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Objective: Our objective was to evaluate temporal trends in outcomes at our institution in the context a more heterogenous application of fenestrated/branched endovascular aneurysm repair (F/BEVAR). Methods: Patient and aneurysm characteristics, procedure details, and postoperative outcomes were collected for consecutive patients undergoing F/BEVAR between 2002 and February 2019 at our institution. Outcomes were compared between tertile 1 (T1, 2002–2010, n=47), T2 (2011–2014, n=47), and T3 (2015-February 2019, n=47). Results: We included 141 patients (74.8 ± 8.1 years, 83% male) with a mean follow-up of 28.0 ± 31.6 months. Proportion of patients with hypertension (63.8% T1, 85.1% T3, p=0.009), diabetes (6.4% T1, 29.7% T3, p=0.005), chronic obstructive pulmonary disease (COPD; 27.6% T1, 42.5% T3, p=0.07), and history of stroke (4.2% T1, 17% T3, p=0.07) increased over time. Aneurysm diameter (65.3±11.4mm) and extent (56.0% juxtarenal/pararenal, 22.0% type IV, 22.0% type I-III) did not differ between groups. Custom made devices were implanted in 96.5% of cases with 3.4 ± 0.7 vessels reimplanted/case. There was a trend toward increased history of aortic surgery (p=0.008) and less custom made devices (p=0.007) in T3. Total procedure time (383.5±119.2 minutes T1, 316.2±88.4 T3, p=0.02), contrast volume (222.8±109.1 mL T1, 139.2±62.7ml T3, pConclusion: We have shown improvement in F/BEVAR outcomes including mortality, MAEs, and procedural metrics with increasing institutional experience. We postulate that a combination of advancements in technique, surgical team and postoperative care experience, graft design and stent technologies, and patient selection contributed to improvement in outcomes.

This review aims to assess the impact of obesity on clinical outcomes for peripheral arterial disease patients undergoing endovascular or open lower extremity revascularization surgery.A systematic search strategy of MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library was conducted. Included studies compared obese and non-obese cohorts with peripheral arterial disease undergoing endovascular or open lower extremity revascularization. The outcomes included mortality, major adverse cardiovascular events, major adverse limb events, surgical site infections, endovascular access site complications, and perioperative complications.8 studies were included which detailed 171,648 patients. Obese patients (body mass index ≥30) were more likely to be women, diabetic, and have more cardiovascular comorbidities despite being younger. There was no association between obesity and peripheral arterial disease severity. Obesity was associated with an overall 22% decreased mortality risk after lower extremity revascularization (RR 0.78, 95% CI [0.71, 0.85], p.001, IObesity was associated with reduced mortality risk in both endovascular and open surgery while a reduction in major adverse cardiovascular events was only observed in open surgery. There is additionally an increased risk for surgical site infections in obese individuals. Obesity was not associated with major adverse limb events, endovascular access site complications, or perioperative complications. The GRADE quality of evidence is very low. This review suggests a survival advantage in obese patients with peripheral arterial disease. Future studies may focus on prospectively investigating the impact of obesity on peripheral arterial disease outcomes. A nuanced evaluation of body mass index as a preoperative risk factor is warranted.

Purpose: We sought to compare the costs of ambulatory endovascular aneurysm repair (a-EVAR) and inpatient EVAR (i-EVAR) at up to 1-year of follow-up. Materials and Methods: A retrospective cohort study of consecutive patients undergoing elective EVAR between April 2016 and December 2018 at two academic centers. Patients planned for a-EVAR were compared with i-EVAR. Costs at 30 days and 1 year were extracted. These included operating room (OR) use, bed occupancy, laboratory and imaging, emergency department (ED) visits, readmissions, and reinterventions. Baseline characteristics were compared. Multiple regression model was used to identify predictors of increased EVAR costs. Repeated measures analysis of variance (ANOVA) was used to compare cost differences at 30 days and 1 year via an intention-to-treat analysis. Bonferroni post hoc test compared between-group differences. A p valueResults: One hundred seventy patients were included. Most underwent percutaneous EVAR (>94%) under spinal anesthesia (>84%). Ambulatory endovascular aneurysm repair was successful in 84% (84/100). Ambulatory endovascular aneurysm repair patients (76±8 years) were younger than i-EVAR (78±9 years). They also had a smaller mean aneurysm diameter (56±6 mm) compared with i-EVAR (59±6 mm). Emergency department visits, readmissions, and reinterventions were similar up to 1 year (all p=NS). Ambulatory endovascular aneurysm repair costs showed a non-statistically significant reduction in total costs at 30 days and 1 year by 27% and 21%, respectively. Patients younger than 85 years and males had a 30-day cost reduction by 34% (p=0.027) and 33% (p=0.035), respectively with a-EVAR. Conclusions: Same-day discharge is feasible and successful in selected patients. Patients younger than 85 years and males have a short-term cost benefit with EVAR done in the ambulatory setting without increased complications or reinterventions. Clinical Impact This study shows the overall safety of ambulatory EVAR with proper patient selection. These patient had similar post-intervention complications to inpatients. Same day discharge also resulted in short-term reduction in costs in male patients and patients younger than 85 years.

