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Abstract Background Functional loss of the tumor suppressor Smad4 is involved in pancreatic and colorectal carcinogenesis and has been associated with the acquisition of invasiveness. We have previously demonstrated that the heterotrimeric basement membrane protein laminin-332 is a Smad4 target. Namely, Smad4 functions as a positive transcriptional regulator of all three genes encoding laminin-332; its loss is thus implicated in the reduced or discontinuous deposition of the heterotrimeric basement membrane molecule as evident in carcinomas. Uncoupled expression of laminin genes, on the other hand, namely overexpression of the laminin-γ2 chain is an impressive marker at invasive edges of carcinomas where tumor cells are maximally exposed to signals from stromal cell types like macrophages. As Smad4 is characterized as an integrator of multiple extracellular stimuli in a strongly contextual manner, we asked if loss of Smad4 may also be involved in uncoupled expression of laminin genes in response to altered environmental stimuli. Here, we address Smad4 dependent effects of the prominent inflammatory cytokine TNFα on tumor cells. Results Smad4-reconstituted colon carcinoma cells like adenoma cells respond to TNFα with an increased expression of all three chains encoding laminin-332; coincubation with TGFβ and TNFα leads to synergistic induction and to the secretion of large amounts of the heterotrimer. In contrast, in Smad4-deficient cells TNFα can induce expression of the γ2 and β3 but not the α3 chain. Surprisingly, this uncoupled induction of laminin-332 chains in Smad4-negative cells rather than causing intracellular accumulation is followed by the release of γ2 into the medium, either in a monomeric form or in complexes with as yet unknown proteins. Soluble γ2 is associated with increased cell migration. Conclusions Loss of Smad4 may lead to uncoupled induction of laminin-γ2 in response to TNFα and may therefore represent one of the mechanisms which underlie accumulation of laminin-γ2 at the invasive margin of a tumor. The finding, that γ2 is secreted from tumor cells in significant amounts and is associated with increased cell migration may pave the way for further investigation to better understand its functional relevance for tumor progression.

BackgroundThere is a lack of evidence for the association between intensive statin therapy and outcomes following vascular surgery. The aim of this study was to evaluate the association between perioperative statin intensity and in-hospital mortality following open abdominal aortic aneurysm (AAA) repair.MethodsPatients undergoing open AAA repair between 2009 and 2015 were identified from the Premier Healthcare Database. Statin use was classified into low, moderate and high intensity, based on American College of Cardiology/American Heart Association guidelines. Supratherapeutic intensity was defined as doses higher than the recommended guidelines. Multivariable logistic regression analyses were undertaken to assess the association between statin intensity and postoperative major adverse events and in-hospital mortality.ResultsOf 6497 patients undergoing open AAA repair, 3217 (49·5 per cent) received perioperative statin. Statin users were more likely to present with three or more co-morbidities than non-users (26·5 versus 21·8 per cent; P

Objective: To gather detailed morphometric data to be able to assess fetal development of the duodenum and its morphology. Material and Method: The present study was carried out on 222 human fetuses (114 males, 108 females) aged 9–40 weeks of gestation with no external pathology or anomaly. Fetuses were grouped based on gestational weeks, months and trimesters. Once general external measurements of the fetuses were carried out, the abdominal wall was dissected. The relationships between the duodenum and surrounding structures and its localization were determined. Morphometric data on height, width, length and diameters were gathered. Findings: Means and standard deviations of all parameters were calculated for each gestational week, month and trimester. There were significant relations between measured parameters and gestational age (p < 0.001). There were no sex differences in parameters (p > 0.05). All data were compared with previous studies and discussed. Conclusion: Data obtained in this study will contribute to other studies carried out in obstetrics, perinatology, forensic medicine and fetal pathology departments, aimed at identifying anomalies, pathologies and variations of the duodenum and treatment of such cases. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

