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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.

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.

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.

Background Additive risks of combining supra-aortic trunk surgical reconstruction (SAT) with carotid endarterectomy (CEA) for associated carotid bifurcation and great vessel disease management are not well defined. This study sought to define risk of combining SAT with CEA. Study design Isolated CEA (ICEA) and CEA+SAT (from 2005 to 2015) were identified from NSQIP, excluding nonocclusive indications. CEA+SAT were compared with ICEA as well as a propensity-matched ICEA cohort. Primary outcomes included 30-day stroke, death, and composite (SD). Outcomes were then weighted by symptomatic status. Univariate and logistic regression analyses were performed. Results Patients included 79,477 ICEA and 270 CEA+SAT. SAT reconstructions included 19 (7%) aorto-carotid bypasses, 21 (8%) carotid-subclavian transpositions, 85 (31%) carotid-carotid bypasses, and 145 (54%) carotid-subclavian bypasses. There was no difference in 30-day mortality (vs CEA+SAT 1.5% vs ICEA 0.7% p = 0.12). CEA+SAT had higher rates of stroke (3.7% vs 1.6%, p = 0.005) and stroke and death (SD) (4.8% vs 2.1%, p = 0.001). Predictors of SD included CEA+SAT (odds ratio [OR] 5.2, 95% CI 1.03–26.3, p = 0.046) and symptomatic status (OR 1.9, 95% CI 1.1–3.2, p = 0.02). After propensity matching, CEA+SAT continued to have higher rates of stroke (3.4% vs 0.4%, p = 0.01) and SD (4.5% vs 1.5%, p = 0.04), with similar mortality (1.5% vs 1.1%, p = 0.70). No differences were noted in primary endpoints in asymptomatic patients. In symptomatic patients, CEA+SAT carried significantly higher stroke (5.6% vs 2.1%, p = 0.04) and SD risk (7.0% vs 2.8%, p = 0.03). Conclusions CEA+SAT confers increased risk of stroke and SD over ICEA. Symptomatic status and concomitant procedure contribute to this risk. Management should be considered within the context of lesion characteristics, patient longevity, and individual operative risk profile.

Thoracic endovascular aortic repair (TEVAR) results have been studied in short-term time frames. This study aimed to evaluate midterm and long-term outcomes of TEVAR, emphasizing postoperative aortic remodeling and need for reintervention.This is an institutional retrospective review of TEVAR for isolated descending thoracic aortic aneurysms. Data were collected from 2004 to 2018. Primary outcomes studied included aneurysm sac remodeling, freedom from reintervention, and all-cause mortality. Other outcomes studied include endoleak rates, neurologic complication rates, and any overall postoperative complication rates.During the study period, 219 patients underwent TEVAR for descending thoracic aortic aneurysms. The median effect of TEVAR on sac diameter was a 0.7-cm decrease in size (interquartile range, -1.4 to 0.0 cm). During the study period, 80% (n = 147) of patients experienced aneurysm sac regression or stability. Perioperative neurologic complications occurred in 16% (n = 34) of patients. Significant predictors of sac growth were endoleak (odds ratio [OR], 65; P .001), preoperative carotid-subclavian bypass (OR, 8; P = .003), and graft oversizing 20% (OR, 15; P = .046). Every 1-mm increase in aortic diameter at the proximal TEVAR landing zone led to an increased odds of endoleak (OR, 2; P = .049). Access complications (OR, 8) and subclavian artery coverage (OR, 6) significantly increased the odds of reintervention, whereas every percentage of graft oversizing protected against reintervention (OR, 0.005). Life-table analysis revealed an overall survival of 78% (71%-83%) at median follow-up. At 3 years, survival was 88% (80%-93%) for those with aneurysm sac stability or regression, whereas it was 70% (49%-84%) for those with aneurysm sac growth (P = .0402). Cox proportional hazards model showed that the only protective factor for mortality was percentage oversizing, with every 1% of oversizing having a hazard ratio (HR) of .001 (P = .032). This was counterbalanced by the fact that patients with graft oversizing30% had an increased odds of mortality with HR10 (P = .049). Other significant factors that increased the odds of mortality included endoleak (HR, 3.6; P = .033), diabetes (HR, 4.1; P = .048), age (every 1-year increase in age; HR, 1.2; P = .002), year of surgery (every year subsequent to 2004; HR, 1.3; P = .012), and peripheral artery disease (HR, 5.2; P = .041).The majority of patients (80%) experience sac stability or regression after TEVAR, which offers a clear survival advantage. Endoleaks are predictive of sac growth, conferring increased mortality. Rigorous surveillance is necessary to prevent future aortic events through reintervention.

