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ObjectivesEmphasis on tobacco cessation given the urgent and emergent nature of vascular surgery is less prevalent than standard elective cases such as hernia repairs, cosmetic surgery, and bariatric procedures. The goal of this study is to determine the effect of active smoking on claudicating individuals undergoing peripheral vascular interventions (PVI). Our goal is to determine if a greater emphasis on education should be placed on smoking cessation in non-urgent cases scheduled through clinic visits and not the Emergency Department.MethodsThis study was performed using the multi-institution de-identified Vascular Quality Initiative-Medicare-Linked database (VISION). Claudicants who underwent PVI for peripheral arterial occlusive disease between 2004-2019 were included in our study. Our final sample consisted of a total of 18,726 patients: 3,617 (19.3%) nonsmokers (NS), 9,975 (53.3%) former smokers (FS) and 5,134 (27.4%) current smokers (CS). We performed propensity score matching (PSM) on 29 variables [age, gender, race, ethnicity, treatment setting (outpatient or inpatient), obesity, insurance, hypertension, diabetes, CAD, CHF, COPD, CKD, previous CABG, CEA, major amputation, inflow treatment, prior bypass or PVI, preop medications, level of treatment, concomitant endarterectomy, and treatment type (atherectomy, angioplasty, stent)] between NS versus FS and FS versus CS. Outcomes were long-term (five-year) overall survival (OS), limb salvage (LS), freedom from reintervention (FR) and amputation free survival (AFS).ResultsPSM resulted with 3,160 well matched pairs of NS and FS and 3,750 well matched pairs of FS and CS. There was no difference between FS and NS in terms of OS [HR = 0.94, 95% CI 0.82-1.09, p=0.43], FR [HR = 0.96, 95% CI 0.89-1.04, p=0.35], or AFS [HR = 0.90, 95% CI 0.79-1.03, p=0.12]. However, when compared to CS, we found FS to have a higher OS [HR = 1.18, 95% CI 1.04-1.33, p =0.01], less FR [HR = 0.89, 95% CI 0.83-0.96, p=0.003] and greater AFS [HR = 1.16, 95% CI 1.03-1.31, p=0.01].ConclusionThis multi-institutional Medicare-linked study looking at elective PVI cases in PAD patients presenting with claudication found that former smokers have similar 5-year outcomes in comparison to non-smokers in terms of OS, FTR and AFS. Additionally, current smokers have lower overall survival and amputation free survival when compared to former-smokers. Overall, this suggests that smoking claudicants should be highly encouraged and referred to structured smoking cessation programs or even required to stop smoking prior to elective PVI due to the perceived 5-year benefit.

Surgery is the mainstay of treatment for meningioma, the most common primary intracranial tumor, but improvements in meningioma risk stratification are needed and indications for postoperative radiotherapy are controversial. Here we develop a targeted gene expression biomarker that predicts meningioma outcomes and radiotherapy responses. Using a discovery cohort of 173 meningiomas, we developed a 34-gene expression risk score and performed clinical and analytical validation of this biomarker on independent meningiomas from 12 institutions across 3 continents (N = 1,856), including 103 meningiomas from a prospective clinical trial. The gene expression biomarker improved discrimination of outcomes compared with all other systems tested (N = 9) in the clinical validation cohort for local recurrence (5-year area under the curve (AUC) 0.81) and overall survival (5-year AUC 0.80). The increase in AUC compared with the standard of care, World Health Organization 2021 grade, was 0.11 for local recurrence (95% confidence interval 0.07 to 0.17, P

Background and Aim: Laboratory assessment of sialic acid as a marker of microvascular complications can be a diagnostic tool for diabetes mellitus. Microalbumin is an established predictor of diabetic nephropathy. The study was undertaken to evaluate serum sialic acid and microalbumin levels and to correlate it with glycemic control in diabetic nephropathy patients. Material and Methods: Clinically diagnosed diabetic nephropathy patientsvisiting the medicine OPD (outdoor patient department) and NCD (Non-Communicable Disease) were selected for the study. This study included 75 subjectswith diabetes types 2 of which 44 were males and 31were females. Control includes a total of 75 out of which 49 Males and 26 females. Blood samples were analysed for the glucose, C-reactive protein, and sialic acid. Urine sample was analyzed for microalbumin and sialic acid. Results: The mean value of FBS was 161±53.2 mg/dl which was significantlyhigher than controls 81±5.2. The Sialic acid in subjects was 105±21 mg/dl which is higher than controls 51±6 mg/dl. The urine microalbumin level was found to be 96.5±17.2 in subjects, whereas 6.4±1.6 mg/dl was in controls. Serum Creatinine level in subjects was 8.75±2.05 mg/dl which was higher than subjects 0.8±0.3mg/dl. Serum Urea in diabetic nephropathy subjects was 93.5±15.4 mg/dl, which is positively higher than controls 30.8±7.1 mg/dl. Conclusion: Urine microalbumin is established as a potential marker for diabetic nephropathy. The correlation of serum sialic acid, urine microalbumin and serum creatinine proposed serum sialic acid as an accessory diagnostic marker for diabetic nephropathy. Estimation of sialic acid before microalbumin in diabetic patients helps assess glycemic control and identify the risk for nephropathy and other secondary complications of diabetes mellitus, which are the main causes of mortality and morbidity among type-2 diabetes mellitus patients.