This study aimed to determine the location and development of the vermiform appendix (VA) in terms of morphometry. It was carried out on 80 human fetuses that exhibited neither external pathology nor anomaly and whose gestational ages were between 10 and 40 weeks. The location of the VA and cecum was established. Total VA diameter, lumen diameter, wall thickness, serosa, muscularis and mucosa thickness were measured on microscope slides. The VA was almost always observed in the subcecal region during the fetal period. The length of the VA and the attachment length of the meso-appendix to the VA increased with the gestational age. Lymphocyte aggregation was first seen at the 17th week of the fetal period. Positive and meaningful correlation was found between gestational age and morphometric parameters of the VA. A significant difference was found between the genders in the thickness of mucosa, which was larger in girls (p<0.05). When the proximal, median and distal parts were compared, the thickness of serosa between the proximal and distal parts was also significantly different (p<0.05). The present study has revealed that the VA matures in the second trimester during the fetal period. Furthermore, the morphologic development of the VA is almost uniform from the proximal to distal part. [ABSTRACT FROM AUTHOR]

Objective: To investigate the development of the intra-abdominal part of the umbilical vessels in human fetuses by light microscopy. Materials and methods. The location of the umbilicus and umbilical vessels in the abdominal cavity of 90 human fetuses of gestational ages 10-40 weeks was determined. The external vessel diameter, lumen diameter, wall thickness, tunica adventitia thickness, tunica media thickness and the number of vasa vasorum were recorded from cross-sections of the intra-abdominal part of the umbilical vessels. Results: Umbilical artery agenesis was observed on the left side in two cases and on the right in one cases. There was a positive correlation between gestational age and umbilical vessel measurements. There were differences between the vessel and lumen diameters, tunica media thicknesses of the vessels of the second and third trimesters, and the full-term period. There were also predictable differences between the vessel and lumen diameters, tunica media and tunica adventitia thicknesses of the umbilical vein and umbilical arteries. Conclusion: Detailed information on quantitative parameters of umbilical vessels at each gestational age may prove helpful in determining pathologies of umbilical vessels and illuminating certain syndromes. [ABSTRACT FROM AUTHOR]

In this study, we aimed to determine the development of the anterior fontanelle during the fetal period by morphometric measurements. One hundred and five (49 males, 56 females) human fetuses were obtained from Isparta Maternity and Pediatric Hospital. The gestational age ranged from 11 to 40 weeks. In all cases, head circumference, head length and biparietal diameter were recorded. The anterior fontanelle, transverse and longitudinal diameters were measured, and the mean anterior fontanelle size and the anterior fontanelle area were calculated. A significant positive correlation was found between the gestational age and all parameters. During the fetal period, the anterior fontanelle area gradually increased with head circumference. There was a sharp increase in third trimester in the area anterior fontanelle. In the present study, there was no significant difference between sexes regarding the all parameters measured or calculated. The mean anterior fontanelle size was larger than that recorded in previous studies for both sexes. As presented in our study, the dimensions of the anterior fontanelle for each gestational age will be useful in the understanding of development and anatomical variation. It may also be useful in the diagnosis of cranial maldevelopment. [ABSTRACT FROM AUTHOR]

Objectives: We have aimed at researching into the morphometric development and variations of the plantaris muscle and its tendon throughout the fetal period and comparing them with the the results of the study performed on adults. Methods: A total of 102 fetal legs (51 human fetuses: 26 male, 25 female) whose ages varied between 15-40 gestational weeks without any external pathology or anomaly were incorporated in the study. The fetuses were divided into groups according to gestational weeks, trimesters and months. After the general external measurements of the fetuses had been made, the leg dissection was performed. Later on, the morphometric parameters of plantaris muscle were measured. Results: The averages and standard deviations of the measured parameters were determined according to gestational weeks, trimesters and months. There was a significant correlation between the measured parameters and the gestational age (p<0.001). There was no difference between genders in terms of parameters (p>0.005). All the obtained results were discussed by making comparisons with the previous studies. Conclusion: We are of the opinion that the data obtained in our study will be of use to the involved clinicians in the evaluation of the development of plantaris muscle, and in the clinical studies and practices. [ABSTRACT FROM AUTHOR]