In the present study, we evaluated the effects of inframalleolar (IM) disease on the occurrence of major adverse limb events (MALE) in patients undergoing endovascular revascularization for chronic limb-threatening ischemia (CLTI).Patients who had undergone endovascular revascularization for CLTI between January 2015 and December 2019 at two university-affiliated hospitals were reviewed retrospectively. Patients with severe IM disease (pedal score of 2) were compared with those with mild to moderate IM disease (score of 0 or 1) using the Global Vascular Guidelines. The primary outcome was MALE (open revascularization, acute leg ischemia, major amputation). The secondary outcomes were mortality, reintervention, major adverse cardiac events, and perioperative complications ≤30 days after endovascular revascularization, primary limb-based patency, and the occurrence of any limb event (defined as any amputation, acute leg ischemia, or open revascularization). Kaplan-Meier estimates were used to compare the primary outcome, and the Cox proportion hazard model was used to assess the effects of IM disease.The study included 167 limbs in 149 patients (36% female; mean age, 74 ± 12 years). Severe IM disease was identified in 71 limbs (43%). No differences were found in the baseline characteristics, except for a higher prevalence of dyslipidemia in the patients with severe IM disease (66% vs 43%; P = .003). Most patients in both groups had had a WIFI (wound, ischemia, foot infection) score of 4 (severe IM disease, 64%; vs mild to moderate IM disease, 57%; P = .462) and GLASS (global limb anatomic severity scale) III anatomy (severe IM disease, 54%; vs mild to moderate IM disease, 48%; P = .752). The Kaplan-Meier estimates showed that severe IM disease was associated with lower freedom from MALE (69% vs 82%; P = .026). The Cox proportion hazard regression model showed that severe IM disease was an independent predictor of increased MALE and amputation risk (hazard ratio, 1.715; 95% confidence interval, 1.015-2.896; P = .044) after adjusting for covariates. During follow-up, patients with severe IM disease had had mortality (27% vs 31%; P = .567) and reintervention (42% vs 38%; P = .608) similar to those for patients with mild to moderate IM disease. Primary limb-based patency was also similar (79% vs 84%; P = .593) at a mean follow-up of 3.8 ± 0.8 years.Severe IM disease was prevalent in 43% of limbs that had undergone endovascular revascularization for CLTI and was associated with lower freedom from MALE. Severe IM disease also independently increased the hazard of adverse limb outcomes and amputations in patients with CLTI by70%, highlighting its importance as a measure of foot perfusion.

Depression is a significant risk factor for death in coronary artery disease. Conversely, the research surrounding depression and peripheral arterial disease is limited. This review aimed to systematically evaluate the available literature on the impact of comorbid depression on adverse outcomes in peripheral arterial disease.A systematic review and meta-analysis were performed using the following databases MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Library from inception until July 2021.Included studies compared depressed and non-depressed patients with peripheral arterial disease. The outcomes included death, major adverse cardiovascular events, and major adverse limb events.A total of 9 297 articles were searched. Of these, seven studies were identified. Depressed patients were more likely to be women, diabetic, have a history of smoking, and have chronic limb threatening ischaemia, despite being younger than non-depressed patients. There was a 20% increase in major adverse limb events in depressed patients (RR 1.20, 95% CI 1.11 - 1.31, z = 3.9, p.001, GRADE strength: very low) but no increased risk of death (RR 1.03, 95% CI 0.72 - 1.40, z = 0.06, p = .95, GRADE strength: very low) or major adverse cardiovascular events (RR 1.16, 95% CI 0.67 - 2.01, z = 0.54, p = .59, GRADE strength: very low). A follow up meta-regression of various comorbidities and demographic variables did not demonstrate a significant contribution to the observed risk ratio for major adverse limb events.Depression was reported in 13% of patients with peripheral arterial disease, associated with more medical comorbidity, and a 20% increased risk of major adverse limb events. Although the strength of this evidence is very low, the current state of the literature remains limited. Future studies should prospectively assess the impact of depression and its relationship to medical comorbidities and high risk health behaviours.

Carotid endarterectomy (CEA) is a well-established surgical intervention for stroke prevention in patients with carotid stenosis of all ages. However, the decision to proceed to operate in the elderly involves a more complicated risk-benefit assessment due in part to increased comorbidities and reduced life expectancy. Some studies suggest that CEA is more risky in the elderly with worse outcomes, whereas others have found no difference. Our objective was to evaluate and compare outcomes of CEA between elderly and younger patients at our institution.All hospital charts were reviewed for consecutive patients undergoing CEA from the Jewish General Hospital and the Royal Victoria Hospital from October 2009 to December 2015. Primary outcomes were ipsilateral stroke, death, and restenosis at 30 days and 1 year. Secondary outcomes were cranial nerve injury, myocardial infarction (MI), hematoma, wound infection, cerebral hyperperfusion, and transient ischemic attacks within 30 days. Primary and secondary outcomes were compared between patients aged ≥80 years and80 years.A total of 361 patients were included in this study with a mean age of 70.2 ± 9.5 years (n = 247 [68.4%] male and n = 272 [75.8%] symptomatic). Elderly patients were more often symptomatic (93.8% vs. 71.6%, P 0.0001) and had an increased length of stay (2.8 ± 5.3 vs. 1.6 ± 1.8, P = 0.001). There was no statistically significant difference in primary outcomes between patients aged80 years and ≥80 years, including 30-day stroke (1.7% vs. 0%), death (no deaths in either group), restenosis (8.8% vs. 12.3%), 1-year stroke (1.7% vs. 0%), death (0.7% vs. 0%), or restenosis (14.9% vs. 13.8%). However, elderly patients had significantly increased MI risk postoperatively (4.6% vs. 0.7%, P = 0.01). Other complications, including cranial nerve injury (3.7% in80 years vs. 4.6% in the elderly group), were similar between the groups.We found that CEA in the elderly does not have an increased risk of stroke or death up to one year postoperatively. However, the postoperative length of stay is increased and complicated by significantly more MIs, which should weigh into the decision of whether to perform CEA on an elderly patient.

