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Despite the progressive advancement of devices for endovascular aortic repair (EVAR), endografts continue to fail, requiring explant. We present a single-institutional experience of EVAR explants, characterizing modern failure modes, presentation, and outcomes for partial and complete EVAR explantation.A retrospective analysis was performed of all EVARs explanted at an urban quaternary center from 2001 to 2020, with one infected endograft excluded. Patient and graft characteristics, indications, and perioperative and long-term outcomes were analyzed. Partial versus complete explants were performed per surgeon discretion without a predefined protocol. This process was informed by patient risk factors; asymptomatic, symptomatic, or ruptured aneurysm presentation; and anatomical or intraoperative factors, including endoleak type.From 2001 to 2020, 52 explants met the inclusion and exclusion criteria. More than one-half (57.7%) were explants of EVAR devices placed at outside institutions, designated nonindex explants. Most patients were male (86.5%), the median age was 74 years (interquartile range, 70-78 years). More than one-half (61.5%) were performed in the second decade of the study period. The most commonly explanted grafts were Gore Excluder (n = 9 grafts), Cook Zenith (n = 8), Endologix AFX (n = 7), Medtronic Endurant (n = 5), and Medtronic Talent (n = 5). Most grafts (78.8%) were explanted for neck degeneration or sac expansion. Five were explanted for initial seal failure, five for symptomatic expansion, and seven for rupture. The median implant duration was 4.2 years, although ranging widely (interquartile range, 2.6-5.1 years), but similar between index and nonindex explants (4.2 years vs 4.1 years). Partial explantation was performed in 61.5%, with implant duration slightly lower, 3.2 years versus 4.4 years for complete explants. Partial explantation was more frequent in index explants (68.2% vs 56.7%). The median length of stay was 8 days. The median intensive care unit length of stay was 3 days, without significant differences in nonindex explants (4 days vs 3 days) and partial explants (4 days vs 3 days). Thirty-day mortality occurred in two nonindex explants (one partial and one complete explant). Thirty-day readmission was similar between partial and complete explants (9.7% vs 5.0%), without accounting for nonindex readmissions. Long-term survival was comparable between partial and complete explants in Cox regression (hazard ratio, 2.45; 95% confidence interval, 0.79-7.56; P = .12).Explants of EVAR devices have increased over time at our institution. Partial explant was performed in more than one-half of cases, per operating surgeon discretion, demonstrating higher blood loss, more frequent acute kidney injury, and longer intensive care unit stays, however with comparable short-term mortality and long-term survival.

Evolution of aortic intramural hematoma (IMH) over time may range from resolution to degeneration and is difficult to predict. We sought to measure differences in contrast attenuation between arterial and delayed phase computed tomography angiography (CTA) images within the IMH as a surrogate of hematoma blood flow to predict resolution versus aortic growth and/or adverse outcomes.IMH institutional data were gathered from 2005-2020. Hounsfield unit ratio (HUR) was measured as hematoma Hounsfield unit (HU), on delayed phase images divided by HU on arterial phase images on CTA. Aortic growth and effect of HUR was determined using a linear mixed effects model. Freedom from adverse aortic event, defined as the composite of intervention, recurrence of symptoms, radiographic progression, and rupture, was determined using Kaplan-Meier analysis.IMH occurred in 73 patients, of which 27 met the inclusion criteria. HUR ranged from 0.38-1.92 (mean: 0.98). Baseline aortic diameter growth independent of HUR measurement was 0.49 mm/year (95% confidence interval CI: -1.23 to 2.2). With the HUR was introduced into the model, the beta coefficient for time was -5.83 mm/year (95% CI: -10.4 to -1.28 mm/year) and the beta coefficient for the HUR was 5.05 mm/year per one-unit HUR (95% CI: 0.56 to 9.56 mm/year). Thus, an HUR1.15 would correspond to aortic growth while an HUR1.15 would correspond to reduction in aortic diameter, consistent with IMH resolution. Aortic adverse events occurred in 13 (48%) patients, 7 (26%) patients had recurrence of symptoms, 8 (30%) required intervention, 5 (18%) progressed to dissection, and 1(4%) had aortic rupture. There was a trend towards an association between higher HUR and composite adverse aortic events (HR 3.2 per 1-unit HUR; 95% CI: 0.6-17.3; P = 0.18).Increased HUR is associated with increased aortic growth and a trend toward adverse aortic events. Diminished delayed phase enhancement may predict partial or complete IMH resolution. HUR can be used to guide IMH surveillance and treatment.

Abdominal compartment syndrome (ACoS) is a devastating complication after endovascular aneurysm repair for ruptured abdominal aortic aneurysms (rEVAR). This study sought to develop a risk score for ACoS to identify patients who would benefit from early decompressive laparotomy.Model derivation was performed with Vascular Quality Initiative data for rEVAR from 2013 to 2020. The primary outcome was evacuation of abdominal hematoma. A multivariable logistic regression was used to create and validate a scoring system to predict ACoS. The model was validated using institutional data for rEVAR from 1998 to 2019.The derivation cohort included 2,310 patients with rEVAR. Abdominal hematoma evacuation occurred in 265 patients (11.5%). Factors associated with abdominal hematoma evacuation on a multivariable analysis included transfer from an outside hospital, preoperative creatinine ≥1.4 mg/dL, preoperative systolic blood pressure ≤85 mmHg, preoperative altered mental status, ≥3.0 liters intraoperative crystalloid, and ≥4 units of red blood cells transfused intraoperatively. The validation cohort consisted of 67 rEVAR; ACoS occurred in 8 patients (11.9%). The c-statistic was 0.84 in the derivation and 0.87 in the validation cohort, whereas Hosmer-Lemeshow was P = 0.15 in the derivation and 0.84 in the validation cohorts, suggesting good model discrimination and calibration. Points were applied based on β-coefficients to produce a risk score ranging from -1 to 13. A cutoff of risk score ≥8 resulted in a sensitivity and specificity of 87.5% and 83.1% for detecting patients with ACoS, respectively. ACoS conveyed a significantly higher mortality in both the derivation (ACoS: 49.8% vs. No ACoS: 17.8%; P0.001) and validation cohorts (ACoS: 75.0% vs. No ACoS: 15.2%; P0.001).In patients with equivocal signs/symptoms of ACoS, this scoring system can be used to guide surgeons on when to perform decompressive laparotomy prior to leaving the operating room for rEVAR. Patients with a risk score ≥8 would benefit from decompressive laparotomy at index rEVAR.

Objectives : Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described. Methods : We studied all elective EVAR from 2010-2018 in a single institution. Late endoleaks were defined as those appearing after one year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival. Results : Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92% and 81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine one-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P=.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P=.02), neck length 60 degrees (HR 3.4 [1.5-7.9], P=.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. Two patients had proximal degeneration and 5 experienced graft migration. There were two ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years). Conclusion : Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR.

Thromboelastography (TEG) is diagnostic modality that analyzes real-time blood coagulation parameters. Clinically, TEG primarily allows for directed blood component resuscitation among patients with acute blood loss and coagulopathy. The utilization of TEG has been widely adopted in among other surgical specialties; however, its use in vascular surgery is less prominent. We aimed to provide an up-to-date review of TEG utilization in vascular and endovascular surgery.Using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a literature review with the Medical Subject Headings (MeSH) terms "TEG and arterial events", "TEG and vascular surgery", "TEG and vascular", "TEG and endovascular surgery", "TEG and endovascular", "TEG and peripheral artery disease", "TEG and prediction of arterial events", "TEG and prediction of complications ", "TEG and prediction of thrombosis", "TEG and prediction of amputation", and "TEG and amputation" was performed in Cochrane and PubMed databases to identify all peer-reviewed studies of TEG utilization in vascular surgery, written between 2000 and 2021 in the English language. The free-text and MeSH subheadings search terms included diagnosis, complications, physiopathology, surgery, mortality, and therapy to further restrict the articles. Studies were excluded if they were not in humans or pertaining to vascular or endovascular surgery. Additionally, case reports and studies with limited information regarding TEG utilization were excluded. Each study was independently reviewed by two researchers to assess for eligibility.Of the 262 studies identified through the MeSH strategy, 15 studies met inclusion criteria and were reviewed and summarized. Literature on TEG utilization in vascular surgery spanned cerebrovascular disease (n = 3), peripheral arterial disease (n = 3), arteriovenous malformations (n = 1), venous thromboembolic events (n = 7), and perioperative bleeding and transfusion (n = 1). In cerebrovascular disease, TEG may predict the presence and stability of carotid plaques, analyze platelet function before carotid stenting, and compare efficacy of antiplatelet therapy after stent deployment. In peripheral arterial disease, TEG has been used to predict disease severity and analyze the impact of contrast on coagulation parameters. In venous disease, TEG may predict hypercoagulability and thromboembolic events among various patient populations. Finally, TEG can be utilized in the postoperative setting to predict hemorrhage and transfusion requirements.This systematic review provides an up-to-date summarization of TEG utilization in multiple facets of vascular and endovascular surgery.