BackgroundThe endovascular repair of infrarenal abdominal aortic aneurysms (AAA) can be performed with a wide variety of devices. Many of these grafts elevate the aortic bifurcation which can limit future repairs if the graft material fails thereby creating a type III endoleak to aorto-uniliac (AUI) grafts. Many manufacturers have grafts susceptible to this, but we have seen this in the Medtronic AneuRx graft. Our goal is to provide technical details and outcomes regarding a novel technique to re-line these grafts while maintaining inline flow to the iliac arteries.MethodsThis was a single institution review of patients who had endoleaks requiring intervention after a previously placed graft with an elevated aortic bifurcation. Primary outcomes included technical success defined as placement of all planned devices, resolution of type III endoleak, aneurysm size at follow-up, and requirement of reintervention. Secondary outcomes included 30-day complications, aneurysm-related mortality (ARM), and all-cause mortality (ACM). Technical details of the operation include back table deployment of an Ovation device, modification of the deployment system tether and preemptive placement of an up and over 0.014" wire. The wire is placed up and over and hung outside the contralateral gate. Once the main body is introduced above the old graft, the 0.014" is snared from the contralateral side and externalized. The main body is then able to be seated at the bifurcation as the limb is not fully deployed and then device deployment is completed per IFU.ResultsOur study consists of four individuals, three of which had an AAA initially managed with an AneuRx EVAR and one with a combination of Gore and Cook grafts. All four patients were male with an average age of 84.5 years at time of re-line. All patients had at least 10 years between initial surgery and re-line at our institution. Primary outcomes revealed no type 1 or 3 endoleaks at follow-up, technical success was 100% and one patient required reintervention for aneurysm growth and type 2 endoleak. In terms of our secondary outcomes, there was one postoperative complication which was cardiac dysfunction secondary to demand ischemia, ARM was 0% and ACM was 25% at average follow up of 2.44 years.ConclusionAs individuals continue to age, there are more patients who would benefit from less invasive reinterventions following EVAR. Whether this is due to aortic degeneration, stent migration, or stent material damage is not always known. In this study we present an endovascular approach to treating type III endoleak patients with a previous graft and elevated aortic bifurcation using Ovation stent grafts and found no evidence of type 1 or 3 endoleaks on follow-up imaging. This approach may allow patients with type III endoleak the option of a minimally invasive, percutaneous approach where they previously would not have had one.

ObjectivePhysician modified endografts (PMEG) and custom manufactured devices (CMD) use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity access from a transfemoral approach. Single institution studies have demonstrated increased risks of access site complications and stroke when upper extremity access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed upper extremity (UEM) access.MethodsThis study is an analysis of the Vascular Quality Initiate for all patients who underwent F/BEVAR from 2014-2021. Patients were stratified based on a TTF delivery of all devices versus any UEM access for deployment of target vessel stents. Primary outcomes included stroke, myocardial infarction and perioperative death. Secondary outcomes included access site hematoma, occlusion, or embolization, operative time, fluoroscopy time, and technical success. Multivariable linear and logistic regression analyses were performed.Results3146 patients underwent a F/BEVAR; 2309 (73.4%) TTF and 837 (26.6%) UEM. Logistic regression analysis indicated a two-fold increased risk of death and MI and a three-fold increased risk of stroke in the UEM group. Furthermore, there is decreased operative time (221 versus 297 minutes, p

BackgroundRecent studies have shown a trend supporting endovascular revascularization (ER) in the treatment of chronic mesenteric ischemia (CMI). However, few studies have compared the cost effectiveness of ER and open revascularization (OR) for this indication. The purpose of this study is to conduct a cost-effectiveness analysis comparing open versus ER for CMI.MethodsWe built a Markov model with Monte Carlo microsimulation using transition probabilities and utilities from existing literature for CMI patients undergoing OR versus ER. Costs were derived from the hospital perspective using the 2020 Medicare Physician Fee Schedule. The model randomized 20,000 patients to either OR or ER and allowed for 1 subsequent reintervention with 3 other intervening health states: alive, alive with complications, and dead. Quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratio (ICER) were analyzed over a 5-year period. One-way sensitivity and probabilistic sensitivity analyses were conducted to study the impact of parameter variability on cost effectiveness.ResultsOR cost $4,532 for 1.03 QALYs while ER cost $5,092 for 1.21 QALYs, leading to an ICER of $3,037 per QALY gained in the ER arm. This ICER was less than our willingness to pay threshold of $100,000. Sensitivity analysis demonstrated that our model was most sensitive to costs, mortality, and patency rates after OR and ER. Probabilistic sensitivity analysis demonstrated ER would be considered cost effective 99% of iterations.ConclusionsThis study found that while 5-year costs for ER were greater than OR, ER afforded greater QALYs than OR. Although ER is associated with lower long-term patency and higher rates of reintervention, it appears to be more cost effective than OR for the treatment of CMI.