Background Exercise-based interventions have become part of the standard of care in rehabilitation programs for cardiovascular risk reduction and the promotion of a healthy lifestyle. The systematic review describes the current state of knowledge of the effects of preoperative exercise training (prehabilitation) on perioperative clinical outcomes in patients undergoing cardiac and vascular interventions. Methods Studies were systematically searched within 14 databases from inception to October 2016. Only studies that assessed a preoperative exercise program in adult patients undergoing cardiac or vascular interventions with clinical or patient-centered endpoints were included in the review. Two independent reviewers selected studies for inclusion, extracted data, and assessed quality using Cochrane Collaboration's tool for RCTs11111111111111111 and ROBINS-I tool for nonrandomized studies. Results Nine studies met our inclusion criteria and were stratified for qualitative analyses by cardiac (n = 7) and vascular (n = 2) procedures. Prehabilitation was associated with decreased length of stay, reduced postoperative complications, improved objective physical functioning, and improved subjective quality of life (SF-36 physical and mental health domains) measures in patients undergoing cardiac and vascular procedures. Given the amount of heterogeneity that was present in the designs, populations, and comparators among the included studies, we were unable to statistically pool data across trials. Conclusions Our qualitative findings suggest that prehabilitation may improve clinical outcomes, physical performance, and health-related quality-of-life measures in patients undergoing cardiac and vascular surgery procedures.

OBJECTIVE We sought to evaluate the impact of obesity on perioperative mortality and complication rates in patients undergoing endovascular aortic repair (EVAR) and open surgical repair (OSR) for abdominal aortic aneurysms (AAA). METHODS A systematic review of all studies reporting AAA treatment perioperative (30 day) outcomes in obese patients (body mass index ≥30 kg/m2). The primary outcome was 30 day mortality. Secondary outcomes included: cardiac complications, respiratory complications, wound complication, renal complications, and neurological complications at 30 days. These outcomes were pooled for meta-analysis. Analysis first compared obese versus nonobese patients undergoing EVAR and OSR then compared EVAR to OSR in obese patients. RESULTS We identified 7 observational studies with 14,971 patients (11,743 EVAR, 3228 OSR). Obese patients undergoing EVAR had lower 30 day mortality (1.5%) compared to nonobese patients (2.2%) (OR 0.69; 95% CI 0.50-0.96; p=0.03; I2= 0%; Grade of evidence: low). In OSR, obese patients (5.0%) had similar 30 day mortality to nonobese patients (5.7%) (OR 0.92; 95% CI 0.70-1.20; p=0.54; I2=0%; Grade of evidence: low). Wound complications were higher in obese patients undergoing OSR (OR 2.30; 95% CI 1.74-3.06; p

Background Patients with peripheral arterial disease (PAD) who suffer from claudication have a low exercise capacity, poor quality of life, and often severe disability. Exercise and healthy nutrition have been shown to be important factors to prevent disease progression. This systematic review aims to assess the evidence supporting the use of combined nutrition and structured exercise in patients with intermittent claudication. Methods Publications that included a combination of structured exercise (SE) and a nutritional intervention and that reported quality of life, exercise capacity, pain-free walking distance, limb blood flow hemodynamics, need for revascularization surgery, or surgical outcomes were systematically searched. Publications were screened, selected, and reviewed by 2 independent reviewers. Results Four publications were found reporting the effects of combined SE and nutrition programs. Pooled statistical analysis across trials was not performed because of the heterogeneity of study designs and type of interventions. Only 2 randomized controlled trials were found, reporting conflicting results with regard to the effects of combined SE and nutrition on exercise capacity. Only one trial reported quality of life measures. Blood flow was increased in the intervention involving inorganic nitrate in addition to SE. Conclusions There are conflicting results and lack of quality data proving the benefit of nutrition and SE programs on patient-centered outcomes and limb blood flow. There are no data on the effects of combined nutrition and exercise on the need for revascularization surgery or postrevascularization outcomes. More randomized controlled trials are needed to assess the effects of multimodal interventions on patient-centered outcomes and clinical outcomes of PAD.

The adoption of endovascular aneurysm repair (EVAR) during the past two decades has led to significantly shorter length of stay as well as lower hospital resource use. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to confirm the safety and feasibility of performing EVAR as outpatient surgery.We developed criteria to identify patients for potential same-day discharge (infrarenal aneurysm, low perioperative risk, to be accompanied for first 24 hours). We then implemented a prospective trial that observed patients planned for same-day discharge and compared them with a historical control group (patients who had undergone EVAR during the previous 2 years and met same-day discharge criteria). Basic demographic and operative data as well as length of stay, inpatient and perioperative complications, emergency department visits, readmissions, reinterventions, and deaths were collected. The primary outcome was the 30-day complication rate, and the study was powered to assess noninferiority.Prospectively, we assessed 266 patients and planned 110 (41%) for outpatient EVAR (62% of historical controls met outpatient criteria). Demographic characteristics were similar between planned outpatients and historical controls. In planned outpatients, hospital stay was significantly shorter (0.7 ± 2.6 days vs 2.5 ± 6.9 days; P .01), and 79% were discharged the same day of surgery. The 30-day follow-up was available for all study patients and 94% of control patients; there were no differences in complication (11% vs 9%), readmission (2% vs 4%), reintervention (4% vs 4%), or mortality (1% vs 1%) rates, but study patients had significantly more emergency department visits (15% vs 6%; P .05). Unsuccessful same-day discharge was associated with longer operative times, increased blood loss, and use of general anesthesia.In selected patients undergoing elective EVAR, same-day discharge is feasible without increasing complication rates. Health resource utilization remains a challenge in transitioning to an outpatient model.

