Journal of Vascular Surgery Cases and Innovative Techniques, Mar 1, 2017
Endovascular repair of iliac artery aneurysms has emerged as an alternative to traditional open s... more Endovascular repair of iliac artery aneurysms has emerged as an alternative to traditional open surgical repair. Although there is little consensus on indications to preserve hypogastric blood flow during aneurysm repair, it is well understood that complications from bilateral hypogastric occlusion may be significant. The GORE EXCLUDER Iliac Branch Endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz) received United States Food and Drug Administration approval in March 2016 for treatment of common iliac artery and aortoiliac aneurysms. This case report discusses an off-label use of GORE EXCLUDER Iliac Branch Endoprosthesis to maintain pelvic perfusion during treatment of bilateral internal iliac artery aneurysms without surrounding aortoiliac pathology.
Purpose Many studies recently focus on complicated and expensive genomic tests, but the prognosti... more Purpose Many studies recently focus on complicated and expensive genomic tests, but the prognostic values of biochemical markers which are easily obtained in clinics are largely overlooked and without further exploration. This study assesses the association of neutrophil-lymphocyte-ratio (NLR) with prognosis of lung cancer patients. Methods In 1032 patients with histologically confirmed lung cancer, the association of pretreatment NLR values with overall survival (OS) was evaluated using a Cox proportional hazards model and the temporal relationship of longitudinal NLR was assessed using a mixed effects model. Results Compared to the patients with a low pretreatment NLR value, those with elevated NLR exhibited a statistically significant worse OS with a hazard ratio (HR) of 1.50 (P \ 0.0001) after adjusting for age, gender, race, smoking status, drinking status, tumor stage, tumor grade, histology, and treatments. A significant trend of increasing HRs along with increasing NLR values was observed. The increased risk of death conferred by pretreatment NLR values reached a peak level around 2 years after diagnosis. Moreover, in longitudinal analysis, we observed a trend of dramatically increased NLR values in patients who died during follow-up, but stable NLR values in those who were still alive, with a significant interaction of death-alive status with follow-up time (P \ 0.0001). Conclusions Elevated NLR is a potential biomarker to identify lung cancer patients with poor prognosis and should be validated in a future clinical trial.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Background: Carotid angioplasty and stenting (CAS) is an alternative to carotid endarterectomy. C... more Background: Carotid angioplasty and stenting (CAS) is an alternative to carotid endarterectomy. CAS outcomes and risk factors affecting postoperative complications in women are not well defined. We sought to determine the effect of sex on particle size captured by embolic protection devices, comorbidities influencing embolization, and results after CAS. Methods: Embolic debris from 188 consecutively collected carotid embolic protection devices were analyzed using photomicroscopy and imaging software. Patient comorbidities, preoperative cerebrovascular symptoms, and perioperative outcomes (cerebrovascular accident, myocardial infarction, mortality) were examined. Results: The mean age was 71.0 years (56.4% males). Men (M) were more likely than women (W) to be smokers (M: 70.4% vs. W: 55.6%, p ¼ 0.046) and have coronary artery disease (M: 65.7% vs. W: 48.1%, p ¼ 0.02). Symptomatic (S) patients had larger mean particle size compared with asymptomatic (AS) patients (S: 469.9 ± 416.4 mm vs. AS: 316.1 ± 241.1 mm, p ¼ 0.01). On subgroup analysis, a larger mean particle size was observed in symptomatic woman compared with asymptomatic women (S: 461.5 ± 348.1 mm vs. AS: 281.4 ± 209.4 mm, p ¼ 0.02). In men, a trend toward a larger mean particle size in symptomatic patients did not reach statistical significance (S: 475.8 ± 462.9 mm vs. AS: 351.2 ± 262.4 mm, p ¼ 0.08). Conclusions: Preoperative cerebrovascular symptoms are associated with a greater mean particle size in symptomatic women compared with asymptomatic women. This difference in mean particle size was not observed in men. These results provide evidence that may help in better selection of CAS patients, but the impact of an increased mean particle size in symptomatic women during carotid stenting requires further investigation.
Despite several reports of proximal arm ischemia due to radiation therapy, there are no reports o... more Despite several reports of proximal arm ischemia due to radiation therapy, there are no reports of hand ischemia, presumably due to the rarity of radiation treatment of the distal upper extremity. We present a case of a 42-year-old male presenting with acute hand ischemia 36 years after being treated with forearm radiation for Ewing's sarcoma. Angiography demonstrated a patent brachial artery, occluded radial and ulnar arteries in the forearm, and a normal-caliber reconstituted radial artery at the anatomical snuffbox feeding a patent palmar arch. Transluminal balloon angioplasty was attempted initially without improvement. The patient was successfully revascularized with a reversed saphenous vein graft bypass from the distal brachial artery to the distal radial artery. At 22 months of follow-up, the graft remains patent with a palpable distal pulse. The patient continues to report acceptable function and range of motion.