Addition of ipsilateral proximal endovascular intervention (PEI, common carotid/innominate) increases the risk of perioperative stroke/death for both carotid endarterectomy (CEA) and carotid stenting (CAS). However, these approaches have not been directly compared and is the subject of this study.VQI (2005-2020) was queried for CEA and CAS with PEI, excluding emergent, bilateral, and repeat procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis50%, and transcarotid ICA stents. Primary outcome were the composite of perioperative stroke/death and long-term stroke/reintervention/death. Operative approach was evaluated with logistic regression, adjusted propensity scores, symptomatic status, and stenosis70%. Long-term outcomes were compared with Kaplan-Meier Analysis.There were 1,433 patients (795 endovascular;638 hybrid); mean age 69.8±9.4 years. Patients undergoing hybrid procedures were more likely to be female (49.4% vs. 37.5%; P0.001), less likely to have diabetes (29.5% vs. 38.2%; P P0.001), less likely to have a prior ipsilateral CEA (3.8% vs. 32.2%; P0.001), less likely to be symptomatic (34.6% vs. 52.8%; P0.001), and less likely to have70% stenosis (77.3% vs. 95.6%%; P0.001). Perioperative stroke/death was 3.6% for hybrid and 3.9% for endovascular approaches (P = 0.77). In the multivariable model, hybrid operative approach (compared to the total endovascular approach) was not significantly associated with stroke/death (OR 1.29; 95%CI: 0.55-3.07; P = 0.56). For the 981 patients with long-term follow-up (556 endovascular; 425 hybrid), 1-year freedom from stroke/reintervention/death was 94.0% (95%CI: 90.9%-96.0%) for hybrid approach vs. 92.3% (95%CI: 89.5%-94.4%) for endovascular approach (P = 0.27).Although simultaneous repair of tandem carotid lesions portends worse outcomes when compared to CEA or CAS alone, there was no difference in short or long-term stroke and death rates with a hybrid or totally endovascular approach. Therefore, it is reasonable to use either approach in the select patients who require simultaneous repair of both lesions.

A nationwide variation in mortality stratified by hospital volume exists after open repair of complex abdominal aortic aneurysms (AAAs). In the present study, we assessed whether the rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) would better explain the lower mortality rates among higher volume hospitals.Using the 2004 to 2018 Vascular Quality Initiative database, we identified all patients who had undergone open repair of elective or symptomatic AAAs, in which the proximal clamp sites were at least above one renal artery. We divided the patients into hospital quintiles according to the annual hospital volume and compared the risk-adjusted outcomes. Multivariable logistic regression, adjusted for patient characteristics, operative factors, and hospital volume, was used to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue.We identified 3566 patients who had undergone open repair of elective or symptomatic complex AAAs (median age, 71 years; 29% women; 4.1% black; 48% Medicare insurance). The unadjusted rates of 30-day postoperative mortality, overall complications, and failure-to-rescue were 5.0%, 44%, and 10%, respectively. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with the specific failure-to-rescue rate ranging from 12% to 22%. On adjusted analysis, the risk-adjusted mortality rate was 2.5 times greater for the lower volume hospitals relative to the higher volume hospitals (7.4% vs 3.0%; P .01). Although the risk-adjusted complication rates were similar between these hospital groups (30% vs 27%; P = .06), the failure-to-rescue rate was 2.3 times greater for the lower volume hospitals relative to the higher volume hospitals (6.3% vs 2.7%; P = .02).Higher volume hospitals had lower mortality rates after open repair of complex AAAs because they were better at the "rescue" of patients after the occurrence of postoperative complications. Both an understanding of the clinical mechanisms underlying this association and the regionalization of open repair might improve patient outcomes.

Objective The objective of this study was to assess the perioperative and long-term outcomes of carotid body tumor (CBT) resection with a multispecialty (head and neck surgery/vascular surgery) approach. Methods Our institutional data registry was queried for Current Procedural Terminology codes (60600, 60605) pertaining to CBT excision. These patient records and operative reports were individually reviewed to determine laterality, preoperative tumor embolization, operative time, estimated blood loss, need for intraoperative transfusion, intraoperative electroencephalogram changes, intraoperative division of the external carotid artery, carotid artery repair, resection of the carotid bifurcation, tumor volume, final pathology, cranial nerve injury, stroke, death, and clinical or radiographic evidence of recurrence. Results From 1996 to 2018, 74 CBT resections were identified in 68 patients (41 [60%] females; mean age, 50.83 years). The mean tumor volume was 9.92 ± 14.26 cm3 (range, 0.0250-71.0627 cm3). Embolization was performed by a neurointerventional specialist in 27 CBT resections (36%) based on size (embolization 14.27 ± 16.84 cm3 vs 7.17 ± 11.86 cm3; P = .063) and superior extension. This practice resulted in one asymptomatic vertebral dissection, which postponed the surgery. There was a trend toward greater blood loss in the embolization group (embolization 437 ± 545 mL vs 262 ± 222 mL; P = .17); however, no transfusions were required in any patient. The mean operative time was also significantly longer in the embolization group (198.33 ± 61.13 minutes vs 161.5 ± 55.56 minutes; P = .03). Three resections had reversible intraoperative electroencephalogram changes, one of which occurred during carotid clamping. These changes resolved with shunting. Eight external carotid resections (11%) and 6 carotid reconstructions (8.1%; two primary, two patch, and two primary anastomosis) were required. Malignancy was identified in four tumors (5.4%), accounting for four of the six carotid reconstructions. There were no postoperative cranial nerve injuries, no strokes, no reexplorations, and no deaths. One patient developed transient dysphagia from pharyngeal tumor infiltration. Long-term follow-up (mean, 43 ± 54 months), available in 61 of the 68 patients (89.7%), revealed three (4.4%) recurrences. Conclusions This large, single-institution series demonstrates that a multispecialty team combining two surgical skill sets for the treatment of this rare, challenging condition yields unparalleled low complication rates with short operative times. This approach, including long-term surveillance for recurrent disease, should be considered to optimize outcomes of CBT resection.

Right ventricular (RV) function is a critical determinant of survival in patients with pulmonary arterial hypertension (PAH). While miR-21 is known to associate with vascular remodeling in small animal models of PAH, its role in RV remodeling in large animal models has not been characterized. Herein, we investigated the role of miR-21 in RV dysfunction using a sheep model of PAH secondary to pulmonary arterial constriction (PAC). RV structural and functional remodeling were examined using ultrasound imaging. Our results showed that post PAC, RV strain significantly decreased at the basal region compared with t the control. Moreover, such dysfunction was accompanied by increases in miR-21 levels. To determine the role of miR-21 in RV remodeling secondary to PAC, we investigated the molecular alteration secondary to phenylephrine induced hypertrophy and miR21 overexpression in vitro using neonatal rat ventricular myocytes (NRVMs). We found that overexpression of miR-21 in the setting of hypertrophic stimulation augmented only the expression of proteins critical for mitosis but not cytokinesis. Strikingly, this molecular alteration was associated with an eccentric cellular hypertrophic phenotype similar to what we observed in vivo PAC animal model in sheep. Importantly, this hypertrophic change was diminished upon suppressing miR-21 in NRVMs. Collectively, our in vitro and in vivo data demonstrate that miR-21 is a critical contributor in the development of RV dysfunction and could represent a novel therapeutic target for PAH associated RV dysfunction.