Most studies describing the outcomes after endovascular abdominal aortic aneurysm repair (EVAR) explantation have been from single, high-volume, centers. We performed a multicenter cross-Canadian study of outcomes after EVAR stent graft explantation. Our objectives were to describe the outcomes after late open conversion and EVAR graft explantation at various Canadian centers and the techniques and outcomes stratified by the indication for explant.The Canadian Vascular Surgery Research Group performed a retrospective multicenter study of all cases of EVAR graft explantation at participating centers from 2003 to 2018. Data were collected using a standardized, secure, online platform (RedCap [Research Electronic Data Capture]). Univariate statistical analysis was used to compare the techniques and outcomes stratified the indication for graft explantation.Patient data from 111 EVAR explants collected from 13 participating centers were analyzed. The mean age at explantation was 74 years, the average aneurysm size was 7.5 cm, and 28% had had at least one instructions for use violation at EVAR. The average time between EVAR and explantation was 42.5 months. The most common indication for explantation was endoleak (n = 66; type Ia, 46; type Ib, 2; type II, 9; type III, 2; type V, 7), followed by infection in 20 patients; rupture in 18 patients (due to type Ia endoleak in 10 patients, type Ib in 1, type II in 1, type III in 2, and type V in 1), and graft thrombosis in 7 patients. The overall 30-day mortality was 11%, and 45% of the patients had experienced at least one major perioperative complication. Mortality was significantly greater for patients with rupture (33.3%) and those with infection (15%) compared with patients undergoing elective explantation for endoleak (4.5%; P = .003). The average center volume during the previous 15 years was 8 cases with a wide range (2-19 cases). A trend was seen toward greater mortality for patients treated at centers with fewer than eight cases compared with those with eight or more cases (19% vs 9%). However, the difference did not reach statistical significance (P = .23). Overall, 41% of patients had undergone at least one attempt at endovascular salvage before explantation, with the highest proportion among patients who had undergone EVAR explantation for endoleak (51%). Only 22% of patients with rupture had undergone an attempt at endovascular salvage before explantation.The performance of EVAR graft explantation has increasing in Canada. Patients who had undergone elective explantation for endoleak had lower mortality than those treated for either infection or rupture. Thus, patients with an indication for explanation should be offered surgery before symptoms or rupture has occurred. A trend was seen toward greater mortality for patients treated at centers with lower volumes.

Objectives To assess feasibility and effect of multimodal prehabilitation in patients with severe life-limiting intermittent claudication and complex infrainguinal disease. Design Case series of patients who underwent a 12-week prehabilitation program. Setting Outpatient clinic of a public tertiary hospital Participants Patients with a diagnosis of severe life-limiting intermittent claudication (Fontaine stage IIb and III) with complex infrainguinal disease or previous failed bypass attempts (N=5) who were referred to the prehabilitation clinic by a vascular surgeon. Interventions Patients underwent a baseline assessment that included quality of life questionnaires and functional capacity tests. After baseline assessment, they received a 12-week prehabilitation program that consisted of (1) a supervised exercise session 1 time per week; (2) home-based exercise prescription; (3) nutritional counseling; (4) smoking cessation; and (5) psychosocial intervention. Adherence to all components was recorded as well as the occurrence of any adverse event. After completion of the 12-week program, patients were reassessed. Main Outcome Measure Feasibility of prehabilitation measured by adherence to the different components of the program and occurrence of adverse events. Results All 5 patients completed the program. No serious adverse events occurred during the length of prehabiliation. Median adherence to each prehabilitation component was 91.7% (interquartile range [IQR], 33.5%) for supervised training, 91.7% (IQR, 40%) for home-based exercise, and 75% (IQR, 50%) for nutrition. Three of the 5 patients underwent psychosocial intervention and all who were active smokers enrolled in the smoking cessation program. Functional capacity measured with the 6-minute walk distance improved by 70 m (IQR, 99 m), and disease-specific quality of life measured with the Vascular Quality of Life Questionnaire improved by 25%. Conclusion Multimodal prehabilitation appears to be a feasible tool that could be used to increase functional capacity and quality of life for patients with complex infrainguinal disease and expected poor revascularization outcome or previous failed bypass attempts.

Aberrant right subclavian artery is the most common congenital malformation of the aortic arch (0.4%-2.0%). Aneurysms of aberrant subclavian arteries are extremely rare. This results in little experience with their treatment. We describe a case of a patient who presented to the emergency department with a dissection of an aberrant right subclavian artery that later progressed to rupture. Besides hemodynamic instability, this caused an acute superior vena cava syndrome, making airway control difficult. In the operating room, we obtained proximal control through thoracic endovascular aortic repair; median sternotomy was performed for distal control and evacuation of massive hemomediastinum.