Introduction COVID-19 is a novel coronavirus which typically results in upper respiratory symptom... more Introduction COVID-19 is a novel coronavirus which typically results in upper respiratory symptoms. However, we describe the acute arterial and venous thrombotic events following COVID-19 infection. Managing acute thrombotic events from the novel virus presents unprecedented challenges during the COVID-19 pandemic. Our study highlights the unique management of these patients and discusses the role of anticoagulation in patients diagnosed with COVID-19. Methods Data for 21 patients with laboratory confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. Patients were analyzed on the basis of demographics, comorbidities, home medications, laboratory markers, and outcomes. The primary postoperative outcome of interest was mortality and secondary outcomes were primary patency and morbidity. To assess for significance, univariate analysis was performed using Pearson χ2 and Fisher exact tests for categorical variables and Student t-test for continuous variables. Results 21 patients with acute thrombotic events met our inclusion and exclusion criteria. The majority of cases were acute arterial events (76.2%) while the remainder were venous cases (23.8%). The average age of all patients was 64.6 years-old and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil: lymphocyte ratio (8.8) and d-dimer (4.9 mcg/mL). Operative intervention included percutaneous angiogram in 25.00% of patients and open surgical embolectomy in 23.8%. The majority of arterial interventions had a postoperative complication (53.9%) versus a 0% complication in the venous interventions. AKI on admission was a factor in 75.0% of mortalities versus 18.2% in survivors (p=0.04). Conclusion We describe our experience in the epicenter of the pandemic of 21 patients who experienced major thrombotic events from COVID-19. Our cohort highlights the need for increased awareness of vascular manifestations of COVID-19 and the important role of anticoagulation in these patients. More data is urgently needed to optimize treatments and prevent further vascular complications of COVID-19 infections.
The ideal treatment option for patients with complex aneurysm morphology remains highly debated. ... more The ideal treatment option for patients with complex aneurysm morphology remains highly debated. The aim of this study was to investigate the impact of endovascular aneurysm repair (EVAR) with active fixation on outcomes in patients with complex aneurysm morphology. There were 340 consecutive patients who underwent EVAR using active fixation devices, 234 with active infrarenal fixation (AIF; Gore Excluder; W. L. Gore & Associates, Flagstaff, Ariz) and 106 with active suprarenal fixation (ASF; 85 Medtronic Endurant [Medtronic, Santa Rosa, Calif] and 21 Cook Zenith [Cook Medical, Bloomington, Ind]). Demographics, comorbidities, anatomic features, and outcomes were analyzed for patients receiving devices with active fixation. Outcomes of using active fixation in necks with <15-mm neck lengths, >60-degree infrarenal neck angle (β), >30-mm infrarenal neck diameter, severe aortic neck calcification or thrombus, and nonstraight neck morphology were evaluated. Of the 340 patients, ...
Objectives: Proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR) can b... more Objectives: Proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR) can be associated with late endoleaks and migration. This study was designed to identify predictors of early AND in patients undergoing EVAR. Methods: The study group comprised 267 prospectively enrolled consecutive patients undergoing EVAR with EndoAnchor implantation at 39 sites in the ANCHOR Registry. Aortic diameter was measured 20 mm proximal to the lowest main renal artery and at three levels within the proximal neck (0 mm, 5 mm, and 10 mm distal to the lowest main renal artery). Dilatation was expressed as the difference between the baseline and the post-EVAR diameters, measured a mean of 6 6 6 months after EVAR. Multivariable analyses were performed to identify independent predictors of early AND at each level. Results: The mean AND was 0.6 6 2.0 mm, 1.1 6 2.3 mm, and 1.4 6 1.6 mm at 0 mm, 5 mm, and 10 mm below the lowest renal artery, and 0.0 6 1.6 mm at the suprarenal level. When a 4-mm threshold was used, dilatation occurred in 4.1%, 10.6%, and 15.6% of patients at the three infrarenal levels, respectively, and in 0.9% of patients at the suprarenal level. No patients had AND beyond the nominal diameter of the endograft. Regression models identified the presence of a suprarenal stent as a risk factor for dilatation at all four levels (Table). Additional predictors of dilatation at the lowest renal artery included increased baseline suprarenal aortic diameter (risk factor), infrarenal diameter (protective), and endograft oversizing (risk factor). Conclusions: Within the first 6 months after EVAR, up to 15.6% of all patients exhibit significant ($4 mm) AND of the infrarenal neck, likely due to the combined effects of endograft radial force and to a lesser extent, aortic dilatation. Aggressive endograft oversizing and use of endografts with suprarenal stents are independent risk factors for AND. Dilatation of the aortic neck was more common in aneurysms with smaller aortic diameter at the lowest renal artery and in those with larger suprarenal diameter before EVAR. Long-term follow-up of these patients will provide information on the efficacy of EndoAnchors in preventing AND beyond the nominal endograft diameter, endograft migration, and late type IA endoleak.
