%) and the central veins (54%). Thirty-day major adverse cardiovascular events were equivalent across all modalities. Thirty-day morbidity and early thrombosis (<18 days) were significantly higher in the unstaged group (4.3%) compared with the two other groups (1.3% and 2.1%, single and staged, respectively), which led to an increased need for a short-term tunneled catheter (8.9%) compared with the two other groups (3.4% and 4.4%, single and staged, respectively), Unstaged repair resulted in an increased incidence of secondary procedures (5.0%) compared with the two other groups (2.6% and 3.1%, single and staged, respectively). Functional dialysis at 5 years was equivalent in the single and staged groups but was significantly decreased in the unstaged group., Conclusions: Open interventions are successful therapeutic modalities for FAs, but unstaged rather than staged repair of two concurrent FAs results in a higher early thrombosis, an increased secondary intervention rate, and a need for a short-term tunneled central line. Staged and single FA repairs have equivalent results. In the setting of two symptomatic FAs, staged repair is recommended., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Arteriovenous accesses develop aneurysms (FA) during their active use, resulting in pain, erosion, bleeding, and difficulty in cannulation. This study aims to evaluate the outcomes of open and endovascular management of single FA in arteriovenous fistulas (AVF)., Methods: A retrospective review of all upper extremity primary AVFs over 12 years was undertaken at a single center. Patients undergoing elective open and endovascular repair of a single FA were identified. Thirty-day outcomes, cannulation failure, line placement, re-intervention, and functional dialysis (continuous hemodialysis) for 3 consecutive months were examined., Results: Three hundred and seventy nine patients presented with a single FA that met the requirements for intervention: 126 (33%) underwent endovascular repair, and the remainder 253 (67%) underwent open repair. Preoperative fistulogram identified anatomically significant issues in 91% of the cases, and these were treated by balloon angioplasty: 10% within the fistula tract, 44% within the outflow tract, and 47% in the central veins. In open repair, 57% underwent plication, 35% underwent resection and re-anastomosis, and the remainder (8%) underwent interposition grafting. In endovascular repair, successful placement of a stent was achieved in all cases with 1 ± 2 (mean ± standard deviation [SD]) covered stents (diameter: 6 -8 mm) placed, achieving successful exclusion of the FA. The combination of early thrombosis and cannulation failures led to the greater need for a tunneled central line in endovascular repair (6.5% vs. 2.4%; endovascular versus open repair; P = 0.04). As a result, the mean time for establishing renewed access in the index AVF was significantly higher in endovascular repair (2 ± 3 vs. 2 ± 2 weeks, mean ± SD; endovascular open repair versus open repair; P = 0.001). In follow-up, there were more secondary interventions per year in the endovascular compared to open repair groups (3.1 vs. 1.4 secondary interventions per year; endovascular versus open repair; P = 0.04). Median functional dialysis durations were superior in the open repair (48 ± 6%, mean + standard error) compared to the endovascular repair at 5 years. (26 ± 7%; P = 0.03)., Conclusions: Open repair results in a more rapid return to access use, lower need for a tunneled central line, lower secondary re-intervention rates, and superior functional dialysis durations compared to endovascular repair. Open FA repair should be considered for symptomatic single FA repairs before endovascular FA repair., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Approximately 3% of all patients presenting with Thoracic Outlet Syndrome have a venous etiology (vTOS), which is considered "effort thrombosis". These patients will present with symptomatic deep venous thrombosis or focal subclavian vein (SCV) stenosis. Endovascular management of vTOS occurs in several phases: diagnostic, preoperative therapeutic intervention before decompression, postoperative interventions after decompression, and delayed interventions in the follow-up after decompression. In the diagnostic phase, dynamic SCV venography can establish functional vTOS. Approximately 4,000 patients have been treated for vTOS and reported in the literature since 1970. Declotting of the SCV was followed by surgical decompression in 53% of patients, while in the remainder, surgical decompression alone (18%), endovascular intervention alone (15%), or conservative therapy with anticoagulation (15%) was performed. The initial intervention was predominantly catheter-directed thrombolysis, with <10% of cases undergoing concomitant balloon angioplasty. 93% of cases were successful. In the postoperative phase, balloon angioplasty was performed to correct residual intrinsic SCV disease after vTOS decompression in under 15% of cases. Stents were rarely deployed. Symptom relief was reported as 94 ± 12% (mean ± SD) and 90 ± 23%, respectively for declotting with decompression and declotting alone. In the delayed phase, balloon angioplasty was performed in under 15% of cases to re-establish patency., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Davies and Hart.)