Background This survey aims to explore trainees' perspectives on how Canadian vascular surgery training programs are using simulation in teaching and assessing technical skills through a cross-sectional national survey. Methods A 10-min online questionnaire was sent to Program Directors of Canada's Royal College of Physicians and Surgeons' of Canada approved training programs in vascular surgery. This survey was distributed among residents and fellows who were studying in the 2013–2014 academic year. Results Twenty-eight (58%) of the 48 Canadian vascular surgery trainees completed the survey. A total of 68% of the respondents were part of the 0 + 5 integrated vascular surgery training program. The use of simulation in the assessment of technical skills at the beginning of training was reported by only 3 (11%) respondents, whereas 43% reported that simulation was used in their programs in the assessment of technical skills at some time during their training. Training programs most often provided simulation as a method of teaching and learning endovascular abdominal aortic or thoracic aneurysm repair (64%). Furthermore, 96% of trainees reported the most common resource to learn and enhance technical skills was dialog with vascular surgery staff. Conclusions Surveyed vascular surgery trainees in Canada report that simulation is rarely used as a tool to assess baseline technical skills at the beginning of training. Less than half of surveyed trainees in vascular surgery programs in Canada report that simulation is being used for skills acquisition. Currently, in Canadian training programs, simulation is most commonly used to teach endovascular skills.

Randomized controlled trials of long-term survival for infrarenal abdominal aortic aneurysms have compared open surgical repair (OSR) with endovascular aneurysm repair (EVAR) in patients with suitable aortic anatomy for EVAR. However, in clinical practice, patients who do not meet instructions for use (IFU) criteria are often still treated by EVAR despite that some studies show higher graft-related adverse events. The goal of this study was to compare the long-term survival of EVAR and OSR in patients with anatomy outside IFU criteria for EVAR.This multicenter retrospective cohort study included patients with at least one anatomic IFU violation for EVAR undergoing either elective EVAR or elective OSR for abdominal aortic aneurysm. Demographics, anatomic data, and follow-up data of patients were collected from three academic centers from 2003 to 2016. Device-specific IFU were used for EVAR patients, whereas generic IFU for EVAR were applied to the OSR patients. The primary outcomes were 30-day mortality and long-term all-cause mortality. Secondary outcomes were aneurysm-related mortality and perioperative complications at 30 days. Kaplan-Meier survival and Cox proportional hazards modeling were performed. Inverse propensity score weights were used to adjust for differences in treatment selection.The study population included 202 EVAR patients and 224 OSR patients with at least one anatomic IFU violation for EVAR. EVAR patients were older (78.1 ± 7.3 vs 70.9 ± 7.0 years; P .001) and less likely to be hypertensive (69.3% vs 79.0%; P = .02) compared with OSR patients. OSR patients were more likely to have proximal aortic neck IFU violations (75.0% vs 47.1%; P .001) and were less likely to have iliac IFU violations (65.2% vs 79.2%; P .001). All-cause mortality was 37.6% in the EVAR group and 24.1% in the OSR group with a median follow-up time of 5.2 (3.5-7.2) and 5.4 (2.8-9.3) years, respectively (P.002). Kaplan-Meier survival analysis revealed a significant association between patients undergoing OSR and increased long-term survival (log-rank P .0001). When adjusted for possible confounders and weighted for propensity for treatment through Cox hazard modeling, the association remained significant (hazard ratio, 0.6; 95% confidence interval, 0.4-0.9). Aneurysm-related mortality was 3.5% in the EVAR group and 2.2% in the OSR group during long-term follow-up (P .001).Our study identified that patients with IFU violations have higher overall long-term survival with open surgery compared with EVAR. Caution should be applied in considering standard EVAR for patients with anatomy outside of IFU.

Objective This review sought to describe the current state of knowledge of the impact of frailty on perioperative clinical outcomes in patients undergoing vascular interventions. Methods A scoping review of the literature from both PubMed and Ovid Embase databases was conducted to identify relevant English- and French-language articles published from inception to May 31, 2018. Patients undergoing vascular surgery interventions were included. Results Twenty-three studies have addressed the prevalence or prognostic impact of frailty in patients undergoing vascular surgery procedures. The prevalence of frailty ranged from 20% to 60%, and notably 14 different frailty assessments were used in these studies. Frailty was associated with increased comorbid status, prolonged length of stay, discharge to assisted living facility, loss of independence, postoperative morbidity, and all-cause mortality. Conclusions There are a variety of heterogeneous tools to measure frailty in patients undergoing vascular surgery interventions. The prevalence of frailty varies by the scale used to measure it, as does its predictive value. Clinicians and surgeons should be sensitized to the importance of assessing frailty preoperatively in older adults undergoing vascular surgery and using it to assist in the decision-making process and allocation of surgical resources.