OBJECTIVE Although the transabdominal approach (TAA) and lateral approach (LA) to open abdominal aortic aneurysm repair (OAR) are both acceptable and widely used, a paucity of data evaluating subsequent postoperative laparotomy-associated complications (LCs) is available. The aim of the present study was to establish the incidence of LCs after OAR and determine which approach was associated with an increase in long-term LCs. METHODS An institutional database for OAR (2010-2019) was queried, excluding urgent and emergent cases. The primary endpoint was long-term LCs, defined as any complication related to entry into the abdomen. The LA included retroperitoneal and thoracoabdominal approaches and the TAA included all patients with midline incisions. A Kaplan-Meier analysis was used to estimate the freedom from LCs, and the Fine-Gray method was used to determine the predictors of LCs, with death as a competing risk. RESULTS A total of 241 patients (mean age, 70.0 ± 9.1 years; 71.7% men) had undergone OAR, 91 via a TAA and 150 via a LA. The patients in the TAA group were significantly younger (age, 66.7 ± 8.9 vs 72.1 ± 8.7 years; P < .001), more likely to be male (83.5% vs 64.7%; P = .002), and more likely to have a history of small bowel obstruction (SBO; 3.3% vs 0%; P = .025). Patients in the LA group were more likely to have required a supraceliac clamp (20.7% vs 1.1%; P < .001). No difference was found in the incidence of perioperative complications or long-term mortality. The most common LCs were hernia (TAA, 26.4%; LA, 11.3%; P = .003), SBO (TAA, 8.8%, LA, 1.3%; P = .005), and other (TAA, 13.2%; LA, 2.0%; P = .001), which included evisceration, bowel ischemia, splenic injuries requiring reintervention, enterocutaneous fistula, internal hernia, and retrograde ejaculation. Operative LCs were more common in the TAA group (17.6% vs 2.7%; P < .001). The unadjusted 1-, 3-, and 5-year freedom from LCs was 77.7% (95% confidence interval [CI], 66.0%-85.8%), 60.5% (95% CI, 46.5%-71.9%), and 54.0% (95% CI, 38.8%-67.0%) for TAA and 94.8% (95% CI, 88.8%-97.7%), 82.2% (95% CI, 72.2%-88.9%), and 79.1% (95% CI, 68.4%-86.5%) for LA, respectively (log-rank P < .001). The predictors for LCs were a history of SBO (P = .001), increasing body mass index (P = .005), and the use of the TAA (P < .001). CONCLUSIONS Use of the TAA was an independent predictor of long-term LCs after OAR, along with an increasing body mass index and a history of SBO. In patients with amenable anatomy, the LA is favorable for preventing long-term LCs, especially in high-risk patients.

Although percutaneous brachial access has been used more often for peripheral vascular interventions (PVIs), previous studies have suggested that open brachial artery exposure for access is associated with fewer complications than percutaneous access. The present study sought to determine the incidence of complications for each access method and identify the predictors of access site complications after brachial access.The Vascular Quality Initiative national database was queried for all patients who had undergone PVI with brachial artery access from 2016 to 2019. Procedures with simultaneous thrombolysis or open procedures were excluded. The primary outcome was any perioperative brachial artery access complications. Multivariable logistic regression was used to identify any associated predictors.A total of 1400 procedures had been performed for 1242 patients; 189 procedures (13.5%) had used an open exposure. The mean patient age was 67.3 ± 9.5 years, and 55.7% of the procedures were on men. No significant demographic differences were found between the open and percutaneous groups. Open exposure procedures were more likely to have used sheaths5F (79.4% vs 59.0%; P .001) and treated more arteries (2.0 ± 1.8 vs 1.7 ± 0.9; P .001) but less likely to have used multiple access sites (8.5% vs 20.1%; P .001). Access complications occurred in 7.5% of the percutaneous procedures and 1.6% of the open exposures (P = .003). Percutaneous access was independently associated with the occurrence of brachial access complications (odds ratio [OR], 5.92; 95% confidence interval [CI], 1.76-19.9; P = .004). Other associated factors included female sex (OR, 2.23; 95% CI, 1.44-3.44; P .001), congestive heart failure (OR, 2.02; 95% CI, 1.26-3.24; P = .003), and increasing sheath size (OR, 1.36 per each 1F increase in size; 95% CI, 1.07-1.72; P = .011); diabetes was protective (OR, 0.53; 95% CI, 0.33-0.83; P = .006).Open exposure might be advantageous compared with percutaneous access for preventing complications after brachial access. However, the difference in complications was driven by hematomas that were managed nonoperatively. Operative complications were more common in the percutaneous group, although this did not reach statistical significance. Percutaneous access should be used cautiously in women, patients with a history of congestive heart failure, those without diabetes, and interventions in which larger sheaths are required.

Objective Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in women, sex-specific differences in outcomes after open type IV thoracoabdominal aortic aneurysm (TAAA) surgery are undefined. The goal of this study was to define sex-based disparities in short- and long-term outcomes after open type IV TAAA surgery. Methods All open type IV TAAA repairs performed during 27 years were evaluated using a single institutional database. Charts were retrospectively evaluated for major adverse events (in-hospital death, other major in-hospital complication) and long-term complications (graft- and aortic-related events and death). Univariate analyses were performed using the Fisher’s exact test for categorical variables and Wilcoxon rank-sum testing for continuous variables. Logistic multivariable regression was used for the in-hospital end points death and major complication, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. Results During the 27-year study period, 234 patients had an open type IV TAAA repair; 85 were female and 149 were male. There were 26 (17.5%) men and 16 (18.8%) women who suffered a major in-hospital complication/death. There were eight (3.4%) in-hospital deaths, all occurring in men. Unadjusted survival at 5 years was 67.9% for women and 58.4% for men. Multivariable analyses revealed no sex-based difference in combined major in-hospital events and death (female: odds ratio [OR], 1.8; confidence interval [CI], 0.83-4.0; P = .13) or any complication (OR, 1.0; CI, 0.55-1.8; P = .99). However, women were less likely than men to be discharged to home (OR, 0.28; CI, 0.13-0.60; P = .001) and had decreased survival compared with men after discharge (hazard ratio, 2.1; CI, 1.2-3.5; P = .008). Conclusions No sex-based differences were found for the in-hospital outcomes of death or major complication after open type IV TAAA repair. However, women are less likely than men to be discharged home. Among those who survive the index operation, female sex portends decreased survival following discharge after repair.