Objectives: It was aimed that the morphometric development of calcaneal tendon and the structures building it up in human fetuses during the fetal period be anatomically studied and that its clinical importance be evaluated. Methods: The study comprised a total of 102 fetus legs (51 human fetuses: 26 male and 25 female) whose ages varied between 15-40 gestational week age, without an external pathology or anomaly. The fetuses were divided in groups according to gestational weeks, trimesters and months. In the wake of the general external measurements of fetuses, leg dissection was performed. Afterwards, the morphometric parameters of gastrocnemius muscle, soleus muscle and calcaneal tendon were measured. Results: The averages and the standard deviations of the measured parameters were determined according to gestational weeks, trimesters and months. There was a significant correlation between the measured parameters and the gestational age (p<0.001). There was no difference between the genders in terms of parameters (p>0.005). All the obtained results were discussed by making a comparison between them and the previous studies made. Conclusion: We are of the opinion that the data obtained in our study will be of use to the involved clinicians in the evaluation of the development of calcaneal tendon and the structures constituting it during the fetal period, and in clinical studies and applications, as well. [ABSTRACT FROM AUTHOR]

The sural nerve is formed by merging of medial sural cutaneous nerve and lateral sural cutaneous nerve nearby the middle of posterior of the leg, which arise from the tibial nerve and common fibular nerve respectively,. Then, it descends with small saphenous vein towards to lateral malleolus and extends at the lateral side of the dorsum of the foot to the little toe as lateral dorsal cutaneous nerve. Variations of sural nerve are quite important for the surgeons who work in this region due to frequent usage as biopsy and nerve transmission rate in diagnosis and nerve graft in therapy. We observed during the routine cadaver dissections in our department laboratory that sural nerve in the lower-left extremity of an adult male cadaver has stemmed from common fibular nerve. We also observed that sural nerve traced towards to distal part of the leg on the lateral side of the small saphenous vein. The course of sural nerve in the lower-right extremity was determined as normal. Various studies were determined about sural nerve in the literature. We believe that the variation we defined in this study be beneficial for the radiological and neurological studies as well as surgical operations related to that area. [ABSTRACT FROM AUTHOR]

During the routine cadaver dissection we performed in the dissection laboratory, it was observed that on the male adult cadaver aged 60, the termination patterns of external jugular vein in the left neck region and cephalic vein in the upper left extremity were different. It was monitored that of external jugular vein in the left neck region of the cadaver joined with suprascapular vein from the left scapular region, that they constituted a common venous trunk and that this common venous trunk communicated with the venous angle. Separately, cephalic vein in the upper left extremity was determined to end in of external jugular vein in the neck region, instead of axillary vein. We are of the opinion that having the knowledge of these variations that we have described about external jugular vein and cephalic vein will be of use to the surgeons, radiologists and anesthetists involved in this region. [ABSTRACT FROM AUTHOR]

Purpose: It was aimed to investigate the development and morphometric changes of the distal femur during the fetal period. Materials and method: 105 human fetuses (55 males and 50 females) aged between 9-40 weeks were used in this study. Fetuses were divided into four groups between gestational weeks; 1st trimester (9-12 weeks), 2nd trimester (13-25 weeks), 3rd trimester (26-37 weeks) and full term (38-40 weeks). Patella and patellar tendon were dissected in all fetal materials and the knee of each fetus was shown. The dimensions; length and width of intercondylar notch, length and width of medial and lateral condyles, total width of the distal femur and the angle of trochlear groove were measured by Vernier's caliper and square. Finding: The length and width of intercondylar notch were found significantly different between trimesters and were rising with gestational age (p<0.05). The length and width of medial and lateral condyles were increased with gestational age. The length and width of lateral condyles were higher than the medial one. The angle of trochlear groove was not changing with gestational age and was found 129.90. It was also found in our study that notch shape index (NSI) was 0,91 and notch width index (NWI) was 0.26 during the fetal period. Result: We consider that the data acquired in our study may contribute to the evaluation the development of distal femur in intrauterine cases. [ABSTRACT FROM AUTHOR]