Background Several low-profile grafts have been created for use in endovascular aneurysm repair in patients with small or difficult to access vessels. Our objective was to evaluate the outcomes of patients undergoing endovascular aneurysm repair with the INCRAFT device in a real-world North American setting. Methods Consecutive patients undergoing INCRAFT implantation between March 2015 and December 2016 at two McGill University teaching hospitals were enrolled in a prospectively maintained registry. Clinical characteristic and perioperative outcomes were entered into the registry. Two authors performed anatomic measurements from preoperative and postoperative computed tomography angiograms and intraoperative angiograms independently. In cases of disagreement a consensus was reached. Results We included 61 patients with a median follow-up of 363 days (mean, 344 ± 244 days). Minimum left and right access vessel sizes were 7.5 ± 1.7 mm and 7.4 ± 1.5 mm, respectively. More than 90% of grafts were implanted for aneurysm size or growth. Vessel access was percutaneous in 95% of cases. We had a mean length of stay of 0.88 ± 1.8 days with 57.3% of patients discharged the same day. There were 14 procedural type II endoleaks, 10 new type II leaks that were discovered during follow-up, and 11 that resolved for 77% of patients remaining endoleak free during follow-up. There were no 30-day mortalities. Three cancer-related deaths occurred during follow-up. Early complications included one access site repair for bleeding, one access site repair for dissection, and two aortounilateral conversions with femoral-femoral bypass owing to inadvertent ipsilateral gate cannulation. Long-term complications included one graft limb thrombosis, one intervention for type II endoleak with sac expansion that subsequently became infected and was explanted, and one intervention for a type III endoleak for an intervention. During follow-up, 95% of patients remained reintervention free. Conclusions Use of the INCRAFT device in a real-world North American setting is relatively safe and effective, and is associated with a low rate of perioperative complications. However, we experienced early issues with inadvertent cannulation and deployment of the contralateral limb in the ipsilateral gate. Therefore, we recommend deploying the entire ipsilateral limb before cannulating the contralateral limb. Data with additional follow-up are needed to assess the long-term effectiveness of the INCRAFT device.

Objective Venous thoracic outlet syndrome (VTOS) is most commonly treated by transaxillary, supraclavicular, or paraclavicular approaches, based on surgeon preference. However, we have adopted an infraclavicular approach to VTOS as the surgical pathology is in the anterior costoclavicular space. We hypothesize that this approach, combined with catheter-directed thrombolysis (CDT) with venoplasty as needed, provides safe and effective treatment of patients with an acute presentation of VTOS. Methods We retrospectively reviewed all consecutive patients that underwent infraclavicular thoracic outlet decompression for an acute presentation of VTOS from July 2005 to February 2014 by a single surgeon. Acute presentation was defined as less than 14 days between the onset of symptoms and CDT. Demographics, primary and secondary subclavian vein patency, perioperative outcomes, and reinterventions were recorded. Results There were 33 patients that underwent an infraclavicular approach for treatment of VTOS. Average age was 35 years, and 61% were male. All patients underwent CDT, subsequent infraclavicular first rib resection, and intraoperative venography. Intraoperative subclavian vein angioplasty was performed in 70%. Median postoperative length of stay was 2 days (range, 2-6 days), blood loss was 78 mL (range, 20-200 mL), and operative time was 120 minutes (range, 76-166 minutes). Median follow-up was 78 days (range, 2-483 days). Follow-up ultrasound showed all patients having a patent subclavian vein at last follow-up. Reinterventions included two cases for rethrombosis and one case of hemothorax. Primary patency was 91%, and secondary patency was 100%. There were no complications of brachial plexus or phrenic nerve injury. All patients at last follow-up were symptom-free, and subclavian veins were patent. Conclusions An infraclavicular approach is a safe and effective treatment for acute VTOS. It provides excellent access to the costoclavicular space for first rib resection and subclavian venolysis while at the same time minimizing the risk of brachial plexus and phrenic nerve injury.

Optimal use of retrievable inferior vena cava (IVC) filters is an important health care issue, and despite an exponential rise in the use of retrievable IVC filters, national trends suggest that most of these filters are not removed. The purpose of this study was to identify risk factors associated with nonretrieval of retrievable IVC filters at our institution.A retrospective institutional review of all patients undergoing IVC filter placement from June 2010 to June 2012 was performed. A number of patient parameters were studied, including relevant demographics, indication for filter placement, clinical history, related hospitalization, and whether filter retrieval was performed. Patient parameters were compared by univariate and multivariate logistic regression analyses.There were 605 retrievable IVC filters placed over a 24-month period by vascular surgery, intervention radiology, and interventional cardiology. The follow-up retrieval rate was 25%. By indication, 272 (45%), 53 (9%), and 280 (46%) filters were placed for absolute, relative, and prophylactic indications, respectively. Independent predictors for nonretrieval by multivariate analysis were age80 years (hazard ratio [HR], 5.0; 95% confidence interval [CI], 1.7-20; P0.001), acute bleed (HR, 2.5; 95% CI, 1.4-5; P0.001), current malignancy (HR, 2.0; 95% CI, 1.3-3.3; P = 0.011), postfilter anticoagulation (HR, 0.5; 95% CI, 0.28-0.9; P = 0.017), and history of pulmonary embolism and/or venous thromboembolism (HR, 0.5; 95% CI, 0.28-0.35; P0.001). Filter placement team and indication were not identified as independent predictors of nonretrieval of IVC filters.Patient variables identified by univariate and multivariate analyses as risk for nonretrieval of retrievable IVC filters have several implications: first, some of these patients may represent a group of patients with a low life expectancy or unresolvable underlying condition in which filter retrieval has diminishing returns and may indicate the clinical option for permanence of the filter; second, identification of risk factors for nonretrieval in patients before filter placement will help to optimize use of retrievable IVC filters and enhance retrieval rates.