Although prior endovascular intervention is a risk factor for inferior outcomes after infrainguinal bypass, there are few studies evaluating the effect of prior aortoiliac endovascular intervention (AIEI) on outcomes after aortofemoral bypass (AFB). We sought to determine if prior AIEI was predictive of adverse events after AFB.The Vascular Quality Initiative was queried for all patients who underwent AFB form 2009 to 2019. Urgent/emergent cases and repeat procedures were excluded. Primary outcomes were major perioperative complications, major adverse limb event (MALE)-free survival, and long-term survival. Multivariable logistic regression identified predictors of major complications. Predictors of MALE-free survival were identified with Cox proportional hazards modeling.There were 3,056 patients who underwent AFB; 618 had a prior AIEI. Mean age was 60.3 ± 8.7 years, and 58.7% of patients were men. There was no difference in major complications between the 2 groups (AIEI: 23.8%, no AIEI: 24.5%; P-value = 0.70). Factors associated with major complications were chronic obstructive pulmonary disease (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.07-1.54; P = 0.008), simultaneous lower extremity intervention (endarterectomy, bypass, or transluminal intervention, OR 1.41, 95% CI: 1.18-1.69; P 0.001), congestive heart failure (CHF) (OR 1.58, 95% CI: 1.15-2.16; P = 0.004), increased age (OR 1.03 per year, 95% CI: 1.02-1.04; P 0.001), increasing operative blood loss (OR 1.35 per liter, 95% CI: 1.21-1.50; P 0.001), increasing operative time (OR 1.07 per hour, 95% CI: 1.02-1.13; P = 0.008), and end-to-side proximal anastomosis (OR 1.23, 95% CI: 1.03-1.46; P = 0.022). One-year MALE-Free survival was 88.2% (95% CI: 85.2-90.7%) for the prior AIEI group and 89.7% (95% CI: 88.3-90.7%) for the group without prior AIEI (logrank P-value = 0.201). Predictors of MALEs/death were history of a bypass (hazard ratio [HR] 1.51, 95% CI: 1.16-1.96; P = 0.002), increasing degree of ischemia on presentation (HR 1.28 per increasing level of ischemia, 95% CI: 1.16-1.41; P 0.001), diabetes (HR 1.29, 95% CI: 1.05-1.59; P = 0.014), simultaneous peripheral vascular intervention (HR 2.06, 95% CI: 1.02-4.15; P = 0.044), CHF (HR 1.60, 95% CI: 1.18-2.18; P = 0.002), end-stage renal disease on hemodialysis (HR 5.07, 95% CI: 2.45-10.48; P 0.001), and presenting hemoglobin9 g/dl (HR 1.76, 95% CI: 1.02-3.02; P = 0.041). One-year survival for the prior AIEI group was 94.5% (95% CI: 92.2-96.1%) and 94.0% (95% CI: 92.9-94.9%) for the group with no prior AIEI (logrank P = 0.486). Prior AIEI did not predict any of the primary outcomes in multivariable analysis.An endovascular-first approach for aortoiliac occlusive disease appears to be safe and does not portend to inferior results after AFB.

With the evolution in vascular surgery toward increased endovascular therapy and decreased open surgical training, comfort with open procedures by current trainees is declining. A proposed method to improve this discomfort is simulator training. We hypothesized that open, cadaver, and endovascular surgery simulation would be associated with increased self-perceived comfort in performing corresponding procedures.Integrated (0 + 5) vascular surgery residents and recent graduates in the United States were asked to complete a survey quantifying comfort via a Likert scale with procedures and experience with simulation training. Simulation groups were then matched using coarsened exact matching. Ordinal logistic regression assessed the association between simulation experience and comfort in performing procedures.Surveys were completed by 68 trainees and 20 attending surgeons in their first 5 years of practice. On unmatched analyses, there were no significant differences in comfort in performing any open or endovascular aorto-mesenteric or peripheral vascular procedures between respondents who reported experience with open or endovascular simulation, respectively. However, respondents who reported cadaver simulation experience (58%, 51/88) had a significantly higher reported comfort score performing open juxtarenal aortic repair (2.4 vs. 1.7), superior mesenteric artery thrombectomy or bypass (2.5 vs. 1.9), inferior vena cava or iliac vein repair (2.2 vs. 1.7), axillary-femoral artery bypass (3.4 vs. 2.5), femoral-popliteal artery bypass (3.7 vs. 2.8), and inframalleolar artery bypass (2.8 vs. 2.1; all P 0.05). After matching on training level, number of abdominal cases completed, and number of open vascular cases completed, ordinal logistic regression demonstrated that previous cadaver simulation was significantly associated with increased comfort in performing open aortic repairs, venous repair, visceral revascularization, and peripheral bypasses.In this nationally representative sample, cadaver, but not open or endovascular, simulation was associated with increased comfort in performing open vascular surgery. Providing cadaver simulation to trainees may help to improve comfort levels in performing open surgery. Integrated vascular surgery training programs should consider implementing these experiences into their curriculum.

The management of patients with carotid stenosis and symptomatic coronary artery disease (CAD) is challenging. This study assessed the impact of clinical coronary disease severity on carotid endarterectomy (CEA) with and without combined coronary artery bypass (CCAB).Using the Vascular Quality Initiative, patients with symptomatic CAD who underwent CCAB or isolated CEA (ICEA) from 2003 to 2017 were identified. Patients were stratified by CAD severity: stable angina (SA) and recent myocardial infarction/unstable angina (UA). Primary outcomes, including perioperative stroke, myocardial infarction (MI), and stroke/death/MI (SDM), were assessed between procedures within each CAD cohort.There were 9098 patients identified: 887 CCAB patients (215 [24%] SA, 672 [76%] UA) and 8211 ICEA patients (6385 [78%] SA, 1826 [22%] UA). Overall, CCAB patients had higher rates of stroke (2.6% vs 1.3%; P = .002) and SDM (7.3% vs 3.5%, P .001) but similar rates of MI (0.9% vs 1.6%; P = .12) compared with ICEA patients. In SA patients, no difference was seen in stroke (ICEA 1.2% vs CCAB 1.9%; P = .36), MI (1.3% vs 1.4%; P = .95), or SDM (2.9% vs 4.7%; P = .13). In UA patients, no difference was seen in stroke (ICEA 1.6% vs CCAB 2.8%; P = .06), but ICEA patients had higher rates of MI (2.4% vs 0.7%; P = .01) and CCAB patients had higher rates of SDM (8.2% vs 5.5%; P = .01). After logistic regression in the UA cohort, predictors of MI included ICEA (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-7.0; P = .04) and carotid symptomatic status (OR, 2.1; 95% CI, 1.1-3.8; P = .01); carotid symptomatic status also predicted stroke (OR, 2.0; 95% CI, 1.1-3.6; P = .03), but CCAB did not.In patients with symptomatic CAD, both clinical CAD severity and operative strategy affect outcomes. In SA patients, CCAB does not increase perioperative morbidity. However, CCAB in UA patients prevents MI while not appreciably increasing stroke risk. This suggests that coronary revascularization before or concomitant with CEA should be considered in UA patients but that prioritizing coronary intervention is less important in SA patients.

In treating concomitant carotid and coronary disease, some recommend staged carotid endarterectomy (CEA) and coronary artery bypass grafting, whereas others favor the combined approach (CCAB). Pressure to reduce surgical variation and to improve quality is real, yet little is known about how geographic practice differences affect outcomes. Using the Vascular Quality Initiative (VQI), this study evaluated regional variation in use and outcomes of CCAB.All CCAB procedures in the VQI from 2003 to 2017 were reviewed and stratified into four regions, as defined by the United States Census Bureau. Primary outcomes included perioperative stroke, death, myocardial infarction (MI), and these as composite (SDM). A χThere were 1495 CCAB procedures identified, representing 1.8% of the VQI CEAs. Regions included the following: Midwest (MW), 32%; Northeast (NE), 39%; South (S), 25%; and West (W), 4%. Most were male (70%) and white (92%). There was significant regional variation in proportional volume of CCABs to all CEAs (0.7% [W] to 2.5% [MW]; P .001). Regional variation in patch use (78% [W] to 93% [MW]; P .001), shunting (29% [W] to 71% [MW]; P .001), and electroencephalography monitoring (13% [W] to 52% [NE]; P .001) was also significant. Overall perioperative stroke was 3.6%; death, 3.0%; and SDM, 6.8%. No regional difference was seen in outcomes of mortality (1.5% [MW] to 4.2% [NE]; P = .05), stroke (2.8% [NE] to 4.4% [MW]; P = .52), and MI (0.6% [MW] to 1.8% [W]; P = .62). When the Bonferroni correction was used, there remained no difference in stroke, MI, or SDM across regions, but mortality became significant. Using the Society for Vascular Surgery guidelines for consideration of CCAB, the minority of patients fell within the symptomatic carotid stenosis (SYMP, 15%; n = 218) or severe (≥70%) asymptomatic bilateral carotid disease (BIL, 18%; n = 267) categories. The most common indication was asymptomatic unilateral severe carotid stenosis (UNI, 37%; n = 552). There were no differences in regional outcomes stratified by indication (SYMP, BIL, UNI). Overall, when SYMP and BIL were compared with UNI, UNI had lower rates of stroke (2.4% vs 4.9%; P = .03) but similar MI (0.7% vs 1.2%; P = .40) and mortality (2.2% vs 2.5%; P = .75).Significant variation exists across VQI centers in the use of CCAB. Despite differences in volume and practices, regional perioperative outcomes are similar. UNI is the most commonly used indication and has lower stroke rates relative to SYMP and BIL. CCAB is performed well across the United States, but most patients fall outside of Society for Vascular Surgery guidelines.