Objective: Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization., Methods: Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure., Results: A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05)., Conclusions: A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization., Competing Interests: Disclosures H.A. is a 2022-2023 trainee in the Society for Vascular Surgery Patient Safety Organization Quality Fellowship in Training (FIT) program. M.M. has an educational grant from Silk Road Medical to the University of California, San Diego, outside the submitted work. G.W. is a member of the Women of Transcarotid Artery Revascularization advisory board. R.L.M. is a principal investigator for the Diffusion-weighted Magnetic Resonance Imaging Transcarotid Artery Revascularization study. No other competing interests were reported., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Several observational studies have demonstrated an association between diabetes mellitus (DM) and above-ankle amputation after lower extremity revascularization (LER). However, data from prospective randomized trials is lacking. This analysis compares the outcomes of patients with and without DM enrolled in the Best Endovascular vs Best Surgical Therapy in patients with Chronic Limb-Threatening Ischemia (BEST-CLI) trial., Methods: Baseline characteristics were compared between patients with and without DM in the BEST-CLI trial. Cox regression was used to determine the association between DM and major outcomes of major adverse limb events (MALE), reintervention, above-ankle amputation, and all-cause death., Results: Among 1777 patients who underwent LER, 69.2% had DM. Compared with patients without DM, those with DM were significantly younger, less likely to be White, and more likely to be Hispanic. Patients with DM were more likely to have hypertension, hyperlipidemia, coronary artery disease, congestive heart failure, and renal disease and be on optimal medical therapy (antiplatelets and statins), whereas patients without DM were significantly more likely to be smokers and have chronic obstructive pulmonary disease. Patients with DM were significantly more likely to present with late Wound Ischemia foot Infection (WIfI) stages (3-4) (73.7% vs 45.9%; P < .001) that were driven predominantly by differences in wound and infection grade. Conversely, patients without DM had significantly lower ankle pressures and toe pressures and were significantly more likely to have WIfI ischemia grade 3 compared with patients with DM (60% vs 52.5%; P = .016). At 3 years, patients with DM exhibited higher rates of above-ankle amputation and all-cause death compared with patients without DM. Kaplan-Meier analysis demonstrated significantly higher MALE or all-cause death compared with patients without DM (3-year estimate: 53.5% vs 46.4%; P < .001). After adjusting for potential confounders, regression analysis demonstrated that DM was independently associated with increased above-ankle amputation (1.75 [1.22-2.51]), all-cause death (1.63 [1.31-2.03]), and MALE or all-cause death (1.24 [1.04-1.47])., Conclusions: Patients with DM undergoing LER for chronic limb-threatening ischemia experienced a greater incidence of MALE or all-cause death compared with patients without DM. The impact of DM seems to be mediated by more severe wounds and infections at the time of presentation, and a higher prevalence of cardiac and renal disease., Competing Interests: Disclosures J.S. reports education grants provided by Becton, Dickinson and Company and W. L. Gore & Associates; funds were paid to Boston University. A.F. reports consultant to LeMaitre, Sanifit, and BiogenCell, and is on the advisory board of iThera and DilaysisX. C.I.O.C. reports consultant for Envveno. Patent: U.S.S.N. 10,524,891 B1 “Inferior vena cava filter retrieval device and method of retrieving same.”, (Copyright © 2024. Published by Elsevier Inc.)

Background: In the Heart Outcomes Prevention Evaluation study, investigators found that ramipril was associated with improved survival as well as decreased MI and stroke rates in patients with peripheral arterial disease. Nonetheless, their effect on chronic limb-threatening ischemia (CLTI)-specific outcomes is unclear. We aim to assess the effect of ACEIs/ARBs on amputation-free survival in patients with CLTI undergoing peripheral vascular intervention (PVI) in a Medicare-linked database., Methods: Patients undergoing PVI in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database were included. Primary outcomes included amputation-free survival. Kaplan-Meier survival and multivariable Cox regression analyses were used to assess 1-year outcomes., Results: A total of 34,284 patients were included, 46.3% of whom were discharged on ACEIs/ARBs. Patients discharged on ACEIs/ARBs were more likely to be smokers, have diabetes, and have hypertension. They were also more likely to present with rest pain. The overall 1-year survival rate for patients on ACEIs/ARBs vs those who are not was (79.1% vs 69.4%; P < .001). Freedom from amputation was 87.8% for patients on ACEIs/ARBs vs 84.2% for those who were not (P < .001). Amputation-free survival was 70.5% vs 59.5% for ACEIs/ARBs vs no ACEIs/ARBs (P < .001). After adjusting for potential confounders, ACEIs/ARBs use was associated with lower 1-year mortality (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.7-0.8; P < .001), amputation (HR, 0.89; 95% CI, 0.8-0.9; P < .001), and amputation or death (HR, 0.79; 95% CI, 0.76-0.8; P < .001)., Conclusions: ACEIs/ARBs were associated independently with lower amputation, improved survival, and amputation-free rates survival at 1 year in patients with CLTI undergoing PVI. The fact that more than one-half the patients were not discharged on these medications presents an area for potential quality improvement., Competing Interests: Disclosures None., (Published by Elsevier Inc.)