Acute ischemic stroke is a significant source of morbidity and mortality across the globe. Currently, the only US Food and Drug Administration approved medical treatment of acute ischemic stroke is intravascular (IV) alteplase. While IV thrombolysis has been shown to decrease morbidity and mortality from acute ischemic stroke, it is limited in both its efficacy in certain types of stroke, as well as in its generalizability. It has been shown that time to revascularization is one of the most important predictors of outcomes in acute ischemic stroke, and thus clinicians have turned to endovascular options in efforts to improve outcomes from stroke. Direct intra-arterial thrombolysis was one of the first of such efforts to improve efficacy rates and increase the timeline for thrombolytic therapy. More recently, investigators and clinicians have turned to newer endovascular options in attempts to further improve recanalization rates. Many different endovascular techniques have been employed and are growing exponentially in use. Examples include stenting, as well as mechanical thrombectomy with both older-generation devices and newer stent retrieval technology. While the majority of the literature focuses on the effectiveness of different techniques, such as recanalization rates and major overall outcomes such as death and disability, there is very little literature on the complications of the different techniques. The purpose of this article is to review the different forms of endovascular treatment of acute ischemic stroke and their associated complications.

Introduction Anesthetic options for arteriovenous fistula (AVF) creation include regional anesthesia (RA), general anesthesia (GA) and local anesthetic for select cases. In addition to the benefits of avoiding GA in high-risk patients, recent studies suggest that RA may increase perioperative venous dilation and improve maturation. Our objective was to assess perioperative outcomes of AVF creation with respect to anesthetic modality and identify patient-level factors associated with variation in contemporary anesthetic selection Methods National Surgical Quality Improvement Project (NSQIP) data (2007-2010) were accessed to identify patients undergoing AVF creation. Univariate analysis and multivariate logistic regression were performed to assess the relationships among patient characteristics, anesthesia modality and outcome. Results Of 1,540 patients undergoing new upper extremity AVF creation, 52% were male and 81% were younger than 75 years. Anesthesia distribution was GA in 85.2%, local/monitored anesthetic care (MAC) in 2.9% and RA in 11.9% of cases. By multivariate analysis, independent predictors of RA were dyspnea at rest (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.1-4.9), age >75 (HR 1.6, 95% CI 1.1-2.3) and teaching hospital status as indicated by housestaff involvement (HR 3.7, 95% CI 2.5-5.5). RA was associated with higher total operative time, duration of anesthesia, length of time in operating room and duration of anesthesia start until surgery start (pDiscussions Despite recent reports highlighting potential benefits of RA for AVF creation, GA was surprisingly used in the vast majority of cases in the United States. The only comorbidities associated with preferential RA use were advanced age and dyspnea at rest. Practice environment may influence anesthetic selection for these cases, as a nonteaching environment was associated with GA use. The trend seen here toward higher mortality in GA and the potential perioperative benefits of RA for the access should encourage more widespread use of RA in practice for this high-risk patient population.

Objective The risk of endoleak and reintervention after endovascular abdominal aortic aneurysm repair necessitates lifelong surveillance, which has associated costs, radiation exposure, and risk of nephrotoxicity. The best imaging method and timing of surveillance remain controversial. We sought to determine if a negative result of first postoperative imaging by computed tomography (CT) scan was predictive of decreased need for reintervention. We hypothesized that initial negative postoperative imaging could identify a low-risk cohort of patients who could be observed less frequently. Methods Retrospective review of prospectively collected institutional outcomes data (2004-2009) included stratification according to postoperative imaging results. Baseline characteristics and aneurysm morphology were compared between the two groups. Cox regression analysis was used to identify risk factors predictive for endoleak-related reintervention. Kaplan-Meier survival curves were used to plot freedom from all-cause reintervention and endoleak-related reintervention for the two groups. Results A total of 134 patients were included in the analysis. A total of 107 patients (80%) had negative initial postoperative imaging, whereas 27 patients (20%) had evidence of an endoleak. There were no significant differences between the two groups in terms of comorbidities or anticoagulation status. Kaplan-Meier survival curves showed that there was a significant difference between those patients who had a negative initial CT scan and those who had a positive scan for endoleak in terms of both overall reintervention rates and leak-related reintervention rates. Endoleak on the first postoperative CT scan was associated with a hazard ratio of 6.37 (confidence interval, 2.02-20.10; P = .002) for leak-related reintervention and a hazard ratio of 6.01 (confidence interval, 2.24-16.17; P Conclusions Patients with negative initial postoperative imaging were significantly less likely to require repeated interventions. These data suggest that these patients are candidates for less rigorous screening protocols.

Compared with other common chronic conditions, admissions for management of peripheral arterial disease (PAD) are associated with prolonged hospitalizations. Length of stay (LOS) is one of many metrics receiving increased attention in the current focus on efficient healthcare delivery. Our objective was to characterize LOS among patients with severe PAD, those undergoing surgical bypass for critical limb ischemia (CLI), and identify risk factors for protracted postoperative LOS.Patient data from the 2007 to 2009 American College of Surgeons National Surgical Quality Improvement Program were used to develop a database consisting of patients undergoing bypass surgery for CLI (n = 4,894). Protracted postoperative LOS was defined as the top quartile of days hospitalized from surgery to discharge. Preoperative risk factors with significant association (Pearson chi-squared test; P0.05) were used to develop a logistic regression model for protracted postoperative LOS.Average postoperative LOS was 7.5 days (median 6 days). The top quartile of postoperative LOS,8 days, was used to define protracted LOS. Independent preoperative risk factors for protracted postoperative LOS included demographic characteristics (advanced age and non-Caucasian race), comorbidities, and medical history (e.g., obesity, dialysis dependence, severe cardiac and pulmonary disease, and bleeding disorders). Indicators of PAD severity (e.g., distal target sites, open wounds or gangrene, and prior arterial surgery) were also independent predictors of protracted LOS after surgery. The greatest predictors of extended postoperative LOS were prolonged preoperative hospitalization (OR 2.2 [95% CI: 1.8-2.6], P0.001) and preoperative dependent functional status (OR 2.0 [95% CI: 1.7-2.3], P0.001 for partial dependence; OR 2.8 [95% CI: 1.8-4.3], P0.001 for totally dependent status), where OR and CI stand for odds ratio and confidence interval.Here, we identify preoperative risk factors for protracted postoperative LOS after infrainguinal bypass for CLI. These findings provide an important evidence basis for ongoing efforts to reduce healthcare spending and facilitate provision of efficient health care. Future efforts will include prospective identification of patients at high risk for protracted postoperative LOS and targeted multidisciplinary efforts to reduce associated costs without sacrificing healthcare quality.