Early outcomes and late mortality after open repair of extent I to III thoracoabdominal aortic aneurysms (TAAAs) are described, but late graft and aortic events are seldom detailed. This study investigated long-term aortic and graft outcomes as these data are increasingly important as endovascular repair matures.During 28 years, 516 patients underwent repair (type I, n = 177 [34%]; type II, n = 100 [20%]; type III, n = 239 [46%]). Patients were monitored for late events. Late aortic events were defined as native aortic disease leading to death or further intervention. Planned secondary procedures were excluded. Graft complications included anastomotic aneurysm, graft infection, and branch occlusions. Variables were assessed for association with end points using log-rank methods and Cox proportional hazards regression. Time-to-event analysis was performed using Kaplan-Meier methods.In-hospital death occurred in 40 patients (8%), leaving 476 for surveillance. Mean age was 69.8 ± 10.5 years. Mean follow-up was 4.9 ± 4.6 years. Repair conduct included distal aortic perfusion and motor evoked potential monitoring (n = 169 [35.5%]), clamp and sew (n = 307 [64.5%]), and selectively applied in-line mesenteric shunting (n = 172 [36.1%]). At the time of repair, 117 patients (24.6%) had 122 synchronous, noncontiguous aortic aneurysms. There were 98 late aortic and graft events in 89 patients (18.7%); 62 aortic-related events occurred in 56 patients (12%; elective repair, n = 47; emergent repair, n = 14; type A dissection, n = 1) at a mean of 4.4 ± 4.2 years after repair. Variables independently predictive of an aortic event were aortic clamp time (hazard ratio [HR], 1.02/min; P = .001), type III extent (HR, 2.5; P = .008), and expansion of retained aorta (HR, 10.4; P .0005). There were 33 patients (7%) who experienced 36 graft-related events (anastomotic aneurysm, n = 14 [3% of cohort; aortic, n = 7; visceral patch, n = 6; side graft, n = 1]; graft infection, n = 12; renovisceral occlusion/repair, n = 9 [1.9%; side-arm graft, n = 8; native, n = 1]; and anastomotic stricture, n = 1) occurring at 4.7 ± 4.5 years. Variables predictive of graft-related complication were type II extent (HR, 3.4; P = .002) and distal aortic perfusion and motor evoked potential monitoring (HR, 3.6; P = .02). Freedom from aortic- or graft-related event was 80% at 5 years. Freedom from any aortic or graft reintervention was 84% at 5 years. Aortic-related mortality after discharge was 2.7% and estimated to be 3.1% at 5 years. Overall survival was 67% and 44% at 5 and 10 years, respectively.After type I-III TAAA repair, late aortic and graft-related events occur in 19% of patients. Native aortic disease sequelae are more common than graft complication. Aortic events are predicted by complex operation and degree of remaining aorta. Extensive reconstruction drives graft-related events. Ultimately, reintervention is rare and aorta-related mortality low. These findings verify durability of extensive TAAA repair, serving as benchmarks for endovascular repair.

There is a paucity of data guiding preoperative counseling on the need for discharge to a facility or nonhome discharge (NHD) following elective endovascular repair of abdominal aortic aneurysms (endovascular aneurysm repair [EVAR]). This study seeks to determine the preoperative predictors of NHD following EVAR in baseline home-dwelling patients and to determine whether NHD is associated with major postdischarge complications and readmission.This retrospective cohort study utilized the National Surgical Quality Improvement Program Vascular Procedure Targeted database to identify elective EVAR cases admitted from home (2011 to 2015). The primary end point was NHD. A multivariable logistic regression model was used to determine predictive preoperative factors for NHD and to determine whether NHD predicted major postdischarge complications and readmission.Overall 6,276 cases were included; 291 (4.6%) required NHD. NHD were more frequently female, anemic, functionally dependent, nonsmokers, had chronic obstructive pulmonary disease, recent congestive heart failure exacerbation, and open baseline wounds. NHD was associated with complex surgery, indicated by operative time more than the median, 2.5 hr. Significant predictors for NHD on multivariable analysis included female sex (odds ratio [OR]: 2.2, confidence interval [CI]: 1.7-2.9, P 0.001), octogenarians (OR: 5.7 CI: 2.3-14.1; P 0.001) and nonagenarians (OR: 14.6, CI: 5.4-39.2; P 0.001), dependent functional status (OR: 5.4, CI: 3.3-8.8; P 0.001), preoperative open wound (OR: 3.5, CI: 1.4-8.9; P = 0.006), high operative time (OR: 2.7, CI: 2.0-3.6; P 0.001), and hypogastric embolization (OR: 1.6, CI: 1.1-2.1 P = 0.022), C-statistic = 0.780. On adjusted analysis, NHD did not independently predict major postdischarge complication (OR: 1.0 CI: 0.6-1.9; P = 0.875) or unplanned readmission (OR 1.0, CI: 0.6-1.5, P = 0.842).Discharge to skilled facility following EVAR can be predicted using preoperative factors. Future studies should seek to validate these findings in a prospective manner. Identifying high-risk patients' NHD can help define expectations and facilitate early referral to skilled facilities that may reduce hospital length of stay, reducing health-care costs.

Background There are limited data guiding preoperative counseling on the need for discharge to facility after elective open abdominal aortic aneurysm repair (OAR). This study aims to determine the preoperative predictors for nonhome discharge (NHD) following OAR. Materials and methods The National Surgical Quality Improvement Program Vascular Procedure Targeted database was queried for elective OAR, 2011-2015. The primary endpoint was NHD. Complex surgery was defined as high operative time. Multivariable logistic regression identified preoperative factors predictive of NHD. Results Overall 510 patients were included; 87 (17.1%) required NHD. Baseline characteristics differed: NHD were more frequently female, partially dependent, older, had history of chronic obstructive pulmonary disease, bleeding disorder, and anemia. After risk adjustment, age≥70 y (odds ratio [OR]: 12.48, confidence interval [CI]: 2.89-53.99; P = 0.001), partial dependence (OR: 8.17, CI: 1.39-47.84; P = 0.02), female sex (OR: 1.88, CI: 1.10-3.20; P = 0.02), history of bleeding disorder (OR: 2.65, CI: 1.14-6.15; P = 0.02), and high operative time (OR: 1.84, CI: 1.03-3.26; P = 0.04) were independent predictors of NHD. On unadjusted analysis, NHD was not associated with increased major postdischarge complications (OR: 1.52, CI: 0.48-4.78; P = 0.47 P = 0.47) or unplanned readmission (OR: 0.74, CI: 0.25-2.16; P = 0.58) Conclusions NHD following OAR can be predicted using preoperative factors including age, functional status, sex, history of bleeding disorder, and complex repair. NHD was not associated with more major postdischarge complications or unplanned readmission. A better understanding of patients at risk for NHD will allow for better preoperative counseling and will help to set appropriate expectations.