Background: Hypertension (HTN) has been implicated as a strong predictive factor for poorer outcomes in patients undergoing various vascular procedures. However, limited research is available that examines the effect of uncontrolled HTN (uHTN) on outcomes after carotid revascularization. We aimed to determine which carotid revascularization procedure yields the best outcome in this patient population., Methods: We studied patients undergoing carotid endarterectomy (CEA), transfemoral carotid artery stenting (TFCAS), or transcarotid artery revascularization (TCAR) from April 2020 to June 2022 using data from the Vascular Quality Initiative. Patients were stratified into two groups: those with cHTN and those with uHTN. Patients with cHTN were those with HTN treated with medication and a blood pressure of <130/80 mm Hg. Patients with uHTN had a blood pressure of ≥130/80 mm Hg. Our primary outcomes were in-hospital stroke, death, myocardial infarction (MI), and 30-day mortality. Our secondary outcomes were postoperative hypotension or HTN, reperfusion syndrome, prolonged length of stay (LOS) (>1 day), stroke/death, and stroke/death/MI. We used logistic regression models for the multivariate analysis., Results: A total of 34,653 CEA (uHTN, 11,347 [32.7%]), 8199 TFCAS (uHTN, 2307 [28.1%]), and 17,309 TCAR (uHTN, 4990 [28.8%]) patients were included in this study. There was no significant difference in age between patients with cHTN and patients with uHTN for each carotid revascularization procedure. However, compared with patients with cHTN, patients with uHTN had significantly more comorbidities. uHTN was associated with an increased risk of combined in-hospital stroke/death/MI after CEA (adjusted odds ratio [aOR], 1.56; 95% confidence interval [CI], 1.30-1.87; P < .001), TFCAS (aOR, 1.59; 95% CI, 1.21-2.08; P < .001), and TCAR (aOR, 1.39; 95% CI, 1.12-1.73; P = .003) compared with cHTN. Additionally, uHTN was associated with a prolonged LOS after all carotid revascularization methods. For the subanalysis of patients with uHTN, TFCAS was associated with an increased risk of stroke (aOR, 1.82; 95% CI, 1.39-2.37; P < .001), in-hospital death (aOR, 3.73; 95% CI, 2.25-6.19; P < .001), reperfusion syndrome (aOR, 6.24; 95% CI, 3.57-10.93; P < .001), and extended LOS (aOR, 1.87; 95% CI, 1.51-2.32; P < .001) compared with CEA. There was no statistically significant difference between the outcomes of TCAR compared with CEA., Conclusions: The results from this study show that patients with uHTN are at a higher risk of stroke and death postoperatively compared with patients with cHTN, highlighting the importance of treating HTN before undergoing elective carotid revascularization. Additionally, in patients with uHTN, TFCAS yields the worst outcomes, whereas CEA and TCAR proved to be safer interventions. Patients with uTHN with symptomatic carotid disease treated with CEA or TCAR have better outcomes compared with those treated with TFCAS., Competing Interests: Disclosures None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Compare stroke/death outcomes across carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) using Centers for Medicare and Medicaid Services (CMS) high-risk criterion., Background: Existing literature has revealed inconsistencies with CMS risk guidelines. With recent approval for TCAR and TFCAS in standard-risk patients, an updated analysis of guidelines is needed., Methods: Data from the Vascular Quality Initiative (VQI) (2016-2023) on CEA, TFCAS, or TCAR patients were used. We used inverse probability of treatment weighting to compare in-hospital stroke/death rates across procedures for high-risk criteria: contralateral occlusion (CLO), prior CEA, CAS, radiation, neck surgery, moderate to severe CHF, severe COPD (on home O 2 ), unstable angina, recent MI (<6 mo), and age (≥75 years-old)., Results: A total of 199,050 patients were analyzed, of whom 122,737 (62%) patients underwent CEA, 50,095 (25%) TCAR, and 26,218 (13%) TFCAS. TCAR had lower odds of stroke/death compared with CEA in patients with CLO [aOR=0.73 (95% CI: 0.55-0.98], P =0.035] and radiation [aOR=0.44 (95% CI: 0.23-0.82), P =0.010]. Contrary to CMS criteria, CEA patients did not have higher stroke/death in patients with prior CEA, CAS, neck surgery, moderate to severe CHF, severe COPD, unstable angina, recent MI, or age (≥75) compared with TCAR and TFCAS., Conclusions: While CMS high-risk criteria have traditionally been recognized as contraindications for CEA, our study reveals inconsistencies-with CEA performing similarly to TCAR and significantly better than TFCAS in patients with prior CEA, moderate to severe CHF, recent MI, or age (≥75). As a result, the definition of high-risk criteria may warrant reconsideration., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Thoracic endovascular aortic repair (TEVAR) and complex endovascular aneurysm repair (cEVAR) are effective and minimally invasive treatment