Objectives The COVID-19 pandemic has had major implications for the United States healthcare system. This survey study sought to identify practice changes, understand current personal protection equipment (PPE) use, and determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers versus low case numbers. Methods A fourteen-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons’ current practice was sent to 365 vascular surgeons across the country via REDCap from 4/14/2020 to 4/21/2020 with responses closed on 4/23/2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania and California) differed from those with lower case numbers (all other states). Results A total of 121 vascular surgeon responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between high case and low COVID case states (p=0.285). High case states were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs. 77.5%, p=0.046), but otherwise case types did not differ. Most attendings work with residents (90.8%) and limited their exposure to procedures on suspected/confirmed COVID-19 cases (56.0%). Thirty-eight percent of attendings have been redeployed within the hospital to a vascular access service, and/or other service outside of vascular surgery. This was more frequent in high case volume states compared to low case volume states (p=0.039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons feel that they do not have adequate PPE to perform clinical their duties. Conclusion The initial response to the COVID-19 pandemic has resulted in reduced elective cases with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty, however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey., ARTICLE HIGHLIGHTS: Type of research: Nationwide survey of attending vascular surgeons Key Finding: Most of the 121 vascular attendings who responded are limiting resident involvement in COVID-19 positive cases, 38% of attendings have been redeployed to services other than traditional vascular surgery, such as the ICU and vascular access service, and 71% are reusing personal protective equipment (PPE). Twenty-one percent of vascular surgeons do not feel they have adequate access to PPE. Take Home Message: There have been major changes to vascular surgery practice during the COVID-19 pandemic.

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.

Objective To determine if premature menopause and early menarche are associated with increased risk of AAA, and to explore potential effect modification by smoking history. Summary of background data Despite worse outcomes for women with AAA, no studies have prospectively examined sex-specific risk factors, such as premature menopause and early menarche, with risk of AAA in a large, ethnically diverse cohort of women. Methods This was a post-hoc analysis of Women's Health Initiative participants who were beneficiaries of Medicare Parts A&B fee-for-service. AAA cases and interventions were identified from claims data. Follow-up period included Medicare coverage until death, end of follow-up or end of coverage inclusive of 2017. Results Of 101,119 participants included in the analysis, the mean age was 63 years and median follow-up was 11.3 years. Just under 10,000 (9.4%) women experienced premature menopause and 22,240 (22%) experienced early menarche. Women with premature menopause were more likely to be overweight, Black, have ≥20 pack years of smoking, history of cardiovascular disease, hypertension, and early menarche. During 1,091,840 person-years of follow-up, 1125 women were diagnosed with AAA, 134 had premature menopause (11.9%), 93 underwent surgical intervention and 45 (48%) required intervention for ruptured AAA. Premature menopause was associated with increased risk of AAA [hazard ratio 1.37 (1.14, 1.66)], but the association was no longer significant after multivariable adjustment for demographics and cardiovascular disease risk factors. Amongst women with ≥20 pack year smoking history (n = 19,286), 2148 (11.1%) had premature menopause, which was associated with greater risk of AAA in all models [hazard ratio 1.63 (1.24, 2.23)]. Early menarche was not associated with increased risk of AAA. Conclusions This study finds that premature menopause may be an important risk factor for AAA in women with significant smoking history. There was no significant association between premature menopause and risk of AAA amongst women who have never smoked. These results suggest an opportunity to develop strategies for better screening, risk reduction and stratification, and outcome improvement in the comprehensive vascular care of women.

BACKGROUND: Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT. METHODS: Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT + CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT + CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed. RESULTS: After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT + CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65 ± 12 years and SAT + CEA were older (69 vs. 64 years, P < 0.001), CEA + SAT were more likely to be men (53% vs. 42%, P < 0.001), have hypertension (86% vs. 75%, P < 0.001) and diabetes (26% vs. 20%, P = 0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT + CEA (71% vs. 54%, P < 0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT + CEA 3.7%, P = 0.09) or mortality (1.4% vs. 1.5%, P = 0.88). SAT + CEA had higher rates of SDM (7% vs. 4%, P = 0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5–8.4, P= 0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5–4.2, P = 0.52) or SDM (OR 1.5, 95% CI 0.6–3.6, P = 0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts. CONCLUSIONS: Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.

This study evaluates 30-day mortality after endovascular aneurysm repair (EVAR) versus open repair for ruptured complex abdominal aortic aneurysms (cAAAs), including juxtarenal, pararenal, suprarenal, and extent IV thoracoabdominal aortic aneurysms (TAAA) in a real-world setting.The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing repair for ruptured cAAA from 2011 to 2017. Primary endpoint was 30-day mortality. Secondary endpoints included renal failure, pulmonary complications, ischemic colitis, cardiac complications, lower extremity ischemia, post-operative rupture, and intensive care unit (ICU) length of stay (LOS). EVAR and open repair were compared using inverse probability weights.Four hundred forty-six patients had a ruptured cAAA repair during the study years; 105 (23.7%) were repaired via EVAR and 338 (76.3%) received open repair. The distribution by aneurysm type was as follows: 253 juxtarenal (57.1%), 59 pararenal (13.3%), and 100 suprarenal (22.6%) AAA with 31 type IV TAAA (7.0%). Juxtarenal aneurysms were more likely to be performed open than EVAR (P 0.001) and pararenal were more likely to be performed endovascularly (P 0.001). There was no significant change in the proportion of EVAR versus open repair in the years evaluated (P = 0.16). Hemodynamic stability was nearly identical between the 2 groups, with 49.5% of the EVAR cohort suffering from preoperative hypotension or requiring vasopressors compared to 49.1% in the open surgical cohort (P = 1.0). No significant difference in death existed based on proximal aneurysmal extent (P = 0.42). Death within 30 days occurred in 135 (30.5%) of the total cohort with 25 (23.8%) deaths in the EVAR cohort and 110 (32.5%) deaths in the open cohort. The EVAR group suffered a 20.0% rate of postoperative renal failure requiring dialysis compared to 18.6% of the open cohort (P = 0.78). Pulmonary complications were more common after open repair (40.5% vs. 25.0%, P = 0.004). After propensity weighting and weighted logistic regression, the open cohort had 1.75 times the odds of death compared to the EVAR cohort (AOR: 1.8, 95% CI: 0.9-2.8; P = 0.06). There was no association between repair type and postoperative renal failure. Open repair was associated with greater odds of pulmonary complications, ischemic colitis, and longer ICU stays in survivors.Mortality after repair for ruptured cAAA is high; and treatment with EVAR may trend toward early survival advantage. Rates of renal failure were similar between each cohort. Open repair is associated with higher rates of pulmonary complications, ischemic colitis, and longer ICU stays.