BACKGROUND Superficial femoral artery (SFA) and profunda patency has been shown to affect aortofemoral bypass (AFB) limb patency. However, the effect of retrograde flow through the external iliac artery (EIA) is unknown and is the subject of this analysis. METHODS Institutional AFB data from 2000-2017 were gathered, excluding those where SFA/EIA patency could not be determined. The cohort was divided into limbs with and without EIA occlusion; primary outcome was limb-based primary patency. Kaplan-Meier estimated patency; cox proportional-hazards model evaluated EIA patency while controlling for other factors. RESULTS Over the study period, there were AFB 557 limbs in 281 patients. Of the 435 AFB limbs in 220 patients that met inclusion criteria and were included in the analysis, 162 had EIA occlusion and 273 had a patent EIA. Mean age was 69.6±9.0. EIA occlusions were more common in male patients (59.9% vs 44.6%; p=0.001), patients with CAD (43.8% vs 34.1%; p=0.042), COPD (34.6% vs 20.5%; p=0.001), and CHF (14.8% vs 5.9%; p=0.002). Limbs with EIA occlusions more often underwent end-to-side proximal anastomosis (40.7% vs 24.2%; p

The proportion of open aneurysm repairs requiring at least a suprarenal clamp has increased in the past few decades, partly owing to preferred endovascular approaches for most patients with infrarenal aneurysms, suggesting that the management of aortic clamp placement has become even more relevant. This study evaluated the association between the proximal clamp site and intraoperative ischemia times with postoperative renal dysfunction and mortality.We used the Vascular Quality Initiative to identify all patients undergoing open repairs of elective or symptomatic juxtarenal AAAs from 2004 to 2018 and compared outcomes by clamp site: above one renal artery, above both renal arteries (suprarenal), or above the celiac trunk (supraceliac). Outcomes evaluated included acute kidney injury (AKI), new-onset renal failure requiring renal replacement therapy (RRT), 30-day mortality, and 1-year mortality. We used multilevel logistic regressions and Cox proportional hazards models, clustered at the hospital level, to adjust for confounding.We identified 3976 patients (median age, 71 years; 70% male; 8.2% non-Caucasian), with a median aneurysm diameter of 5.9cm (interquartile range [IQR], 5.4-6.8 cm). Proximal clamp sites were above one renal artery (31%), suprarenal (52%), or supraceliac (17%). The rates of unadjusted outcomes were 20.5% for AKI, 4.1% for new-onset RRT, 4.9% for 30-day mortality, and 8.3% for 1-year mortality. On adjusted analyses, independent of ischemia time, suprarenal clamping relative to clamping above a single renal artery had higher odds of postoperative AKI (adjusted odds ratio [aOR], 1.50; 95% confidence interval; 95% CI, CI, 1.28-1.75), but similar odds for new-onset RRT (aOR, 1.27; 95% CI, 0.79-2.06) and 30-day mortality (aOR, 1.12; 95% CI, 0.79-1.58) and hazards for 1-year mortality (adjusted hazard ratio, 1.12; 95% CI, 0.86-1.45). However, every 10 minutes of prolonged intraoperative ischemia time was associated with an increase in odds or hazards ratio of postoperative AKI by 7% (IQR, 3%-11%), new-onset RRT by 11% (IQR, 4%-17%), 30-day mortality by 11% (IQR, 6%-17%), and 1-year mortality by 7% (IQR, 2%-13%). Patients with more than 40 minutes of ischemia time had notably higher rates of all four outcomes.Suprarenal clamping relative to clamping above a single renal artery was associated with AKI, but not new-onset RRT or 30-day mortality. However, the intraoperative renal ischemia time was independently associated with all four postoperative outcomes. Although further studies are warranted, our findings suggest that an expeditious proximal anastomosis creation is more important than trying to maintain clamp position below one renal artery, suggesting that suprarenal clamping may be the best strategy for open AAA repair when needed to efficiently perform the proximal anastomosis.

Objective In the last two decades, vascular surgery training evolved from exclusively learning open skills to learning endovascular skills in addition to a functional reduction in training duration with 0+5 residency programs. The implications for this on trainee evolution to independence are unknown. We aimed to assess self-perceived comfort performing open and endovascular procedures and to identify predictors of high comfort among senior vascular surgery trainees and recent graduates. Methods Junior and senior 0+5 vascular surgery residents, traditional fellows, and attendings in their first 4 years of practice were asked to complete a survey assessing the number of vascular procedures performed to date, comfort performing these procedures on a Likert scale, and validated scales of self-efficacy and grit. Groups were then matched by training level and age. Logistic regression identified independent predictors of the top quartile of self-perceived comfort performing procedures. Results Surveys were completed by 92 trainees and 71 attending surgeons in their first 4 years of practice. After matching, completing ≥7 open juxtarenal aortic repairs (OR = 4.73, 95% CI = 1.59–14.07) and a higher self-efficacy score (OR = 3.24, 95% CI = 1.20–8.76), were independent predictors of top quartile comfort performing open vascular procedures. 0+5 residency training inversely correlated with top quartile comfort performing open vascular operations (OR = 0.12, 95% CI = 0.03–0.47). Completing ≥7 complex EVARs (OR = 3.94, 95% CI = 1.61–9.59) and a higher self-efficacy personality score (OR = 2.76, 95% CI = 1.09–7.02) were predictors of top quartile comfort performing endovascular procedures. Conclusion In this nationally representative survey, both trainees and junior attendings completed a paucity of complex open vascular cases, which corresponded to reduced comfort performing these procedures. Furthermore, 0+5 residency training was associated with lower self-perceived comfort performing open vascular surgery, a trend that persisted through the first years of practice. Endovascular comfort did not show a similar correlation.

A recent review of Vascular Study Group of New England data suggested that simultaneous endovascular treatment of tandem carotid lesions (TCAL: common carotid artery + internal carotid artery) is associated with a fourfold increase in perioperative neurologic events and death. However, given the small cohort, the effect of symptomatic status could not be evaluated. This study sought to determine the risk of simultaneous TCAL stenting in cohorts stratified by symptom status.Vascular Quality Initiative data (2005-2020) were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, internal carotid artery lesions with stenosis 50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative stroke and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with TCAL forced into the models.There were 18,886 carotid arteries stented (18,441 patients): 18,077 (96%) with isolated carotid artery lesions and 809 (4%) with TCAL. Mean age was 70.0 ± 9.7. Symptomatic lesions were present in 58.9% of cases (isolated carotid artery lesions: 59.1% vs TCAL: 52.5%; P .001). More TCAL arteries had a prior carotid endarterectomy (38.3% vs 23.8%; P .001). TCAL had a higher perioperative stroke/death (3.4% vs 1.8%; P = .026) for asymptomatic lesions, but not symptomatic lesions (4.5% vs 3.7%; P = .41). TCAL were independently associated with stroke/death in asymptomatic patients (odds ratio, 1.85; 95% confidence interval, 1.03-3.33; P = .039) but not symptomatic patients (odds ratio, 1.22; 95% confidence interval, 0.76-1.97; P = .42).The addition of endovascular treatment of common carotid artery lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of TCAL is not associated with an increased risk of stroke/death for symptomatic lesions.