options for preventing rupture and decreasing mortality of aortic aneurysms. Patients with renal insufficiency are prone to worse postoperative cardiovascular morbidity and mortality due to the atherosclerosis burden as well as increased levels of angiotensin II. Nonetheless, knowledge about the outcomes of aortic stent graft therapy in patients with chronic kidney disease (CKD) or dialysis is scarce. This study aimed to examine outcomes after TEVAR and cEVAR in patients on CKD and dialysis., Methods: Utilizing data from the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network database, we retrospectively evaluated patients who underwent TEVAR or cEVRA from 2010 to 2018. Patients were divided into patients with no CKD or dialysis, CKD patients, and dialysis patients. Outcomes were in-hospital stroke, myocardial infarction (MI), spinal cord ischemia (SCI), 30-day mortality, 1-year mortality, aneurysmal rupture, and reintervention. In-hospital outcomes were assessed using multivariable logistic regression analysis and 1-year outcomes were evaluated using Kaplan-Meier Survival and Cox regression analyses., Results: A total of 4,867 patients were included in the study, 2,694 had no CKD or dialysis, 2,047 had CKD, and 126 were on dialysis. Dialysis patients were significantly younger, and more likely to be non-White and of Hispanic/Latino origin. They were also more likely to have medical comorbidities. CKD patients had higher odds of in-hospital MI (odds ratio [OR]: 2.02, 95% confidence interval [CI] (1.43-2.86), P < 0.001) and 30-day mortality (OR: 1.56, 95% CI (1.18-2.07), P < 0.001) compared to patients with no CKD or dialysis. Dialysis patients had higher odds of 30-day mortality (OR: 3.31, 95% CI (1.73-6.35), P < 0.001). At 1 year, dialysis was associated with a higher risk of mortality (hazard ratio [HR]: 3.48, 95% CI (2.39-5.07), P < 0.001) and reintervention (HR: 1.72, 95% CI (1.001-2.94), P < 0.049). CKD was associated with a higher risk of mortality (HR: 1.45, 95% CI (1.21-1.75), P < 0.001) compared to patients with no CKD or dialysis., Conclusions: Among patients undergoing TEVAR or cEVAR, there was no significant difference in the risk of in-hospital stroke, SCI, and 1-year aneurysmal rupture among dialysis and CKD patients compared to patients with no CKD or dialysis. However, CKD patients had twice the risk of in-hospital MI. Dialysis patients had a higher risk of 1-year reintervention. Both dialysis and CKD patients had a higher risk of 30-day and 1-year mortality., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive., Methods: Using Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing., Results: We identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001)., Conclusions: In asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: As a result of conflicting, inadequate or controversial data in the literature, several issues concerning the management of patients with abdominal aortic aneurysms (AAAs) remain unanswered. The aim of this international, expert-based Delphi consensus document was to provide some guidance for clinicians on these controversial topics., Methods: A three-round Delphi consensus document was produced with 44 experts on 6 prespecified topics regarding the management of AAAs. All answers were provided anonymously. The response rate for each round was 100%., Results: Most participants (42 of 44 [95.4%]) agreed that a minimum case volume per year is essential (or probably essential) for a center to offer open or endovascular AAA repair (EVAR). Furthermore, 33 of 44 (75.0%) believed that AAA screening programs are (probably) still clinically effective and cost effective. Additionally, most panelists (36 of 44 [81.9%]) voted that surveillance after EVAR should be (or should probably be) lifelong. Finally, 35 of 44 participants (79.7%) thought that women smokers should (or should probably/possibly) be considered for screening at 65 years of age, similar to men. No consensus was achieved regarding lowering the threshold for AAA repair and the need for deep venous thrombosis prophylaxis in patients undergoing EVAR., Conclusions: This expert-based Delphi consensus document provides guidance for clinicians regarding specific unresolved issues. Consensus could not be achieved on some topics, highlighting the need for further research in those areas., Competing Interests: Disclosures A.K. has received speaker fees from Cook Inc., & W.L. Gore & Associates, and is a consultant for Bentley Innomed. M.A.F. has received clinical trial support and is a Consultant for Cook, W. L. Gore & Associates, Getinge, and ViTAA. He has received research support from Cook and has stock options in Centerline Biomedical. M.E. is a paid consultant for W. L. Gore & Associates and Silk Road Medical. M.G. is a consultant for Cook Medical, W. L. Gore & Associates and Medtronic and a proctor for Cook Medical., (Copyright © 2024 Society for Vascular Surgery. All rights reserved.)