The current management of acute complicated type B aortic dissection is a combination of medical therapy and endovascular repair. Endovascular repair is not feasible when the dissection extends into the aortic arch. We describe 3 patients with acute type B aortic dissection complicated by retrograde arch extension and visceral malperfusion who were successfully treated with a total arch replacement and frozen elephant trunk.

This study aimed to determine if there is an association between ABO blood type and severity of COVID-19 defined by intubation or death as well as ascertain if there is variability in testing positive for COVID-19 between blood types. In a multi-institutional study, all adult patients who tested positive for COVID-19 across five hospitals were identified and included from March 6th to April 16th, 2020. Hospitalization, intubation, and death were evaluated for association with blood type. Univariate analysis was conducted using standard techniques and logistic regression was used to determine the independent effect of blood type on intubation and/or death and positive testing. During the study period, there were 7648 patients who received COVID-19 testing throughout the institutions. Of these, 1289 tested positive with a known blood type. A total of 484 (37.5%) were admitted to hospital, 123 (9.5%) were admitted to the ICU, 108 (8.4%) were intubated, 3 (0.2%) required ECMO, and 89 (6.9%) died. Of the 1289 patients who tested positive, 440 (34.2%) were blood type A, 201 (15.6%) were blood type B, 61 (4.7%) were blood type AB, and 587 (45.5%) were blood type O. On univariate analysis, there was no association between blood type and any of the peak inflammatory markers (peak WBC, p = 0.25; peak LDH, p = 0.40; peak ESR, p = 0.16; peak CRP, p = 0.14) nor between blood type and any of the clinical outcomes of severity (admission p = 0.20, ICU admission p = 0.94, intubation p = 0.93, proning while intubated p = 0.58, ECMO p = 0.09, and death p = 0.49). After multivariable analysis, blood type was not independently associated with risk of intubation or death (referent blood type A; blood type B: AOR: 0.72, 95% CI: 0.42-1.26, blood type AB: AOR: 0.78, CI: 0.33-1.87, blood type O: AOR: 0.77, CI: 0.51-1.16), rhesus factor positive (Rh+): AOR: 1.03, CI: 0.93-1.86. Blood type A had no correlation with positive testing (AOR: 1.00, CI: 0.88-1.13), blood type B was associated with higher odds of testing positive for disease (AOR: 1.28, CI: 1.08-1.52), AB was also associated with higher odds of testing positive (AOR: 1.37, CI: 1.02-1.83), and O was associated with a lower risk of testing positive (AOR: 0.84, CI: 0.75-0.95). Rh+ status was associated with higher odds of testing positive (AOR: 1.23, CI: 1.003-1.50). Blood type was not associated with risk of intubation or death in patients with COVID-19. Patients with blood types B and AB who received a test were more likely to test positive and blood type O was less likely to test positive. Rh+ patients were more likely to test positive.

