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Vascular Ehlers-Danlos syndrome is caused by mutations in the COL3A1 (collagen type III alpha-1) gene, resulting in loss of integrity of arteries and hollow organs. Patients are predisposed to dissection, aneurysm, and organ rupture. The median life expectancy is ∼51 years. We have described a unique presentation of spontaneous compartment syndrome, likely secondary to ischemia reperfusion injury, in a 32-year-old man with vascular Ehlers-Danlos syndrome. The compartment syndrome was treated with four-compartment fasciotomy, and subsequent evaluation demonstrated a pseudoaneurysm of the tibioperoneal trunk. Endovascular intervention and stent graft deployment guided by intravascular ultrasound successfully excluded the pseudoaneurysm with three vessel run off preserved.

Objective/Introduction Increased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following EVAR in AAA patients. Methods Patients who underwent elective EVAR between 2004 and 2018 were reviewed. Thoracic tortuosity index (TTI) was measured using 3D reconstruction software. Patients were dichotomized across the median TTI into high tortuosity [HT] (TTI >1.27, Figure1(a) ) and low tortuosity [LT] (TTI ≤1.27, Figure 1(b) ) groups. Perioperative complications, postoperative outcomes, and CT-based features of thoracic aortic wall degeneration ( Figure 1(c)-(e) ) were collected and analyzed. Results 136 patients underwent treatment: 70 HT patients, including 54 males and 16 females (mean age: 77 years), and 66 LT patients, including 62 males and 4 females (mean age: 70 years) (age; P < .001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P = .045, P = .01). Presence of degenerative aortic wall markers was greater in HT patients (P = .045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P = .002). Frequency of AAA rupture/dissection was 4.3% for HT and 1.5% for LT (P = .339). A trend was observed in all cause 30-day mortality in the HT group (P = .061). Other perioperative complications and postoperative outcomes were similar between groups. Conclusion High TTI was associated with older age at time of EVAR, greater prevalence of degenerative markers in the descending thoracic aortic wall, and widespread aorto-iliac dilation. While not predictive of EVAR outcomes, TTI can provide valuable information regarding aneurysm pathophysiology.

Peripheral artery disease (PAD) remains a major cause of morbidity and future cardiovascular events despite advancement in the surgical interventions and optimal medical therapy. The aim of our study is to evaluate the efficacy and safety of anticoagulation (AC) therapy for reducing cardiovascular and limb events in patients with PAD. PUBMED, Medline, and Cochrane Library were searched through 2020 for randomized clinical trials comparing major adverse cardiovascular events (MACE) and risk of major bleeding (MB), between AC and standard of care (SOC) therapy, among patients with PAD. Meta-analysis was performed using weighted pooled absolute risk difference (RD) with 95% confidence interval (CI) and fixed effects model for overall and sub-groups of full dose (FD) and low dose (LD) AC therapies. Amongst 17,684 patients from 7 different studies, the addition of AC to SOC therapy was associated with MACE reduction (RD -0.022, 95% CI -0.033 to -0.012, p0.001) and increased MB (RD 0.02, 95% CI 0.014 to 0.025, p0.001). For FD, MACE reduction was (RD -0.021, 95% CI -0.042 to 0.001, p = 0.061) and MB (RD 0.036, 95% CI 0.025 to 0.047, p0.001). For LD, MACE reduction was (RD -0.023, 95% CI -0.035 to -0.011, p0.001) and MB (RD 0.011, 95% CI 0.005 to 0.017, p0.001). In conclusion, addition of AC to the current SOC therapy can mitigate future MACE events in patients with PAD albeit at risk of increased bleeding. LD AC is associated with an efficacy/safety net benefit compared to FD AC therapy.