Objective: YouTube® has gained popularity as an unofficial educational resource for surgical trainees, but its content's quality and educational value remain to be evaluated. The aim of this study is to analyze the current content on these techniques for lower extremity DVT (LEDVT) on YouTube® ., Methods: A search was performed on YouTube® using 13 search terms in August 2022 on a clear-cached browser. Open-access videos focusing on the surgical techniques of venous thrombolysis or thrombectomy for LEDVT were included. Quality and educational value were assessed and graded based on metrics for accountability (4 items), content (13 items), and production (9 items)., Results: Out of 138 videos regarding LEDVT oriented towards medical professionals, only 14 met inclusion criteria. Videos ran for a median of 3.4 min (range 0.37-35.6 min) with a median of 941 views (range 106-54624). Videos scored a median of 5.5 (range 1.0-8.0) out of 11 for content, a median of 2.0 out of 6.0 (range 0.0-2.0) for accountability, and a median of 5.5 out of 9.0 (range 3.0-9.0) for production., Conclusion: Few YouTube® videos focus on the technical aspects of DVT thrombolysis/thrombectomy, and they vary significantly in content with overall poor accountability and production quality., 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.

Massive pulmonary embolism (MPE) carries significant 30-day mortality and is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Given the continued high mortality associated with MPE, there has been ongoing interest in utilizing extracorporeal membrane oxygenation (ECMO) to provide oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and RV pressure will improve outcomes. Two modalities can be employed: Veno-arterial-ECMO is a reliable process to decrease RV overload and improve RV function, thus allowing for hemodynamic stability and restoration of tissue oxygenation. Veno-venous ECMO can support oxygenation but is not designed to help circulation. Several societal guidelines now suggest using ECMO in MPE with interventional therapy. There are three strategies for ECMO utilization in MPE: bridge to definitive interventional therapy, sole therapy, and recovery after interventional treatment. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Considerable heterogeneity in studies is a significant weakness of the available literature. Applying ECMO is also associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, which must be factored into the outcomes. The application of ECMO in MPE should be combined with an aggressive pulmonary interventional program and should strictly adhere to the current selection criteria., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Davies and Hart.)

Background: Establishing long-term arteriovenous access is an important component in the long-term care of a patient with end-stage renal disease. The increasing frequency of obesity is reported to impact the access management of end-stage renal disease patients. This study aims to evaluate the outcomes of arteriovenous fistulae (AVF) in obese and nonobese patients., Methods: A retrospective review of all patients over ten years with primary autogenous AVF (radiocephalic, brachiocephalic, and brachial-basilic) was undertaken at a single center. Patients were subcategorized by body mass index into nonobese, class I, II, and III obesity. Outcomes of maturation (successful progression to hemodialysis), reintervention, functional dialysis (continuous hemodialysis for 3 consecutive months), and patency were examined., Results: From January 1999 to December 2019, 2311 patients (67% female; mean age, 61 ± 15 years) underwent primary AVF placement (12% radiocephalic, 53% brachiocephalic, and 35% brachial basilic). Forty-one percent were nonobese, 29% had class I obesity, 19% had class II obesity, and 11% had class III obesity. The majority of patients were diabetic and Hispanic. The 30-day major adverse cardiovascular event rate was elevated in class II (0.20%) and class III (0.50%) obesity compared with class I obesity (0.15%) and nonobese (0.05%). The 30-day morbidity rate was higher in all classes of obesity (0.5% vs0.3% vs 0.2% vs 0.05% for class III vs class II vs class I obesity and nonobese, respectively). Early thrombosis was significantly increased in class II (9%) and class III obesity (12%) compared with class I obesity (5%) and nonobese (3%). There was a two-fold increase in procedures to effect maturation in class II (51%) and class III (74%) obesity compared with class I obesity (22%) and nonobese (34%). Secondary patency at 3 years was significantly lower in class III (62 ± 4%) and class II (79 ± 3%) compared with class I obesity (87 ± 2%) and nonobese (93 ± 4%). All classes of obesity required significantly more secondary Interventions per year compared with nonobese (3.9 vs 3.1 vs 2.5 