imaging, carotid duplex ultrasound criteria, and ultimately, threshold for surgery. We sought to ... more imaging, carotid duplex ultrasound criteria, and ultimately, threshold for surgery. We sought to identify national variation in preoperative imaging, duplex ultrasound criteria, and surgical intervention threshold for asymptomatic CEA. Methods: The Society for Vascular Surgery Vascular Quality Initiative (VQI) database was used to identify all CEA procedures performed for asymptomatic carotid artery stenosis between 2003 and 2014. VQI currently captures 100% of CEA procedures performed at >270 centers by >2000 physicians nationwide. Three analyses were performed to quantify the variation in 1) preoperative imaging modality, 2) duplex ultrasound criteria, and 3) degree of stenosis threshold used for CEA. Results: Of 35,695 CEA procedures in 33,488 patients, 19,610 (55%) were performed for asymptomatic disease. The preoperative imaging modality varied widely, with 53% of patients receiving a single imaging study (duplex ultrasound, 41%; computed tomography angiography, 8.3%; magnetic resonance angiography, 2.5%; cerebral angiography, 1.1%) and 47% receiving multiple preoperative imaging studies. Of the 16,997 asymptomatic patients (87%) who underwent a preoperative duplex ultrasound study, there was significant variability between centers in the degree of stenosis (50%-69%, 70%-79%, 80%-99%) designated for a given peak-systolic velocity, end-diastolic velocity, and internal carotid artery/common carotid artery ratio. Although asymptomatic CEA procedures were performed in 68% of patients for an 80% to 99% stenosis, 26% were for a 70% to 79% stenosis, and 4.1% were for a 50% to 69% stenosis. At the center level, institutions range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis from 2.8% to 86%. At the surgeon level, surgeons ranged from 0.6% to 88% in the percentages of CEA procedures performed for a <80% asymptomatic carotid artery stenosis from 0.6% to 88%. Conclusions: Despite CEA being an extremely common procedure, there is widespread variation in the three primary determinantsdpreoperative imaging, duplex ultrasound criteria, and treatment thresholddof whether CEA is performed for asymptomatic carotid stenosis. The observed variation likely has significant downstream effects that influence health care quality and health care costs, which may be improved with increased standardization of care.
001). Metformin use (hazard ratio, 0.7 [0.5-0.9]; P ¼ .008) was an independent factor associated ... more 001). Metformin use (hazard ratio, 0.7 [0.5-0.9]; P ¼ .008) was an independent factor associated with survival (Fig). Conclusions: Metformin is not associated with improved patency or limb salvage rates but is independently associated with improved survival and decreased MACEs in patients with PAD. Limb salvage was similar in nondiabetics and patients taking metformin and other OHs. Insulin use was associated with increase limb loss. Fig. Overall survival: Kaplan-Meier and Cox regression analysis.
INTRODUCTION This study analyzes sex-based differences in the risk of discharge to a nonhome faci... more INTRODUCTION This study analyzes sex-based differences in the risk of discharge to a nonhome facility (loss of independence) after lower extremity revascularization and resultant outcomes. METHODS Data from the NSQIP database for years 2015-2017 was utilized to assess sex-based differences in loss of independence and associated unplanned readmission and 30-day amputation using chi-square, student t-test, and multivariate logistic regression analyses where appropriate. RESULTS There was increased loss of independence in women (34.9% vs. 26.1 %, p < .01) and associated increase in unplanned readmission (18.4% vs. 13.6 %, p = .01) and length of stay (12.1 days vs 6.5 days, p < .01). Endovascular revascularization was associated with decreased likelihood of loss of independence (OR 0.43, CI 0.36-0.50). CONCLUSION Loss of independence after lower extremity bypass surgery affects women more than men and it is associated with worse postoperative outcomes.