Background Our objective is to explore the Peripheral Intravascular Lithotripsy (IVL) System in the treatment of calcific access vessels during thoracic endovascular aortic repair (TEVAR), endovascular aortic repair (EVAR), and transcatheter aortic valve intervention. Methods This retrospective, single-center study evaluated the outcomes of patients undergoing TEVAR, EVAR, or transcatheter aortic valve intervention with severe calcific arterial disease between July 2018 and August 2019. Maximum circumferential calcification, length of calcification, and inner/outer diameter measurements were collected with curved planar reformation by medical imaging software (Aquarius APS, TeraRecon, Foster City, Calif). Effective luminal gain was calculated using the minimal inner diameter and the largest bore passed within the vessel lumen. End points included technical success, mortality, adverse events, and requirement for bail out maneuvers. Technical success was defined as successful delivery and deployment of device or endograft. Results Nine patients were included (mean age, 79.3 ± 9.79 years; range, 59-97 years]). four transcatheter aortic valve replacement, one TEVAR, one EVAR, and three fenestrated EVAR. Six patients (66.7%) had more than one artery treated; the segments treated included common iliac artery (seven patients [77.8%]), the external iliac artery (seven patients [77.8%]), and the common femoral artery (one patient [11.1%]). The average inner iliac vessel diameter was 3.38 ± 0.99 mm (range, 1.87-4.72 mm). The average outside diameter of device introduced was 7.2 ± 0.94 (range, 6.3-8.8 mm) with 229% effective luminal gain. Technical success was achieved in 100% of cases with a 0% mortality. Adjunctive measures were needed in five cases (55.6%). One vessel perforation was controlled with covered stent (Viabahn; W. L. Gore & Associates, Flagstaff, Ariz) deployment. Dissection was identified in two cases requiring stent placement. Two cases required the use of the Terumo International Systems SOLOPATH Balloon Expandable TransFemoral System (Terumo Interventional Systems, Somerset, NJ). One case deployed a Viabahn stent applying the "crack and pave" technique. Conclusions As the population of the United States ages, calcified arterial disease will become an everyday clinical conundrum. Furthermore, the procedures for which the IVL system is geared toward facilitating will likely also increase in use. The IVL system is an additional tool in the vascular surgeon's armamentarium to obtain large-bore access in these calcified vessels. Further studies are needed to better assess the clinical effectiveness of the IVL system.

OBJECTIVE The objective of this study was to determine predictors of increased length of stay (LOS) in patients who underwent lower extremity bypass for tissue loss. METHODS Using 2011 to 2016 National Surgical Quality Improvement Program vascular targeted databases, we compared demographics, comorbidities, procedural characteristics, and 30-day outcomes of patients who had expected LOS vs extended LOS (>75th percentile, 9 days) after nonemergent lower extremity bypass for tissue loss. We also compared factors associated with short LOS ( 75th percentile, 9 days) vs the interquartile range of LOS (4-9 days). Yearly trends and independent predictors were determined by linear and logistic regression. This study was exempt from Institutional Review Board approval. RESULTS In 4964 analyzed patients, there were no significant yearly trends or changes in LOS in the recent 5 years (P > .05). Overall 30-day mortality, major amputation, and reintervention rates were 1.6%, 4.5%, and 4.8%, respectively, also with no significant yearly trends (all P > .05). On univariate analysis, nonwhite race, dependent functional status, transfers, dialysis, congestive heart failure, hypertension, beta blockers, distal bypass targets, and extended operative time were associated with extended LOS (P < .05). Extended LOS was also associated with higher rates of 30-day major adverse limb and cardiac events, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility but lower 30-day readmission rates. After adjustment for covariates, the independent factors for extended LOS included dialysis, beta blockers, prolonged operative time, reintervention, major amputation, additional procedures related to wound care, deep venous thrombosis, complications (pulmonary, renal, septic, bleeding, and wound), and discharge to facility (P < .05). On the other hand, multivariable analysis showed that patients with expected LOS were significantly more likely to have been of white race or readmitted postoperatively (P < .05). CONCLUSIONS From 2011 to 2016, there were no significant changes in LOS. Efforts to decrease LOS without increasing readmission rates while focusing on some of the identified factors, including preventable postoperative complications and pre-existing socioeconomic factors, may improve the overall vascular care of these challenging patients.