vs 1.4 secondary interventions per year for class III vs class II vs class I obesity and nonobese, respectively)., Conclusions: Advancing obesity class is associated with an increased number of procedures to achieve AVF maturation and is associated with poorer patency and functionality as the category of obesity advances., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch., Methods: Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions., Results: 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change., Conclusions: In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: This study seeks to evaluate the quality and readability of freely available online patient information resources for deep vein thrombosis (DVT) and pulmonary embolism (PE)., Methods: Internet searches were performed for five DVT and PE search terms in July 2020 across three search engines and two metasearch engines. Qualitative content analysis was performed. Readability was assessed using four validated instruments., Results: Two hundred fifty websites were identified of which 62 websites met inclusion criteria.Website structure and content were satisfactory (>50% overall score), accountability was mixed between DVT (47%) and PE (56%) sites, while interactivity was poor (<30%). On qualitative content analysis, anticoagulation (95.2%) was the most discussed treatment while the most discussed procedures were IVC filter placement for DVT and thrombolysis for PE. Overall readability was difficult with median level suitable for ages 14-18 years., Conclusion: Freely available online DVT and PE patient information resources publish appropriate content but have very variable accountability and poor readability for the average patient.

Background: Accurate arterial blood gas (ABG) analysis is essential in the management of patients with hypercapnic respiratory failure, but repeated sampling requires technical expertise and is painful. Missed sampling is common and has a negative impact on patient care. A newer venous to arterial conversion method (v-TAC, Roche) uses mathematical models of acid-base chemistry, a venous blood gas sample and peripheral blood oxygen saturation to calculate arterial acid-base status. It has the potential to replace routine ABG sampling for selected patient cohorts. The aim of this study was to compare v-TAC with ABG, capillary and venous sampling in a patient cohort referred to start non-invasive ventilation (NIV)., Methods: Recruited patients underwent near simultaneous ABG, capillary blood gas (CBG) and venous blood gas (VBG) sampling at day 0, and up to two further occasions (day 1 NIV and discharge). The primary outcome was the reliability of v-TAC sampling compared with ABG, via Bland-Altman analysis, to identify respiratory failure (via PaCO 2 ) and to detect changes in PaCO 2 in response to NIV. Secondary outcomes included agreements with pH, sampling success rates and pain., Results: The agreement between ABG and v-TAC/venous PaCO 2 was assessed for 119 matched sampling episodes and 105 between ABG and CBG. Close agreement was shown for v-TAC (mean difference (SD) 0.01 (0.5) kPa), but not for CBG (-0.75 (0.69) kPa) or VBG (+1.00 (0.90) kPa). Longitudinal data for 32 patients started on NIV showed the closest agreement for ABG and v-TAC (R 2 =0.61). v-TAC sampling had the highest first-time success rate (88%) and was less painful than arterial (p<0.0001)., Conclusion: Mathematical arterialisation of venous samples was easier to obtain and less painful than ABG sampling. Results showed close agreement for PaCO2 and pH and tracked well longitudinally such that the v-TAC method could replace routine ABG testing to recognise and monitor patients with hypercapnic respiratory failure., Trial Registration Number: NCT04072848; www., Clinicaltrials: gov., Competing Interests: Competing interests: Prof SER had a minor shareholding in Obimedical, the funders of the study. His institution, Aalborg University, previously received research funding from Obimedical., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patients with chronic limb-threatening ischemia (CLTI) and chronic kidney disease (CKD) are at risk of developing renal injury following revascularization. We aimed to compare the risk of adverse renal events following endovascular revascularization (ER) or open surgery (OS) in patients with CLTI and CKD., Methods: A retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) databases (2011-2017) was performed including patients with CLTI and non-dialysis-dependent CKD, comparing ER to OS. The primary outcome was a composite of postprocedural kidney injury or failure within 30 days. Thirty-day mortality, major adverse cardiac and cerebrovascular events (MACCE), amputation, readmission or target lesion revascularization (TLR) were compared using multivariate logistic regression and