Background This study evaluates the impact of surgical specialty, specifically vascular surgery (VS) versus non-VS (NVS; namely, cardiac surgery, thoracic surgery, general surgery, or neurosurgery) on perioperative carotid endarterectomy (CEA) outcomes stratified by symptom status on presentation. Methods The National Surgical Quality Improvement Program Vascular Procedure Targeted database was queried for elective asymptomatic or symptomatic CEA (excluding concomitant CEA and cardiac surgery) from 2011 to 2016. Data were stratified by VS versus NVS and symptom presentation. Primary end points were 30-day stroke and stroke/death; secondary end points included perioperative complications. Multivariable logistic regression determined predictors of all assessed primary outcomes and propensity-weight analysis was used to confirm results. Results Overall, 21,060 CEA (12,671 [59%] asymptomatic) were identified with 19,687 (93%) done by VS. In the asymptomatic CEA cohort, VS had lower unadjusted stroke (1.3% vs 2.4%; P = .021) and stroke/death (1.7% vs 3.2%; P = .006) rates. In addition, VS had fewer deaths (0.6% vs 1.3%; P = .033) and pulmonary complications (1.6% vs 2.7%; P = .036). After risk adjustment, the NVS asymptomatic cohort predicted stroke (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-3.1; P = .032), driven by neurosurgery (OR, 3.1; 95% CI, 1.3-7.2; P = .008). This NVS cohort also predicted stroke/death (OR, 1.8; 95% CI, 1.1-2.9; P = .013), driven by neurosurgery (OR, 2.5; 95% CI, 1.1-5.7; P = .035). After propensity weighting, these differences persisted (stroke: OR, 1.9; 95% CI, 1.1-3.3; P = .030; stroke/death: OR, 1.9; 95% CI, 1.2-3.0; P = .011). Among symptomatic CEA, there was no difference between VS and NVS in unadjusted primary end points of stroke (3.1% vs 4.2%; P = .106) or stroke/death (3.8% vs 4.6%; P = .275). However, in this cohort, VS had fewer major complications (12.7% vs 15.5%; P = .029). Conclusions This study identifies the VS specialty as having significantly better outcomes after CEA in patients presenting with asymptomatic disease than NVS specialty, as evidenced by lower rates of stroke and stroke death, which persisted after risk adjustment and propensity weighting. This difference in stroke and stroke/death was not apparent in the symptomatic cohort; however, NVS did have increased unadjusted rates of major complications. Although this finding may reflect multiple factors, including higher operative volume, training, or technical approach, these differences in 30-day CEA outcomes may be crucial for the proper interpretation of ongoing national outcome trials such as CREST2.

Patients undergoing lower extremity bypass (LEB) for peripheral artery disease require intensive health care resource utilization including rehabilitation and skilled nursing facilities. However, few studies have evaluated factors that lead to nonhome discharge (NHD) in this population of patients. This study sought to predict NHD by preoperative risk factors in patients undergoing LEB for peripheral artery disease using a novel risk score.The Vascular Study Group of New England database was queried for elective LEB for peripheral artery disease including claudication and critical limb ischemia from 2003 to 2017. Patients were excluded if the procedure was not elective, if they were not admitted from home, if they were bedridden, or if they died during the index admission. Only preoperative factors were considered in the analysis. The primary end point was NHD including rehabilitation and skilled nursing facilities. Data were split two-thirds for model derivation and one-third for validation. In the derivation cohort, bivariate analysis assessed the association of preoperative factors with NHD. A parsimonious manual stepwise binary logistic regression for NHD aimed at maximizing the C statistic while maintaining model simplicity was performed. A risk score was developed using the β coefficients and applied to the validation data set. The risk score performance was assessed using a C statistic and Hosmer-Lemeshow test for model fit.There were 10,145 cases included with an overall NHD rate of 26.4% (n = 2676). Mean age was 66 years (range, 41-90 years). NHD patients were older (72 years vs 64 years; P .01) and more frequently male (57.2% vs 42.8%; P .01) and nonwhite (16.1% vs 9.9%; P .01); they more frequently had tissue loss (54.2% vs 23.0%; P .01), anemia (16.0% vs 5.3%; P .01), severe cardiac comorbidity (21.8% vs 10.5%; P .01), and insulin-dependent diabetes (33.3% vs 18.2%; P .01). On multivariable analysis, factors associated with NHD included age, sex, nonwhite race, tissue loss, cardiac comorbidity, partial ambulatory deficit, and insulin-dependent diabetes. The C statistic was 0.78 in the derivation group and 0.79 in the validation group, with Hosmer-Lemeshow P.999. The risk score ranged from 0 to 18, with a mean score of 4 (standard deviation ±3.5). The risk score was divided into low risk (0-4 points; n = 5272 [52%]; NHD = 10.1%]), moderate risk (5-9 points; n = 3663 [36.7%]; NHD = 36.7%), and high risk (≥10 points; n = 1210 [11.9%]; NHD = 66.1%).This novel risk score was highly predictive for NHD after LEB for peripheral artery disease using only preoperative comorbidities. High-risk patients account for 12% of LEB but nearly a third of all patients requiring NHD. This risk score can be used preoperatively to determine high-risk patients for NHD, which may help improve preoperative counseling and hospital efficiency by allocating resources appropriately.

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.