Background: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava ... more Background: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava (IVC) filter and separate (SEP) IVC filter placement with open pulmonary thromboembolectomy (PTE) in pulmonary embolism and its clinical outcomes. Materials and Methods: From November 2006 to May 2014, 23 patients (14 females and 9 males; median age 58 years; range, 21–88 years) underwent emergent PTE for submassive (12) or massive (11) pulmonary embolism (PE). All had a preoperative computed tomography (CT) scan and echocardiography consistent with right ventricular (RV) strain. Mean cardiopulmonary bypass times and temperatures; chest tube outputs; length of stay; perioperative complications; and survival were compared between groups. Results: There were 13 patients in the SIM group and 10 in the SEP group. PE consisted of 14 acute (60.9%) and nine acute on chronic (39.1%). There were seven deaths (30.4%). Median follow up was 44 days (range, 2–2204 days). Follow up was 81% complete in...
This literature review discusses the current evidence on acute limb ischemia (ALI) in patients wi... more This literature review discusses the current evidence on acute limb ischemia (ALI) in patients with COVID-19. Throughout the pandemic, these patients have been at increased risk of arterial thrombotic events and subsequent mortality as a result of a hypercoagulable state. The exact mechanism of thrombosis is unknown; however arterial thrombosis may be due to invasion of endothelial cells via angiotensin-converting enzyme 2 (ACE2) receptors, endothelial injury from inflammation, or even free-floating aortic thrombus. Multiple studies have been performed evaluating the medical and surgical management of these patients; the decision to proceed with operative intervention is dependent on the patient’s clinical status as it relates to COVID-19 and morbidity of that disease. The interventions afforded typically include anticoagulation in patients undergoing palliation; alternatively, thrombectomy (endovascular and open) is utilized in other patients. There is a high risk of rethrombosis, despite anticoagulation, given persistent endothelial injury from the virus. Postoperative mortality can be high in these patients.
Journal of Vascular Surgery Cases and Innovative Techniques, Mar 1, 2017
Endovascular repair of iliac artery aneurysms has emerged as an alternative to traditional open s... more Endovascular repair of iliac artery aneurysms has emerged as an alternative to traditional open surgical repair. Although there is little consensus on indications to preserve hypogastric blood flow during aneurysm repair, it is well understood that complications from bilateral hypogastric occlusion may be significant. The GORE EXCLUDER Iliac Branch Endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz) received United States Food and Drug Administration approval in March 2016 for treatment of common iliac artery and aortoiliac aneurysms. This case report discusses an off-label use of GORE EXCLUDER Iliac Branch Endoprosthesis to maintain pelvic perfusion during treatment of bilateral internal iliac artery aneurysms without surrounding aortoiliac pathology.
Purpose Many studies recently focus on complicated and expensive genomic tests, but the prognosti... more Purpose Many studies recently focus on complicated and expensive genomic tests, but the prognostic values of biochemical markers which are easily obtained in clinics are largely overlooked and without further exploration. This study assesses the association of neutrophil-lymphocyte-ratio (NLR) with prognosis of lung cancer patients. Methods In 1032 patients with histologically confirmed lung cancer, the association of pretreatment NLR values with overall survival (OS) was evaluated using a Cox proportional hazards model and the temporal relationship of longitudinal NLR was assessed using a mixed effects model. Results Compared to the patients with a low pretreatment NLR value, those with elevated NLR exhibited a statistically significant worse OS with a hazard ratio (HR) of 1.50 (P \ 0.0001) after adjusting for age, gender, race, smoking status, drinking status, tumor stage, tumor grade, histology, and treatments. A significant trend of increasing HRs along with increasing NLR values was observed. The increased risk of death conferred by pretreatment NLR values reached a peak level around 2 years after diagnosis. Moreover, in longitudinal analysis, we observed a trend of dramatically increased NLR values in patients who died during follow-up, but stable NLR values in those who were still alive, with a significant interaction of death-alive status with follow-up time (P \ 0.0001). Conclusions Elevated NLR is a potential biomarker to identify lung cancer patients with poor prognosis and should be validated in a future clinical trial.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Background: Carotid angioplasty and stenting (CAS) is an alternative to carotid endarterectomy. C... more Background: Carotid angioplasty and stenting (CAS) is an alternative to carotid endarterectomy. CAS outcomes and risk factors affecting postoperative complications in women are not well defined. We sought to determine the effect of sex on particle size captured by embolic protection devices, comorbidities influencing embolization, and results after CAS. Methods: Embolic debris from 188 consecutively collected carotid embolic protection devices were analyzed using photomicroscopy and imaging software. Patient comorbidities, preoperative cerebrovascular symptoms, and perioperative outcomes (cerebrovascular accident, myocardial infarction, mortality) were examined. Results: The mean age was 71.0 years (56.4% males). Men (M) were more likely than women (W) to be smokers (M: 70.4% vs. W: 55.6%, p ¼ 0.046) and have coronary artery disease (M: 65.7% vs. W: 48.1%, p ¼ 0.02). Symptomatic (S) patients had larger mean particle size compared with asymptomatic (AS) patients (S: 469.9 ± 416.4 mm vs. AS: 316.1 ± 241.1 mm, p ¼ 0.01). On subgroup analysis, a larger mean particle size was observed in symptomatic woman compared with asymptomatic women (S: 461.5 ± 348.1 mm vs. AS: 281.4 ± 209.4 mm, p ¼ 0.02). In men, a trend toward a larger mean particle size in symptomatic patients did not reach statistical significance (S: 475.8 ± 462.9 mm vs. AS: 351.2 ± 262.4 mm, p ¼ 0.08). Conclusions: Preoperative cerebrovascular symptoms are associated with a greater mean particle size in symptomatic women compared with asymptomatic women. This difference in mean particle size was not observed in men. These results provide evidence that may help in better selection of CAS patients, but the impact of an increased mean particle size in symptomatic women during carotid stenting requires further investigation.