Peripheral artery disease (PAD) can often present with chronic limb threatening ischemia (CLTI), including ischemic rest pain and severe tissue loss. Progression of PAD can lead to "no option" or end-stage disease in which there are no traditional open or endovascular interventions available for revascularization. This cohort of patients have a poor prognosis, with a major amputation rate of 40% and mortality of up to 20% at six months. For this patient population, surgical deep vein arterialization (DVA) is offered as an attempt to provide blood flow to the distal preserved venous bed and reverse the ischemic process. Surgical DVA has traditionally been offered as an option and was pioneered by Herb Dardik. The evolution of endovascular technology has allowed for percutaneous DVA (pDVA). Using ultrasound and fluoroscopic guidance, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts to increase distal limb perfusion with the goals of improving wound healing and amputation-free survival. Lysis of venous valves with a valvulotome also aids with reversal of flow into the distal venous system. Investigations of percutaneous deep vein arterialization are underway with one device, the LimFlow System (LimFlow SA, Paris, France), which is undergoing feasibility trials. Here we present the current clinical indications, feasibility, results, and our institutional experience with the use of percutaneous deep vein arterialization.

Double-barrel iliocaval reconstruction is performed by deploying two stents simultaneously in a side-by-side, or "double-barrel," configuration in the inferior vena cava (IVC) with extension into the bilateral common iliac veins. The aim of this study was to examine the outcomes of double-barrel reconstruction using closed-cell dedicated venous stents for the treatment of iliocaval deep venous thrombosis and iliac vein compression syndrome.All endovascular procedural reports comprising vascular surgery and interventional radiology operators from a single urban academic hospital between May 1, 2019, and April 30, 2021, were retrospectively searched. A cohort of 22 consecutive patients who underwent double-barrel iliocaval stenting with closed-cell dedicated venous stents for chronic or acute-on-chronic iliocaval venous disease without prior endovascular iliocaval repair was identified. Baseline characteristics, procedural data, and patient outcomes were determined via a manual review of preprocedure clinical notes, diagnostic imaging studies, procedure notes and images, and follow-up clinical notes.The median (range) age was 59 (27-81) years, and the cohort consisted of 59.1% female. The most common presenting symptoms of venous disease were lower extremity swelling (90.9%) and pain (50.0%). CEAP clinical classification was C3 in 86.4% of patients, whereas the remainder had C4 disease. Most patients (72.7%) had post-thrombotic syndrome, 22.7% had a nonthrombotic iliac vein lesion, and one patient (4.5%) had the congenital absence of the infrarenal IVC. A total of 40.9% of patients had a pre-existing IVC filter at the time of treatment. Six of the 22 patients underwent concurrent pharmacomechanical thrombectomy during the index iliocaval reconstruction and stenting procedure. The number of stents placed ranged from 2 to 5. With a mean follow-up period of 7.1 months, ranging from 12 days to 16.7 months, the freedom from reintervention rate was 90.9%. Twenty of 22 patients achieved subjective improvement or resolution of symptoms. The major adverse event rate was 9.1%, as two patients had access site complications requiring intervention.Double-barrel iliocaval reconstruction with closed-cell dedicated venous stents for the treatment of post-thrombotic syndrome or iliac vein compression syndrome is technically feasible and clinically effective with a low reintervention rate.