Trainee burnout is on the rise and negative training environments may contribute. In addition, as the proportion of women entering vascular surgery increases, identifying factors that challenge recruitment and retention is vital as we grow our workforce to meet demand. This study sought to characterize the learning environment of vascular residents and to determine how gender-based discrimination and bias (GBDB) affect the clinical experience.A survey was developed to evaluate the trainee experience; demographics and a two-item burnout index were also included. The instrument was sent electronically to all integrated (0 + 5) vascular surgery residents in the United States. Univariate analyses were performed and predictors of burnout identified.A total of 284 integrated vascular residents were invited to participate and 212 (75%) completed the survey. Participants were predominantly male (64%) and white (56%), with a median age of 30 years (interquartile range, 28-32 years). Seventy-nine percent of respondents endorsed some form of negative workplace experience and 30% met high-risk criteria for burnout. More than a third (38%) of residents endorsed personally experiencing GBDB, with a significant difference between men and women (14% vs 80%; P .001). Women were more likely than men to report witnessing GBDB (76% vs 56%; P = .003). Patients and nurses were the most frequently cited sources of GBDB (80% and 64%, respectively), with vascular surgery attendings cited by 41% of trainees. One in four female resident respondents indicated being sexually harassed during the course of training; this was significantly higher than for male residents (25% vs 1%; P .001). Nearly half (46%) of trainees who witnessed or experienced GBDB thought that quality of patient care, job satisfaction, personal well-being, and personal risk of burnout were directly affected as a result of GBDB. GBDB was predictive of burnout (odds ratio, 1.9; 95% confidence interval, 1.1-3.5; P = .04), as were longer work hours (80 h/wk; odds ratio, 2.8; 95% confidence interval, 1.1-7.1; P = .03).GBDB was experienced by 38% of integrated trainees, with women significantly more affected than men. GBDB is predictive of burnout, and this has significant implications for our specialty in the recruitment and retention of female physicians. Resources addressing these issues are needed to maintain a diverse workforce and to promote physician well-being.

Endovascular therapy is first-line treatment for aortoiliac occlusive disease. This shift has altered case volume, patient selection, and risk profile for aortobifemoral bypass (ABF). Given this, we sought to investigate factors influencing morbidity and mortality after ABF in the endovascular era.Data for patients undergoing primary ABF from 2000 to 2017 were queried. Primary endpoints included major complication (unplanned return to the operating room, life-or-limb-threatening complications, and 30-day readmission or death) and long-term survival. Logistic regression and Cox proportional hazard models determined predictors of primary endpoints. Kaplan-Meier analysis estimated patency, freedom from reintervention, and long-term survival.During these 17 years, 256 patients underwent primary ABF. Mean age was 67.9 ± 10.6 years and 51.2% were women. Most had claudication (69.5%); 28.9% had critical ischemia. Sixty-five (25.4%) patients had prior aortoiliac endovascular intervention, 106 (41.4%) required aortic cuff endarterectomy, 111 (43.3%) femoral outflow adjunct, 9 (3.5%) simultaneous lower extremity bypass, and 230 (89.8%) had Trans-Atlantic Inter-Society Consensus D lesions. Concomitant renovisceral revascularization was needed in 42 (16.4%) patients. Thirty-day mortality was 2.7%. Major complication occurred in 92 patients (35.9%). Predictors included prior endovascular intervention (odds ratio [OR], 2.2; 95% confidence interval [CI]: 1.2-4.1; P = 0.01), malignancy (OR, 2.6; 95% CI: 1.3-5.3; P = 0.01), intraoperative complication (OR, 3.3; 95% CI: 1.3-9.2; P = 0.03), operative blood loss, (OR, 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.03), and cuff endarterectomy (OR, 1.8; 95% CI: 1.0-3.1; P = 0.04). Median follow-up was 5.3 years (interquartile range: 7.2 years). Survival at 1, 3, and 5 years was 94%, 90%, and 82% respectively. Primary patency and freedom from reintervention at 5 years were 76% and 79%, respectively. Predictors of late mortality included malignancy (hazard ratio [HR], 2.3; 95% CI: 1.3-3.9; P 0.01), chronic obstructive pulmonary disease (HR, 1.8; 95% CI: 1.1-3.1; P = 0.02), congestive heart failure (HR, 2.3; 95% CI: 1.2-4.3; P = 0.01), Rutherford's class (HR, 1.5; 95% CI: 1.1-2.1; P = 0.01), operative blood loss (HR 1.0 per 100 ml; 95% CI: 1.0-1.0; P = 0.04) and chronic kidney disease (HR, 2.3; 95% CI: 1.2-4.2; P = 0.01).Although late outcomes after ABF in the contemporary era remain acceptable, major complications are frequent. Operative complexity and prior endovascular revascularization predict complications. Long-term survival is driven by degree of limb ischemia and comorbidities. These should be considered in selection for ABF, potentially modifying approach to improve outcomes.

To determine if routine completion angiography for lower extremity bypasses using vein conduit results in lower rates of postoperative bypass occlusion.With the increasing availability of on-table angiography and significant advancements in endovascular techniques, some operators routinely perform completion angiograms. The effect of this surgical paradigm has yet to be rigorously compared to the more widespread selective use of completion imaging in the modern era.This retrospective cohort study included infrainguinal arterial bypass procedures utilizing vein conduit completed at a single hospital system from 2001 to 2018 and compared postoperative outcomes between bypasses that underwent routine completion angiography versus selective completion angiography. Notably, any bypasses that underwent completion angiography due to intraoperative concerns were excluded from this analysis.666 bypasses that were performed in 589 patients met inclusion criteria. 126 (16.9%) bypasses were classified into the routine completion angiogram group compared to 540 (81.0%) into the selective completion angiogram group. Patients who underwent routine completion angiograms had a rate of intraoperative reintervention of 22.2%. The routine angiogram group had lower rates of reintervention (3.9% vs 10.0%, P = 0.03) and graft occlusion (2.3% vs 9.2%, P = 0.01) at 1-month postoperatively.Lower extremity bypasses using vein conduit that undergo routine completion angiography are associated with lower rates of graft occlusion at 30-days postoperatively. Completion angiography should thus be routinely performed in infrainguinal bypasses that utilize venous conduit.