propensity-score matched analysis., Results: A total of 5009 patients were included (ER: 2361; OS: 3409). The risk for the composite primary outcome was comparable between groups (odds ratio [OR]: 0.78, 95% confidence interval (CI): 0.53-1.17) as for kidney injury (n=54, OR: 0.97, 95% CI: 0.39-1.19) or failure (n=55, OR: 0.68, 95% CI: 0.39-1.19). In the adjusted regression, a significant benefit was observed with ER for the primary outcome (OR: 0.60, p=0.018) and renal failure (OR: 0.50, p=0.025), but not for renal injury (OR: 0.76, p=0.34). Lower rates of MACCE, TLR, and readmissions were observed after ER. Thirty-day mortality and major amputation rates did not differ. In the propensity score analysis, revascularization strategy was not associated with renal injury or failure., Conclusions: In this cohort, the incidence of renal events within 30 days of revascularization in CLTI was low and comparable between ER and OR., Clinical Impact: In a cohort of 5009 patients with chronic limb-threatening ischemia and non-end-stage chronic kidney disease (CKD), postprocedural kidney injury or failure within 30 days was comparable between patients submitted to open or endovascular revascularization (ER). Lower rates of major adverse cardiac and cerebrovascular events, target lesion revascularization, and readmissions were observed after endovascular revascularization. Based on these findings, ER should not be avoided due to fear of worsening renal function in CKD patients with chronic limb-threatening ischemia. In fact, these patients benefit more from ER regarding cardiovascular outcomes with no increased risk of kidney injury.

Objective: Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset., Methods: Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak., Results: Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms., Conclusions: Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: As vascular surgery training continues to evolve with the growth of integrated vascular surgery residency (0+5) programs and the consolidation of fellowship programs, optimizing all aspects of the education for vascular surgery trainees, both fellows and 0+5 residents, has become increasingly important. In the present study, we aimed to determine the prevalence, quality, and content of vascular surgery education publications across journals., Methods: Journal websites (n = 26) and PubMed were queried to identify vascular surgery education publications from 2012 to 2021. The publications were organized into 11 content categories: (1) curriculum, (2) simulation, (3) trainee assessment, (4) program evaluation, (5) wellness/burnout, (6) diversity/inclusion, (7) mentorship/career, (8) case outcomes, (9) perceptions of training, (10) social media, and (11) other. Publication interactivity and quality were measured via PlumX data and Medical Education Research Study Quality Instrument scores. The data were analyzed via univariate analysis and linear regression., Results: A total of 115 vascular surgery education publications (0.2% [interquartile range (IQR), 0.04%-0.5%] of total publications) were identified from the selected journals. The Journal of Vascular Surgery had the highest proportion (0.8%) of vascular surgery education publications, followed by the Journal of Surgical Education (0.7%) and Annals of Vascular Surgery (0.6%). Vascular surgery journals constituted most (79%) of the publications. Of the authors, 15% (IQR, 0%-25%) had a master's or doctorate degree in education. Senior authors were more often identified as male gender (77%), and more first authors (41%) were identified as female gender. An interactivity analysis showed that there were 10.3 citations (IQR, 12), 33.1 captures (IQR, 34), and 8.4 social media interactions (IQR 14) per publication. The educational quality had a median Medical Education Research Study Quality Instrument score of 11 (IQR, 9-12.5), with 49% of publications having a score greater than the median. Publications on training (44% curriculum and 20% simulation) were significantly more frequent than other topics (P < .001), with no change in the publication content over 10 years (P = .29). The volume of vascular surgery education publications did not change during the study period (P = .13) despite the ongoing changes in the educational environment., Conclusions: Despite the increasing importance placed on vascular surgery education by national vascular societies, publications on vascular surgery education have remained sparse among all journals. Also, the vascular surgery educational content has not changed during the past 10 years, with a primary focus on curriculum and simulation training. Further promotion of vascular surgery educational research is required to increase the quality, volume, and diversity of education publications., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)