Aneurysm sac regression following endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) is an established indicator of surgical success. However, even with a completely excluded aneurysm, the degree of aortic sac regression may vary. This study evaluates the relationship between aneurysm sac regression after EVAR and the presence of morphological features in the thoracic aorta that can be associated with a subclinical aortic dissection, termed dissection morphology in this study.Patients who underwent EVAR to repair an infrarenal aortic aneurysm at Mount Sinai Hospital between 1996 and 2017 with a postoperative CT scan and a 3-year follow-up scan available for analysis were included in the study. Patients with a type I or type III endoleak were not included. The thoracic aorta was evaluated for dissection morphology on CT scan, which included the presence of aortic dissection, penetrating aortic ulcers, and intramural hematomas. AAA sac regression after EVAR was compared between patients with dissection morphology (n = 157) and patients without those characteristics (n = 141). An independent investigator performed the CT analysis and was blinded to the degree of sac regression.Demographics and comorbid clinical conditions were compared between patients with and without dissection morphology. There were no significant differences in age, gender, smoking habits, or cardiovascular conditions. The median AAA diameter after EVAR, over the course of the study, in patients with dissection morphology decreased by 11.30 mm (-17.20, -3.60) compared to a median change of 0.30 mm (-8.60, 8.60) in patients without dissection morphology features (p 0.001). Patients with dissection morphology also had fewer type II endoleaks in postoperative follow-up scans (22.9% vs. 53.9%, p 0.001). Additionally, patients with dissection morphology had longer EVAR operative times (192.00 min [167.25, 230.00] vs.174.00 min [150.00, 215.00], p = 0.004). AAA-related mortality after 3 years was not significantly different between the 2 groups (p = 1.0).The presence of imaging features consistent with dissection morphology in the thoracic aorta correlated with greater AAA sac regression and fewer type II endoleaks after EVAR. Assessing these imaging features in patients undergoing EVAR may be useful in understanding aneurysm behavior in terms of aneurysm growth, risk of rupture, and outcomes following endovascular surgery. Identifying differential rates of aneurysm sac regression may have implications regarding the role of subclinical dissections in the etiology of AAA development.

Acute aortic occlusion is an infrequent clinical event with high morbidity and mortality. Management is determined by the cause of the occlusion, with thromboembolectomy used for embolic events and bypass for thrombotic events. After bypass, recanalization of a total aortic occlusion has been sparsely reported. We present a case of a total occlusion of an infrarenal abdominal aorta that was managed surgically with a left axillary-bifemoral bypass. Imaging performed 6 months postoperatively revealed a spontaneously recanalized aorta and occluded bypass graft.

Objective Proximal venous outflow obstruction (PVOO) in the iliac veins and superficial venous disease are inter-related in ways not fully understood. We observed among our patients undergoing vein stent placement for PVOO a significant number having had prior endovenous thermal ablations (EVTA) in their history. This study was undertaken to better characterize these patients and develop an algorithm in their management. Methods In a combined retrospective and prospective data registry of 682 patients who underwent vein stent placement for chronic PVOO at a single institution from March 2013 to November 2017, 100 limbs of 99 patients (14.5% of all patients) had a history of EVTA or other superficial venous procedures before their vein stenting. Limbs with dilated truncal veins on ultrasound examination or limbs that underwent poststent EVTA or superficial venous procedures were excluded. The mean age of these 99 patients was 60.2 years (range, 28-88 years; standard deviation, 13.855). Fifty-one percent of the patients were male. The most common presenting symptom of the patient cohort was edema (n = 59), followed by venous-related skin changes (n = 22). Results Bilateral stents were performed in 58%, with a mean number of 2.06 stents per patient. EVTA was the primary superficial vein procedure in 97%. Bilateral EVTA were performed in 53% and unilateral EVTA in 47%. The mean time between the first EVTA to vein stenting was 1202.7 days. Patients were followed at 30 days, 90 days, 6 months, 1 year, and >1 year. The outcome for each patient at each postoperative visit was compared with preoperative parameters (subject's assessment, physical examination, and provider assessment) and was scored as follows: -1 (worse than preoperative), 0 (no change), +1 (mildly improved), +2 (significantly improved), or +3 (completely recovered). The mean outcome score at 30 days was 1.63 (84 patients), 2.05 at 90 days (62 patients), 2.09 at 6 months (74 patients), 1.93 at 1 year (54 patients), and 1.97 at >1 year (39 patients). Conclusions Approximately 15% of patients undergoing vein stent placement for chronic PVOO have an antecedent history of superficial venous disease and EVTA. PVOO should be considered and the patient evaluated accordingly if symptoms persisted or recurred after EVTA. Vein stent placement among these patients with PVOO will result in further symptomatic relief, but complete symptomatic relief is not observed in everyone. The algorithm for the management of these patients warrants further investigation.