Background and Purpose: High-risk atherosclerosis is an underlying cause of cardiovascular events, yet identifying the specific patient population at immediate risk is still challenging. Here, we used a rabbit model of atherosclerotic plaque rupture and human carotid endarterectomy specimens to describe the potential of molecular fibrin imaging as a tool to identify thrombotic plaques. Methods: Atherosclerotic plaques in rabbits were induced using a high-cholesterol diet and aortic balloon injury (N=13). Pharmacological triggering was used in a group of rabbits (n=9) to induce plaque disruption. Animals were grouped into thrombotic and nonthrombotic plaque groups based on gross pathology (gold standard). All animals were injected with a novel fibrin-specific probe 68 Ga-CM246 followed by positron emission tomography (PET)/magnetic resonance imaging 90 minutes later. 68 Ga-CM246 was quantified on the PET images using tissue-to-background (back muscle) ratios and standardized uptake value. Results: Both tissue-to-background (back muscle) ratios and standardized uptake value were significantly higher in the thrombotic versus nonthrombotic group ( P 68 Ga-CM246 PET agreed with gross pathology assessment (85%). In ex vivo surgical specimens obtained from patients undergoing elective carotid endarterectomy (N=12), 68 Ga-CM246 showed significantly higher binding to carotid plaques compared to a D-cysteine nonbinding control probe. Conclusions: We demonstrated that molecular fibrin PET imaging using 68 Ga-CM246 could be a useful tool to diagnose experimental and clinical atherothrombosis. Based on our initial results using human carotid plaque specimens, in vivo molecular imaging studies are warranted to test 68 Ga-CM246 PET as a tool to stratify risk in atherosclerotic patients.

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

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.

Objective The Registered Physician in Vascular Interpretation (RPVI) credential is a prerequisite for certification by the Vascular Surgery Board of the American Board of Surgery. Of concern, as more current trainees and recent program graduates take the Physician Vascular Interpretation (PVI) examination, vascular surgery trainee pass rates have decreased. Residents and fellows have a lower PVI examination pass rates than practicing vascular surgeons. The purpose of this study was to assess current vascular laboratory (VL) training for vascular surgery residents and fellows and to identify gaps that residency and fellowship programs might address. Methods Program directors (PDs) of Accreditation Council for Graduate Medical Education-accredited vascular surgery programs (107 fellowships, 53 integrated residency programs) were surveyed using a web-based tool. Responses were submitted anonymously. Data collected included information about the program, the PD, accreditation status of the VL, and the curriculum used to meet the PVI prerequisites. Concurrent data (June 2017) on the credentials of all PDs were obtained from the Alliance for Physician Certification and Advancement (APCA). Results Sixty-one of 117 PDs participated in the survey (52% response rate). Of these, 44 individuals (72% of responders) reported they held the RPVI and/or Registered Vascular Technologist credential. Records from APCA indicated that 51 of 117 PDs of accredited vascular surgery residencies and fellowships (44%) had an RPVI/Registered Vascular Technologist credential. Ninety-four percent reported that their VL was accredited. Practical VL experience for trainees was reported to be 20 hours or less by 62% of respondents. The use of a structured curriculum for practical experience was reported by only 15 programs. Programs with fellowships established for more than 10 years were more likely to have a structured program for didactic instruction (P = .03). Only 23 programs reported a dedicated VL rotation. Didactic instruction provided was 20 hours or less for 75% of the cohort. Conclusions In the absence of a standardized VL curriculum, there is variation in the VL instruction provided to trainees. Fellowship programs with longer histories have more structured instruction, but time allocated to VL education is substantially less than the 30 hours of didactic and 40 hours of practical experience recommended by the APCA. Programs and learners may benefit from the development of VL training guidelines and curriculum resources.

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.