Objectives: To evaluate the effectiveness of ofloxacin ear drops versus no intervention in the repair of traumatic tympanic membrane (TM) perforations from randomized controlled trials (RCTs). Data Sources: Medline/PubMed, CENTRAL, Clinical Trials.Gov, and Google Scholar. Study Selection: Inclusion criteria: (1) English language; (2) RCT studies; (3) reported the outcomes on the application of ofloxacin and outcomes of spontaneous healing. Exclusion criteria: (1) studies without a control group; (2) patient with severe otologic disease such as chronic suppurative otitis media or ossicular disruption or patients with craniocerebral injury; (3) studies with no pretreatment values or single-arm clinical studies. Data Extraction: Country, year of publication, number of participants in each arm, patient characteristics such as age, sex, intervention details, laterality, cause of TM perforation, position of perforation, follow-up time, hearing gain, rate of TM closure, and closure time. Results: A total of 6 RCTs studies were analyzed. A total of 502 participants were included; the relative risk for closure rate of ofloxacin treatment was 1.18 [95% confidence interval (CI), 1.08 to 1.28, P < .001] and the mean difference (MD) for healing time was -18.4 (95% CI, -19.96 to -16.82, P < .001), suggesting ofloxacin has a significant effect on closure of TM perforations. However, no clinically significant effect in hearing (SMD: 0.21, 95% CI, 0.02 to 0.40, P = .03) was seen in ofloxacin group. Also, patients in the ofloxacin group were associated with a 13% reduction in the risk of infections compared to their observation-assigned counterparts, but this estimate was not statistically significant. Conclusion: Ofloxacin use in patients with traumatic TM perforation is effective in reducing healing time and increasing rate of TM perforation closure. No evidence of increased risk of hearing loss or infection rates are encountered when ofloxacin is prescribed to patients with traumatic TM perforation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We present a case of venous thoracic outlet syndrome involving upper extremity venous thrombosis confirmed by hyperabduction during balloon inflation in the subclavian vein. This provocative test provides clear evidence of extrinsic venous compression, confirming venous thoracic outlet syndrome., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Objective: Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy [CEA], transfemoral carotid artery stenting [TFCAS], or transcarotid artery revascularization [TCAR]). This study looks to identify modality-specific outcomes for patients with recent MI undergoing carotid revascularization., Methods: Data was collected from the Vascular Quality Initiative (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 months) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. TCAR vs TFCAS were compared in a secondary analysis. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI, adjusting for potential confounders. Primary outcomes included 30-day in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, postoperative hypertension, postoperative hypotension, prolonged length of stay (>2 days), and 30-day mortality., Results: The final cohort included 1217 CEA (54.2%), 445 TFCAS (19.8%), and 584 TCAR (26.0%) cases. Patients undergoing CEA were more likely to have prior coronary artery bypass graft/percutaneous coronary intervention and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of American Society of Anesthesiologists class IV to V, P2Y12 inhibitor, and protamine use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P = .079), death (P = .002), and 30-day mortality (P = .007). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.36-5.35; P = .005) and stroke/death/MI (aOR, 1.67; 95% CI, 1.07-2.60; P = .025) compared with CEA. However, TCAR had similar outcomes compared with CEA. Both TFCAS and TCAR were associated with increased risk of postoperative hypotension (aOR, 1.62; 95% CI, 1.18-2.23; P = .003 and aOR, 1.74; 95% CI, 1.31-2.32; P ≤ .001, respectively) and decreased risk of postoperative hypertension (aOR, 0.59; 95% CI, 0.36-0.95; P = .029 and aOR, 0.50; 95% CI, 0.36-0.71; P ≤ .001, respectively) compared with CEA., Conclusions: Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared with TFCAS. TCAR had similar stroke/death/MI outcomes in comparison to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The impact of social determinants of health on the presentation, management, and outcomes of patients requiring hemodialysis (HD) arteriovenous (AV) access creation have not been well-characterized. The Area Deprivation Index (ADI) is a validated measure