Objective The objective of this study was to better understand the pathophysiology and underlying genetic mechanisms behind two abdominal aortic aneurysm (AAA) subtypes using computed tomographic imaging in combination with whole genome sequencing. Methods Patients with a known AAA and European ancestry were included in this investigation and underwent genetic and image analysis. Patients with AAAs and indications of descending thoracic aortic pathology (aortic dissection, penetrating aortic ulcers, intramural hematoma, atheromas, ulcerative plaque, and intramural ulceration, and intimal flaps/tears) were classified as having thoracic aortic disease, grouped together, and compared with patients with an AAA and a normal descending thoracic aorta. Whole genome sequencing was then performed on the 93 patients who had imaging features consistent with thoracic aortic disease and the 126 patients with a normal descending thoracic aorta. Results The results of this study suggest one variant-level, four gene-level, and one gene set-level associations in patients with thoracic aortic disease who also had an AAA. The variant rs79508780 located in TSEN54 achieved study-wide significance (P = 1.71E-06). BATF3 and SMLR1 were significantly associated and EFCAB3 and TAF4 were reached suggestive assocation with a diseased descending thoracic aorta (P = 5.23E-26, P = 1.86E-25, P = 1.54E-05, and P = 8.31E-05, respectively). Gene sets were also compiled using MSigDB and trait-based index single nucleotide variation from major genome-wide association studies. GO_DNA_DOUBLE_STRAND_BREAK_PROCESSING, a gene set related to double-stranded DNA break repair, was significantly associated with thoracic aortic disease in AAA patients (P = 1.80E-06). Conclusions This pilot study provides further evidence that an AAA may be the end result of multiple degenerative pathways. Genetic variations in vitamin D signaling, cholesterol metabolism, extracellular matrix breakdown, and double-stranded DNA break repair pathways were associated with European patients who had an AAA and thoracic aortic disease. Additionally, this study provides support for the application of a radiogenomic approach for the investigation of other potential pathologies that could lead to the development of an AAA or influence future management decisions. (JVS–Vascular Science.) Clinical Relevance In this study, we provide evidence that abdominal aortic aneurysms (AAAs) may be a result of multiple pathophysiologies rather than a single disease. We have identified genetic variants involved in vitamin D signaling, cholesterol metabolism, extracellular matrix breakdown, and double-stranded DNA break repair associated with structural defects in the aortic wall in patients with AAAs who are of European descent. Patients with AAAs and structural defects in the thoracic aorta have been previously linked to differential behavior after endovascular aneurysm repair. These patients with wall defects exhibited greater sac regression, a marker of surgical success, after endovascular aneurysm repair. Our study demonstrates the usefulness of a radiogenomic approach for elucidating mechanisms behind the formation and future behavior of AAAs that could aid surgeons in making future procedural and management decisions.

This study aimed to understand the impact of surgeon volume on outcomes of thoracic endovascular aortic repair (TEVAR) in patients being treated for aortic dissection.Patients undergoing TEVAR from January 2014 to March 2021 in the Vascular Quality Initiative database were analyzed. Patients with aortic dissection who underwent TEVAR were divided into quartiles based on the annual TEVAR volume of their vascular surgeon. The highest quartile, middle two quartiles, and lowest quartile were deemed high volume (HV), moderate volume (MV), and low volume (LV), respectively. Multivariable logistic regressions were performed to compare cohort outcomes in terms any postoperative complication, stroke, spinal cord ischemia, reintervention, and 30-day mortality. A Cox proportional hazard model was used to assess the hazard of overall postoperative mortality.Among 1217 patients undergoing TEVAR, 321, 621, and 275 were performed by HV, MV, and LV surgeons, respectively. HV surgeons performed19 annual TEVARs, MV surgeons between five and 18, and LV surgeons four or less. Adjusted odds of any postoperative complication revealed that HV and MV surgeons had lower odds of overall postoperative complications (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.30-0.85; P = .011 and OR, 0.60; 95% CI, 0.38-0.87; P = .008, respectively) when compared with patients of LV surgeons. Patients of HV surgeons had lower odds of respiratory complications than those of LV surgeons (OR, 0.42; 95% CI, 0.17-0.93; P = .039). Adjusted analysis of outcomes including spinal cord ischemia, stroke, myocardial infarction, 30-day mortality, and overall mortality did not reveal statistically significant differences between cohorts.Surgeon volume does not to impact 30-day mortality or long-term mortality after TEVAR for aortic dissection, but the odds of overall postoperative complications were lower for HV and MV surgeons when compared with LV surgeons.