Endovascular aneurysm repair (EVAR) is associated with worse outcomes in patients whose anatomy does not meet the device instructions for use (IFU). However, whether open surgical repair (OSR) and commercially available fenestrated EVAR (Zenith Fenestrated [ZFEN]) represent better options for these patients is unknown.We identified all patients without prior aortic surgery undergoing elective repair of abdominal aortic aneurysms with neck length ≥4 mm at a single institution with EVAR, OSR, and ZFEN. We applied device-specific aneurysm neck-related IFU to EVAR patients, and a generic EVAR IFU to ZFEN and OSR patients. Long-term outcomes were studied using propensity scores with inverse probability weighting. We compared outcomes in patients undergoing EVAR by adherence to IFU and outcomes by repair types in the subset of patients not meeting IFU.Of 652 patients (474 EVAR, 34 ZFEN, 143 OSR), 211 had measurements outside of standard EVAR IFU (109 EVAR [23%], 27 ZFEN [80%], and 74 OSR [52%]). Perioperative mortality was 0.5% overall. For EVAR, treatment outside the IFU was associated with significantly higher adjusted rates of long-term type IA endoleak (22% at 5 years compared to 2% within IFU, hazard ratio [HR]: 5.8 [3.1-10.9], P .001), and lower survival (5- and 10-year survival: 56% and 34% vs 81% and 53%, HR: 2.3 [1.2-4.3], P = .01). There was no difference in reinterventions or open conversion. In patients not meeting IFU, ZFEN was associated with higher adjusted rates of reinterventions (EVAR as referent: HR: 2.6 [1.5-4.4, P .001), whereas OSR and EVAR patients experienced similar reintervention rates (HR: 0.7 [0.4-1.1], P = .13). Patients outside the IFU experienced lower mortality with OSR compared with either EVAR (HR: 0.4 [0.2-0.9], P = .005) or ZFEN (HR: 0.3 [0.1-0.7], P = .002). When restricted to patients outside the IFU deemed fit for open repair, OSR patients remained associated with lower adjusted mortality compared with ZFEN (HR: 0.2 [0.1-0.5], P .001), but statistical significance was lost in the comparison to EVAR (HR: 0.6 [0.3-1.1], P = .1).Treatment outside device-specific IFU is associated with adverse long-term outcomes. Open surgical repair is associated with higher long-term survival in patients who fall outside of the EVAR IFU and should be favored over EVAR or ZFEN in suitable patients. A three-vessel-based fenestrated strategy may not be a durable solution for difficult aortic necks, but more data are needed to evaluate the performance of newer, four-vessel devices.

Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study.Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression.There were 2016 carotid arteries stented in 1950 patients-1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006).The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.

Objective Splenectomy is often performed during open thoracoabdominal aortic aneurysm (TAAA) repair, because capsular tears are common and can be associated with significant bleeding. It is unknown whether splenectomy affects the short- or long-term outcomes after TAAA repair. Methods All open type I to IV TAAA repairs performed from 1987 to June 2015 were evaluated using a single institutional database. The primary endpoints were in-hospital death, major adverse events (MAE) and long-term survival. The secondary endpoint was hospital length of stay (LOS). All repairs performed for aneurysm rupture were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic and linear multivariable regression were used for the in-hospital endpoints, and survival analyses were performed using Cox proportional hazards modeling and Kaplan-Meier techniques. Results A total of 649 patients met the study inclusion criteria. Of the 649 patients, 150 (23%) underwent concurrent splenectomy (CS) and six required emergency splenectomy secondary to bleeding postoperatively, leading to 156 cases of total in-hospital splenectomy. The perioperative mortality rate was 5.2% in the CS group and 5.2% in the non-CS group (P = 1.0). MAE were experienced by 48% of the CS patients compared with 34% of the non-CS patients (P = .003). Multivariable analysis revealed splenectomy was not independently predictive of perioperative death (adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.41-2.23; P = .9). However, splenectomy was independently associated with any MAE (adjusted odds ratio, 1.78; 95% CI, 1.19-2.65; P = .005). Splenectomy was also associated with a longer length of stay (+5.39 days; 95% CI, 1.86-8.92; P = .003). No survival difference was found between the cohorts in the total splenectomy cohort in the unadjusted (log-rank P = 1.0) or adjusted (splenectomy adjusted hazard ratio, 1.02; 95% confidence interval, 0.78-1.35; P = .9). Conclusions CS during open TAAA repair did not lead to increased perioperative mortality but did lead to significantly increased perioperative morbidity and longer hospital lengths of stay. We found no difference in long-term survival outcomes when CS was performed. Splenectomy during TAAA repair did not affect long-term survival.

OBJECTIVES Kommerell diverticulum (KD) is a rare congenital vascular anomaly often associated with an aberrant subclavian artery (ASCA). Definitive indications for intervention remain unclear. We present open and endovascular (EV) operative outcomes in a large contemporary series and propose a management algorithm. METHODS Between 2004 and 2020, 224 patients presented with ASCA and associated KD to our institution. Of the 43 (19.2%) patients who underwent operative repair, 31 (72.1%) had open surgical (OS) repair via thoracotomy and 12 (27.9%) had EV repair. Univariable and bivariable statistical analyses were conducted stratified by approach. The median follow-up time was 5.4 years (IQR, 2.9–9.7). RESULTS Patients in EV group were older (68 years vs 47 years, P CONCLUSIONS KD can be managed using open or EV approaches with low morbidity and mortality. Treatment strategy should depend on clinical presentation and patient factors.

BACKGROUND Anterior lumbar spine surgery (ALSS) requires mobilization of the great vessels, resulting in a high risk of iatrogenic vascular injury (VI). It remains unclear whether VI is associated with increased risk of postoperative complications and other related adverse outcomes. PURPOSE The purpose of this study was to (1) assess the incidence of postoperative complications attributable to VI during ALSS, and (2) outcomes secondary to VI such as procedural blood loss, transfusion of blood products, length of stay (LOS), and in hospital mortality. STUDY DESIGN Retrospective propensity-score matched, case-control study at 2 academic and 3 community medical centers, PATIENT SAMPLE Patients 18 years of age or older, undergoing ALSS between January 1st, 2000 and July 31st, 2019 were included in this analysis. OUTCOME MEASURES The primary outcome was the incidence of postoperative complications attributable to VI, such as venous thromboembolism, compartment syndrome, transfusion reaction, limb ischemia, and reoperations. The secondary outcomes included estimated operative blood loss (milliliter), transfused blood products, LOS (days), and in-hospital mortality. METHODS In total, 1,035 patients were identified, of which 75 (7.2%) had a VI. For comparative analyses, the 75 VI patients were paired with 75 comparable non-VI patients by propensity-score matching. The adequacy of the matching was assessed by testing the standardized mean differences (SMD) between VI and non-VI group (>0.25 SMD). RESULTS Two patients (2.7%) had VI-related postoperative complications in the studied period, which consisted of two deep venous thromboembolisms (DVTs) occurring on day 3 and 7 postoperatively. Both DVTs were located in the distal left common iliac vein (CIV). The VI these patients suffered were to the distal inferior vena cava and the left CIV, respectively. Both patients did not develop additional complications in consequence of their DVTs, however, did require systemic anticoagulation and placement of an inferior vena cava filter. There was no statistical difference with the non-VI group where no instances (0%) of postoperative complications were reported (p=.157). No differences were found in LOS or in hospital mortality between the two groups (p=.157 and p=.999, respectively). Intraoperative blood loss and blood transfusion were both found to be higher in the VI group in comparison to the non-VI group (650 mL, interquartile range [IQR] 300–1400 vs. 150 mL, IQR 50–425, p≤.001; 0 units, IQR 0–3 vs. 0 units, IQR 0–1, p=.012, respectively). CONCLUSION This study found a low number of serious postoperative complications related to VI in ALSS. In addition, these complications were not significantly different between the VI and matched non-VI ALSS cohort. Although not significant, the found DVT incidence of 2.7% after VI in ALSS warrants vigilance and preventive measures during the postoperative course of these patients.