Background Endovascular interventions are increasing; however, there are little data regarding outcomes of complex interventions involving the below-knee popliteal/P3 artery. This study evaluated the short-term and long-term results and predictors of success of below-knee popliteal artery endovascular interventions. Methods This was a retrospective review of a prospectively maintained endovascular lower extremity database of all patients with below-knee popliteal interventions from 2004 to 2012. Patient demographics, angiographic findings, interventions, primary and secondary patency, limb loss, and mortality were recorded. Analysis was performed using Kaplan-Meier life-table and multivariate analysis, with P Results There were 221 patients (56% male) with below-knee popliteal/P3 artery lesions. Mean age was 73 ± 11.2 years. Claudication was present in 22% and critical limb ischemia (CLI) in 78%. Mean lesion length was 10 ± 8.5 cm, with 45% having total occlusions. Treatment included percutaneous transluminal angioplasty (PTA) with or without a stent (47%), atherectomy (ATH) with or without PTA/stent (52%), and stenting with PTA and ATH (3%). Complications included embolization (0.4%), hematoma (2.7%), pseudoaneurysm (1.3%), and dissection (7%). Freedom from restenosis (peak systolic velocity ratio >2.4) was 65% at 1 year. Independent predictors of restenosis were CLI (hazard risk [HR], 4.4; 95% confidence interval [CI], 1.9-9.9) and stenting combined with PTA and ATH (HR, 2.7; 95% CI, 1.01-7.4). Primary assisted and secondary patencies were 95% and 85% at 1 year. ATH with PTA had lower short-term restenosis in diabetic patients compared with nondiabetic patients (95% vs 78% at 4 months). Limb loss was 18% at 4 years. Mortality was 24% at 4 years. Statin use was protective against primary restenosis (HR, 0.39; 95% CI, 0.23-0.67) and death (HR, 0.5; 95% CI, 0.28-1.0). Conclusions Endovascular intervention for lesions involving the below-knee popliteal artery is a safe and effective therapy for claudication and CLI. Diabetic patients benefit most from ATH with PTA. Statin use is protective against restenosis and mortality and should be the standard of care in patients undergoing peripheral endovascular interventions.

Proximal surgical ligation of internal iliac artery aneurysms without occlusion of the outflow vessels can lead to continued aneurysm expansion and possible rupture from retrograde flow. Percutaneous embolization options are limited because there is no direct transarterial antegrade access to the aneurysm if the internal iliac artery has been ligated. We describe the first case of bilateral percutaneous transgluteal coil embolizations to treat surgically excluded bilateral internal iliac artery aneurysms.

Successful treatment of patients with critical limb ischemia (CLI), hinges on the adequacy of revascularization. However, CLI is associated with a severe burden of systemic atherosclerosis, and patients often suffer from multiple cardiovascular comorbidities. Therefore, CLI patients in general represent a cohort at increased risk for procedural complications and adverse events. Although endovascular therapy represents a minimally invasive alternative to open surgical bypass, the durability of surgical reconstruction is superior, and it remains the "gold standard" approach to revascularization in CLI. Therefore, selection of the optimal treatment modality for individual patients requires careful consideration of the procedural risks and likelihood of adverse events associated with surgery. Individualized decision-making with regard to revascularization strategy requires a comprehensive understanding of the likelihood of adverse outcomes after major surgery. Here we review the risks of surgical bypass in patients with CLI, with particular emphasis on the identification of preoperative variables that predict poor outcome.

Race and insurance status are seen as potential barriers to health care access and maintenance. Our goal was to see how these, as well as other patient and procedural characteristics, affected our populations' upper extremity vascular access outcomes.We retrospectively reviewed 601 vascular access patients from 2004 through 2012 in our urban university hospital. We recorded patient demographics, insurance status, comorbidities, and complications. Primary outcomes were reintervention, long-term mortality, and transplantation.Median age was 62 ± 15.8 years, and 58% were male. Most operations were arteriovenous fistulas (66%). The majority of patients identified themselves as Hispanic (50%), followed by white (22%), and black (19%). Most patients had Medicare only (42%), 31% had private insurance, and 27% had Medicaid as their insurance. Black/African American patients were more likely to receive an arteriovenous graft (AVG) compared with white and Hispanic patients (44% vs. 28% and 33%, P0.05). White patients were significantly older (68) than Hispanics (61) or blacks (58). Freedom from reintervention at 5 years was 55% with previous tunneled catheter use predictive. Mortality at 5 years was 35% and predicted by age, AVG placement, white race, and not receiving a kidney transplant. Predictors of not receiving a transplant included older age, lower albumin, AVG placement, and coronary artery disease.There were no disparities with insurance status in long-term outcomes in our population. Race was not a factor for reintervention or transplantation; however, black/African American patients were more likely have an AVG placed, and white patients had a lower long-term survival after access placement.