This study sought to evaluate long-term symptom relief and reintervention rates after iliac vein stenting (IVS) in patients with chronic venous outflow obstruction.A single-institution database of patients undergoing IVS from August 2011 to June 2021 was analyzed. Patients were stratified into three cohorts based on the clinical component of the clinical, etiology, anatomical, and pathophysiology (CEAP) classification: CAmong 737 total patients, there were 435 CThe present study is one of the largest investigations of long-term outcomes in IVS patients. Most patients with long-term follow-up experienced an improvement in their composite VCSS. CEAP clinical classification at the time of IVS had a significant influence on the likelihood and quantity of reintervention.

Medical compression stocking (MCS) therapy remains a core treatment for chronic venous disease, particularly in patients with lower extremity edema. This study investigated the impact of postoperative MCS adherence on patients with moderate to severe edema who underwent iliac vein stenting (IVS).Patients at a large tertiary care center who underwent IVS from August 2011 to June 2021 were analyzed. Symptoms were quantified using the venous clinical severity score (VCSS) and clinical assessment score (CAS). The criterion for inclusion was moderate or severe lower extremity edema at the time of IVS. Patients were stratified into two cohorts: complete postoperative compression therapy compliance (MCS+) and no postoperative compression therapy use (MCS-).Among 376 patients fitting our study criteria, we identified 168 MCS+ and 208 MCS- patients. The VCSS edema score did not significantly differ between groups (P = 0.179). Postoperatively, the mean changes in VCSS edema at the first postoperative visit, the one-year follow-up, and the two-year follow-up were not significantly different between the MCS+ and MCS- cohorts (P = 0.123, 0.296, and 0.534, respectively). An analysis of CAS for edema revealed that the MCS+ cohort had a modestly better improvement in edema at the 90-day follow-up visit versus the MCS- cohort (P = 0.018), but this difference was not observed in the 30-day (P = 0.834) or six-month follow-up visit (P = 0.755). A multivariate analysis revealed no difference in the need for major intervention (OR 0.93, 95% CI 0.44 to 1.50, P = 0.504). A Kaplan-Meier analysis via log-rank test revealed no difference in reintervention-free survival between groups (P = 0.77).Many patients with moderate to severe lower extremity edema experience a reduction in their edema after IVS. In our study, compression stocking compliance after surgery had a little impact on edema relief in this population.

Endovascular intervention has become first-line treatment for the majority of atherosclerotic lesions associated with peripheral artery disease. Traditionally, treatment modalities have included various types of balloon angioplasty and stenting. However, recent technological advancements have introduced the concept of endovascular lithotripsy as a novel alternative to angioplasty and stenting. This new addition to the armamentarium of surgeons and interventionalists has the potential to alter the treatment paradigm for patients with complex peripheral artery disease.

An active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU-).A single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU-) VLUs.A total of 872 patients (71 VLU+ and 801 VLU-) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU- cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years.Patients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

Innominate artery occlusion is a rare entity, particularly when coupled with severe left common carotid artery stenosis. Innominate artery disease may present with varying degrees of symptomatology and can place patients at risk for both posterior fossa and hemispheric ischemic events. We present a symptomatic case of innominate artery occlusion with severe left common carotid disease. We reviewed the literature and current options for the treatment of innominate artery disease. The patient underwent successful hybrid repair with left carotid artery retrograde stenting and left carotid artery to right carotid artery bypass. She has been symptom and re-intervention free during her one-year follow-up. We describe a successful hybrid repair of symptomatic innominate artery occlusion with concomitant severe left carotid artery stenosis in a patient with a prohibitive open thoracic surgical risk.