Stroke after carotid endarterectomy (CEA) has been assessed widely. However, factors enhancing non-ipsilateral stroke risk are poorly defined. The aim of this study was to identify drivers of 30 day non-ipsilateral stroke after CEA in the Vascular Quality Initiative (VQI) and assess long-term survival based on laterality of post-operative stroke.The VQI was queried between April 1, 2003, and March 31, 2017, for all CEA. Bilateral carotid procedures within 30 days were excluded. Thirty day non-ipsilateral strokes were identified. Factors were examined to discriminate between patients with and without non-ipsilateral stroke. Univariable analysis followed by multivariable logistic regression was performed. Kaplan-Meier and log rank methods were used to estimate and compare survival.During this 14 year period, 80,230 CEA in 74,928 patients met the criteria. The average age was 70.3 ± 9.3 years. Most were male (48,506; 60%), Caucasian (73,967; 92%), smokers (60,543; 76%), and asymptomatic (43,074; 54%). Contralateral stenosis ≥70% was present in 8033 (10%) with 2239 (3%) having contralateral occlusion. In 491 (0.6%) patients, peri-operative non-ipsilateral stroke occurred. After characterising univariable associations, logistic regression identified independent drivers of non-ipsilateral stroke after CEA. Operative urgency (p = .001), symptomatic disease (p .001) and contralateral occlusion (p = .001) were pre-operative drivers. Operative predictors included shunt use (p = .008), CEA with cardiac surgery (p = .013), and CEA with concomitant proximal ipsilateral endovascular intervention (p = .01). Use of dextran (p = .005) and anti-angiotensin therapy (p = .03) were protective. Reperfusion syndrome (p .001), re-exploration (p .001), myocardial infarction (p .001), and intravenous treatment of hypotension (p .001) or hypertension (p .001) were post-operative correlates. Non-ipsilateral stroke 30 day mortality was less than ipsilateral stroke (6.1% vs. 10.3%; p = .007). Five year survival after non-ipsilateral stroke was 73%, and no different from ipsilateral stroke 76% (p = .16). Both were worse than without stroke (88%; p .001).Non-ipsilateral stroke after CEA is rare. Features driving risk surround global disease burden, combined procedures, and haemodynamic fluctuations. Contralateral occlusion independently increases non-ipsilateral stroke risk. Regardless of laterality or location, effects of stroke after CEA on long-term survival are similar.

Adding ipsilateral, proximal endovascular (IPE) intervention to carotid endarterectomy (CEA) for the treatment of tandem bifurcation and supra-aortic trunk disease is controversial. Some suggest that this combined strategy (CEA + IPE) confers no risk over isolated CEA (ICEA). Others disagree, reserving CEA + IPE for symptomatic patients. Using the Vascular Quality Initiative (VQI), this study assessed the effect of adding IPE to CEA on stroke and death risk. We further weighed CEA + IPE outcomes in the context of symptomatic status and Society for Vascular Surgery guidelines.All CEAs in the VQI database from 2003 to 2017 were reviewed. Urgent and redo CEAs were excluded. CEA + IPE procedures were identified. To isolate the effect of IPE, patients undergoing other concurrent procedures were removed, providing an ICEA cohort. Primary end points were perioperative (30-day) stroke and death. Univariate and logistic regression analyses were performed.After exclusion and identification of CEA + IPE, 66,519 procedures were available for analysis. Of these, 66,115 represented ICEA and 404 represented CEA + IPE. Most patients (60%) were male, 93% were white, and 41% were symptomatic. Average age was 70 ± 9 years. Those undergoing CEA + IPE were more likely to be female (50% vs 40%; P .001) and smokers (87% vs 76%; P .001), and they were more likely to have coronary artery disease (32% vs 27%; P = .04), congestive heart failure (14% vs 10%; P = .01), and chronic obstructive pulmonary disease (30% vs 22%; P .001). ICEA patients were more likely to have severe ipsilateral stenosis (86% vs 80%; P = .002) and to undergo intraoperative shunting (53% vs 49%; P = .05). There was no difference in 30-day mortality between cohorts (1% vs 1%; P = .23). However, CEA + IPE had higher rates of perioperative stroke (3.0% vs 1.4%; P = .01) and combined 30-day stroke and death (3.5% vs 1.8%; P = .02). When patients were stratified by symptomatic status, there were no differences in primary end points between cohorts in asymptomatic patients. In symptomatic patients, CEA + IPE carried significantly higher stroke (4.9% vs 1.9%; P = .002) and stroke and death risk (6.0% vs 2.4%; P = .002). After risk adjustment, predictors of stroke and death were diabetes (odds ratio [OR], 1.2; P = .001), symptomatic status (OR, 1.7; P .001), and CEA + IPE (OR, 1.9; P = .02).The addition of IPE to CEA confers increased stroke and death risk over ICEA. Risk is largely in symptomatic patients. Although CEA + IPE increases risk compared with ICEA, overall risk remains low. Based on this VQI analysis, CEA + IPE outcomes for asymptomatic patients fall within Society for Vascular Surgery guidelines for ICEA. Those for symptomatic patients do not, and consideration should be given to other surgical bypass, cerebral protection, and staged strategies.

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.