Open repair of thoracoabdominal aortic aneurysms (TAAAs) that have developed secondary to chronic dissection (CD) is often more complex than repair of degenerative aneurysms (DAs). However, the literature is conflicted regarding the effect of CD on perioperative and long-term outcomes after open TAAA repair. The goal of this study was to determine whether CD predicts negative outcomes after TAAA repair.All open type I to type III TAAA repairs performed from 1987 to 2015 were evaluated using a single institutional database. End points included in-hospital death, spinal cord ischemia (SCI), major adverse events (MAEs), and long-term survival. Repairs performed for rupture or acute dissection were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic multivariable regression was used for the in-hospital end points, and survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques.During the study period, 453 patients underwent an intact open type I to type III TAAA repair. Ninety (20%) were performed for patients with CD. Those with CD were more likely to be younger (59 years vs 72 years; P .001), to have an extent II lesion (30% vs 16%; P .001), and to have Marfan syndrome (18% vs 0.6%; P .001) and less likely to have coronary artery disease (28% vs 25%; P = .01) or chronic obstructive pulmonary disease (12% vs 27%; P = .004) compared with patients with DA. Twelve percent of patients with CD died perioperatively compared with 6% of those with DA (P = .03). Eighteen percent of CD patients suffered from SCI compared with 12% of DA patients (P = .2). Fifty-nine CD patients suffered a MAE compared with 42% of those with DA (P = .006). Multivariable analysis revealed CD to be an independent predictor of perioperative death (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.2-8.0; P = .02) with adjustment for age and Crawford extent. CD was also found to be independently predictive of any MAE (AOR, 2.5; 95% CI, 1.4-4.6; P = .002). CD was not associated with increased risk of SCI (AOR, 1.4; 95% CI, 0.6-3.2; P = .4). There was a long-term survival advantage in the CD cohort in the unadjusted analysis (log-rank, P = .009) but not in the adjusted analysis (CD adjusted hazard ratio, 0.9; 95% CI, 0.6-1.4; P = .7).When analysis is limited to type I to type III TAAAs, open repair of patients with CD leads to increased perioperative mortality and morbidity compared with patients with DA. However, age-adjusted long-term survival is no different between the two cohorts.

Although outcomes after infrarenal abdominal aortic aneurysm surgery are worse in females, sex-specific differences in outcomes after open thoracoabdominal aortic aneurysm (TAAA) repair are less clear. The goal of this study was to identify sex-based disparities in short- and long-term outcomes after open type I-III TAAA surgery.All open type I-III TAAA repairs performed from 1987 to 2015 were evaluated using an institutional database. Charts were retrospectively evaluated for perioperative outcomes: major adverse events (MAEs), in-hospital death, and long-term survival. Univariate analysis was performed using the Fisher's exact test for categorical variables and the Wilcoxon rank-sum test for continuous variables. Logistic regression was used for in-hospital end points; survival analyses were performed with Cox proportional hazards modeling and Kaplan-Meier techniques. Sensitivity analyses were performed for relevant multivariable models, one with ruptures removed and another evaluating only repairs performed before 2006 to account for any selection bias due to wider use of complex endovascular technology.Five-hundred sixteen patients underwent open type I-III TAAA repair during the study period. Females accounted for 54.3% (n = 280) of the cohort. Women were older, less likely to have a chronic dissection etiology, more likely to present with a symptomatic/ruptured lesion, and had a lower admission creatinine than men. Perioperative death occurred in 23 men (9.8%) and 19 women (6.8%) (P = 0.26); 133 women (47.3%) and 116 men (49.2%) suffered an MAE (P = 0.72). Multivariable analyses revealed no sex-based difference in perioperative death (Female sex adjusted odds ratio (AOR): 0.72, 95% confidence interval (CI): 0.4-1.4, P = 0.34) or MAE (AOR: 1.0 CI: 0.7-1.5, P = 0.82). Unadjusted survival at five years was 50% for women and 67% for men (log-rank P 0.001). Female sex was an independent predictor of decreased survival (hazard ratio (HR): 1.5 95% CI: 1.2-1.9, P = 0.001) when adjusted for age, aneurysm extent, creatinine, chronic obstructive pulmonary disease, and ruptures. After removing all ruptures, female sex remained nonpredictive of perioperative death (AOR: 1.1, 95% CI 0.5-2.5, P = 0.75) or MAE (AOR: 1.2, CI: 0.8-1.9, P = 0.31) and predictive of decreased long-term survival (HR: 1.5, 95% CI: 1.2-2.0, P = 0.001).Those undergoing open type I-III TAAA repair have similar rates of perioperative mortality and MAEs, regardless of sex. However, female sex is an independent risk factor for decreased long-term survival.

Objectives In the ever-advancing era of endovascular thoracoabdominal aneurysm (TAAA) repair, understanding long-term patency of renovisceral reconstructions after open TAAA repair provides important benchmarks. Methods Institutional open TAAA repair patient data were queried. Patients dying during index admission or with incomplete operative detail were excluded. Visceral and renal reconstructions were categorized as bypass, incorporation into a proximal or distal beveled aortic anastomosis, inclusion button, Carrel patch, or hybrid stent along with endarterectomy/stent adjuncts. Axial imaging or angiography determined long-term patency. Vessel event was defined as new occlusion or reintervention after repair. Overall time-to-event analysis was performed as well as separate analyses for each vessel (celiac, superior mesenteric artery [SMA], right renal, left renal) by reconstruction type utilizing Kaplan-Meier methods. Log-rank testing was employed to compare reconstructive strategies. Results Over 28 years, 604 repairs (type I, 106 [18%]; type II, 73 [12%]; type III, 195 [32%]; and type IV, 230 [38%]) were identified. Follow-up (median, 500 days) was available in 410/570 (72%) celiac, 406/573 (71%) SMA, 379/532 (71.2%) right renal, and 370/515 (72%) left renal reconstructions. There were five celiac, one SMA, eight right renal, and 10 left renal events. No type of reconstruction or adjunct was significantly associated with event. Overall 5-year patency of all renal/visceral reconstructions was 94% (95% confidence interval, 90%-96%). Estimated 5-year patency of the celiac, SMA, left renal, and right renal were similar, and were 99%, 100%, 97%, and 96%, respectively (P = .09). Conclusions Visceral and renal long-term patency after open TAAA repair is excellent regardless of reconstructive technique. No differences are appreciated even when target vessel disease is addressed at the time of reconstruction. These findings continue to substantiate the effective long-term durability of open TAAA repair and are particularly germane to the ongoing evolution of endovascular strategies.

Background No standard exists for the use of deceased donor liver biopsy during procurement. We sought to evaluate liver biopsy and the impact of findings on outcomes and graft utilization. Methods A prospective observational study of donors after neurologic determination of death was conducted from 02/2012-08/2017 (16 OPOs). Donor data were collected through the UNOS Donor Management Goals Registry Web Portal and linked to the Scientific Registry of Transplant Recipients (SRTR) for recipient outcomes. Recipients of biopsied donor livers (BxDL) were studied and a Cox proportional hazard analysis was used to identify independent predictors of 1-year graft survival. Results Data from 5449 liver transplant recipients were analyzed, of which 1791(33%) received a BxDL. There was no difference in graft or patient survival between the non-BxDL and BxDL recipient groups. On adjusted analysis of BxDL recipients, macrosteatosis (21%-30%[n = 148] and >30%[n = 92]) was not found to predict 1-year graft survival, whereas increasing donor age (HR1.02), donor Hispanic ethnicity (HR1.62), donor INR (HR1.18), and recipient life support (HR2.29) were. Conclusions Excellent graft and patient survival can be achieved in recipients of BxDL grafts. Notably, as demonstrated by the lack of effect of macrosteatosis on survival, donor to recipient matching may contribute to these outcomes.

Liver transplant (LT) patients are at high risk for readmission. This study sought to identify predictors of readmission following liver transplantation and to evaluate their impact on survival in a region with prolonged waiting list times.A single center review of adult deceased donor LT's from 2005 to 2015 was performed, with linkage to the UNOS Standard Transplant Analysis and Research registry. Readmission was defined as hospitalization within 90 days of discharge. Logistic regression was used to identify independent predictors of readmission and Kaplan-Meier analysis for survival.325 patients underwent LT with an overall 90-day readmission rate of 46%. Upon adjusted analysis, predictors of readmission were age (OR 0.97 per year), male gender (OR 0.48), hospital length of stay (OR 1.03 per day), and hepatitis C liver failure (OR 2.37). Readmitted patients demonstrated a significantly lower 5-year survival (75% vs. 88%, p = 0.008) with only one patient (0.7%) dying during initial readmission.Nearly half of all patients are readmitted after LT. As readmission portents decreased survival, an emphasis should be placed on identifying and optimizing those at increased risk. If readmission does occur, however, it presents an opportunity to intervene, as virtually no patients died during initial readmission.