of aggregate community-level social determinants of health disparities experienced by members living within a community. Our goal was to examine the effect of ADI on health outcomes for first-time AV access patients., Methods: We identified patients who underwent first-time HD access surgery in the Vascular Quality Initiative between July 2011 to May 2022. Patient zip codes were correlated with an ADI quintile, defined as quintile 1 (Q1) to quintile 5 (Q5) from least to most disadvantaged. Patients without ADI were excluded. Preoperative, perioperative, and postoperative outcomes considering ADI were analyzed., Results: There were 43,292 patients analyzed. The average age was 63 years, 43% were female, 60% were of White race, 34% were of Black race, 10% were of Hispanic ethnicity, and 85% received autogenous AV access. Patient distribution by ADI quintile was as follows: Q1 (16%), Q2 (18%), Q3 (21%), Q4 (23%), and Q5 (22%). On multivariable analysis, the most disadvantaged quintile (Q5) was associated with lower rates of autogenous AV access creation (OR, 0.82; 95% confidence interval [CI], 0.74-0.90; P < .001), preoperative vein mapping (OR, 0.57; 95% CI, 0.45-0.71; P < .001), access maturation (OR, 0.82; 95% CI, 0.71-0.95; P = .007), and 1-year survival (OR, 0.81; 95% CI, 0.71-0.91; P = .001) compared with Q1. Q5 was associated with higher 1-year intervention rates than Q1 on univariable analysis, but not on multivariable analysis., Conclusions: The patients undergoing AV access creation who were most socially disadvantaged (Q5) were more likely to experience lower rates of autogenous access creation, obtaining vein mapping, access maturation, and 1-year survival compared with the most socially advantaged (Q1). Improvement in preoperative planning and long-term follow-up may be an opportunity for advancing health equity in this population., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Significant regional variation is known with multiple surgical procedures. This study describes regional variation in carotid revascularization within the Vascular Quality Initiative (VQI)., Methods: Data from the VQI carotid endarterectomy (CEA) and carotid artery stenting (CAS) databases from 2016 to 2021 were used. Nineteen geographic VQI regions were divided into three tertiles based on the average annual volume of carotid procedures performed per region (low-volume: 956 cases [range, 144-1382]; medium-volume: 1533 cases [range, 1432-1589]; and high-volume: 1845 cases [range, 1642-2059]). Patients' characteristics, indications for carotid revascularization, practice patterns, and outcomes (perioperative and 1-year stroke/death) of different revascularization techniques were compared between these regional groups. Regression models that adjust for known risk factors and allow for random effects at the center level were used., Results: CEA was the most common revascularization procedure (>60%) across all regional groups. Significant regional variation was observed in the practice of CEA such as variability in the use of shunting, drain placement, stump pressure and electroencephalogram monitoring, intraoperative protamine, and patch angioplasty. For transfemoral CAS, high-volume regions had a higher proportion of asymptomatic patients with <80% stenosis (30.5% vs 27.8%) in addition to higher use of local/regional anesthesia (80.4% vs 76.2%), protamine (16.1% vs 11.8%), and completion angiography (81.6% vs 77.6%) during transfemoral carotid artery stenting (TF-CAS) compared with low-volume regions. For transcarotid artery revascularization (TCAR), high-volume regions were less likely to intervene on asymptomatic patients with <80% stenosis (32.2% vs 35.8%) than low-volume regions. They also had a higher proportion of urgent/emergent procedures (13.6% vs 10.4%) and were more likely to use general anesthesia (92.0% vs 82.1%), completion angiography (67.3% vs 63.0%), and poststent ballooning (48.4% vs 36.8%). For each carotid revascularization technique, no significant differences were noted in perioperative and 1-year outcomes between low-, medium-, and high-volume regions. Finally, there were no significant differences in outcomes between TCAR and CEA across the different regional groups. In all regional groups, TCAR was associated with a 40% reduction in perioperative and 1-year stroke/death compared with TF-CAS., Conclusions: Despite significant variation in clinical practices for the management of carotid disease, no regional variation exists in the overall outcomes of carotid interventions. TCAR and CEA continue to show superior outcomes to TF-CAS across all VQI regional groups., (Copyright © 2023 Society for Vascular Surgery. All rights reserved.)