Made available in DSpace on 2022-04-28T19:47:00Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-10-01 Introduction: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. Methods: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. Results: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) Conclusion: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material. University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine the Ronald Reagan UCLA Medical Center University of California Los Angeles SSM Healthcare Semmelweis University Keck School of Medicine University of Southern California University of North Carolina School of Medicine University of Arizona the Indiana University Health Physicians Vascular Surgery Michigan Medicine University of Michigan University Heart Center Hamburg University Medical Center Hamburg-Eppendorf Penn State Heart and Vascular Institute Milton S. Hershey Medical Center Johns Hopkins Hospital The Heart Hospital Baylor Plano the Cardiovascular Surgery Clinic University of Messina National & Kapodistrian University of Athens University of Patras Keio University University of Pennsylvania Vancouver General Hospital & University of British Columbia Mayo Clinic Christiana Health System University of Chicago Harborview Medical Center University of Washington Washington University Stanford University CHU de Poitiers Baylor College of Medicine MedStar Georgetown University Hospital SSM Health St. Louis University Faculdade de Medicina de Botucatu-Unesp Beth Israel Deaconness Medical Center Brigham and Women's Hospital St. Joseph's Hospital Massachusetts General Hospital Robert Wood Johnson Medical School Rutgers University Vita-Salute University School of Medicine San Raffaele Scientific Institute Kaiser Permanente University Heart Center Freiburg-Bad Krozingen Freiburg University of Virginia Medical Center University of Siena Kyung Hee University Gustave Dron Hospital Centro Hospitalar de Lisboa Norte Wexner Medical Center Ohio State University Uppsala University University Hospital of Trieste University Hospital of Verona University Hospital of Padova University of Alabama University of California Davis University of Florida Michael E. DeBakey Department of Surgery Baylor College of Medicine University Hospital University of Missouri Faculdade de Medicina de Botucatu-Unesp

Objectives Acute mesenteric ischemia (AMI) is a life-threatening condition associated with dismal outcomes. This study sought to evaluate the evolution of presentation, treatment, and outcomes of AMI over the past two decades. Methods AMI patients presenting at a single institution were reviewed (1993–2016). Venous thrombosis patients were excluded. Primary outcome was 30-day mortality. Patients were stratified by etiology and diagnosis date (before 2004 versus 2004 and later). Ordered logistic regression was performed for longitudinal temporal analysis. Results 303 patients were identified. AMI mechanisms included: embolic (49%), thrombotic (29%), and non-occlusive (NOMI) (22%). The majority were women (55%), 50% had atrial fibrillation, and 23% were on anticoagulation (AC) therapy. Mean age was 72±13 years. 345 procedures were performed in 242 patients: 321 open and 24 hybrid/endovascular. Among the 189 embolic/thrombotic patients who were managed operatively, 45% (n=85) underwent mesenteric revascularization while 39 (21%) had findings of non-survivable bowel necrosis (NSBN). Among the 104 patients who did not undergo revascularization, 64 (62%) died within 30-days compared to 36 out of 85 (42%) patients who were revascularized (P=0.01). 30-day mortality was 61% and stable over time (P=0.91); when stratified by AMI etiology, the thrombotic cohort had worse survival than embolic and NOMI patients (P=0.04). Since 2000, there was a significant decrease in the percentage of embolic AMI events (P=0.04). The percentage of patients who underwent operative management decreased also over time (P=0.01, 81% → 61%), which was correlated with an increasing number of patients being made comfort measures only (CMO) prior to surgical intervention (50% → 70%, P=0.02). The majority of patients (55%) were ultimately made CMO during their hospitalization. Predictors of 30-day mortality included a preoperative white blood cell count (WBC) ≥ 25 K/ µL. (OR 3.0, P=0.002) and lactate ≥ 2.3 mmol/L (OR 2.8, P=0.045). NSBN predictors included WBC ≥ 24 K/ µL. (OR 3.4 P=0.03) and lactate ≥ 3.8 mmol/L (OR 3.6, P=0.04). Conclusions Despite advances in critical care over the past 25 years, AMI continues to be associated with poor prognosis. The survival benefit observed in patients who undergo revascularization supports an aggressive approach towards early vascular intervention, although this requires further study. The importance of early diagnosis, prognostication and advanced directives is highlighted given the high morbidity, mortality and use of comfort measures associated with AMI.

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.

Objective:Acute peripheral arterial events, such as aortic dissection, carotid artery dissection, vertebral artery dissection, and ruptured renoviseral aneurysms, have been reported during pregnancy in case series, but there is a paucity of population-based data. This study sought to establish pregnancy and preeclampsia as risk factors for acute peripheral arterial events.Approach and Results:All women who gave birth between 1998 and 2020 within a multicenter health care system were identified. Births that occurred in women 50 years of age were excluded. Primary outcome was any acute peripheral arterial event that was symptomatic or required intervention. Cox regression model was used to evaluate the association between vascular events and pregnancy as a time-varying covariate. The pregnancy exposure period was from the estimated date of conception to 3 months postpartum. There were 277 697 pregnancies (81.3% deliveries, 17.0% abortions, and 1.7% ectopics) among 176 635 women with 1.68 million patient-years of total follow-up (median, 7.9 years; interquartile range, 2.4–16.2). Preeclampsia complicated 5.3% of pregnancies; 67 790 of 225 763 (30.0%) deliveries were delivered by cesarean. Ninety-six acute arterial events occurred during follow-up, of which 24 occurred during pregnancy, including the postpartum period. Pregnancy (hazard ratio, 1.85 [95% CI, 1.01–3.38];P=0.046) and preeclampsia (hazard ratio, 10.9 [95% CI, 5.24–22.7];PConclusions:While taking into account limitations from estimating conception and outcome dates, pregnancy, especially when complicated by preeclampsia, is associated with an increased risk of acute peripheral arterial events.

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.