Despite several reports of proximal arm ischemia due to radiation therapy, there are no reports o... more Despite several reports of proximal arm ischemia due to radiation therapy, there are no reports of hand ischemia, presumably due to the rarity of radiation treatment of the distal upper extremity. We present a case of a 42-year-old male presenting with acute hand ischemia 36 years after being treated with forearm radiation for Ewing's sarcoma. Angiography demonstrated a patent brachial artery, occluded radial and ulnar arteries in the forearm, and a normal-caliber reconstituted radial artery at the anatomical snuffbox feeding a patent palmar arch. Transluminal balloon angioplasty was attempted initially without improvement. The patient was successfully revascularized with a reversed saphenous vein graft bypass from the distal brachial artery to the distal radial artery. At 22 months of follow-up, the graft remains patent with a palpable distal pulse. The patient continues to report acceptable function and range of motion.
Introduction COVID-19 is a novel coronavirus which typically results in upper respiratory symptom... more Introduction COVID-19 is a novel coronavirus which typically results in upper respiratory symptoms. However, we describe the acute arterial and venous thrombotic events following COVID-19 infection. Managing acute thrombotic events from the novel virus presents unprecedented challenges during the COVID-19 pandemic. Our study highlights the unique management of these patients and discusses the role of anticoagulation in patients diagnosed with COVID-19. Methods Data for 21 patients with laboratory confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. Patients were analyzed on the basis of demographics, comorbidities, home medications, laboratory markers, and outcomes. The primary postoperative outcome of interest was mortality and secondary outcomes were primary patency and morbidity. To assess for significance, univariate analysis was performed using Pearson χ2 and Fisher exact tests for categorical variables and Student t-test for continuous variables. Results 21 patients with acute thrombotic events met our inclusion and exclusion criteria. The majority of cases were acute arterial events (76.2%) while the remainder were venous cases (23.8%). The average age of all patients was 64.6 years-old and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil: lymphocyte ratio (8.8) and d-dimer (4.9 mcg/mL). Operative intervention included percutaneous angiogram in 25.00% of patients and open surgical embolectomy in 23.8%. The majority of arterial interventions had a postoperative complication (53.9%) versus a 0% complication in the venous interventions. AKI on admission was a factor in 75.0% of mortalities versus 18.2% in survivors (p=0.04). Conclusion We describe our experience in the epicenter of the pandemic of 21 patients who experienced major thrombotic events from COVID-19. Our cohort highlights the need for increased awareness of vascular manifestations of COVID-19 and the important role of anticoagulation in these patients. More data is urgently needed to optimize treatments and prevent further vascular complications of COVID-19 infections.
The ideal treatment option for patients with complex aneurysm morphology remains highly debated. ... more The ideal treatment option for patients with complex aneurysm morphology remains highly debated. The aim of this study was to investigate the impact of endovascular aneurysm repair (EVAR) with active fixation on outcomes in patients with complex aneurysm morphology. There were 340 consecutive patients who underwent EVAR using active fixation devices, 234 with active infrarenal fixation (AIF; Gore Excluder; W. L. Gore & Associates, Flagstaff, Ariz) and 106 with active suprarenal fixation (ASF; 85 Medtronic Endurant [Medtronic, Santa Rosa, Calif] and 21 Cook Zenith [Cook Medical, Bloomington, Ind]). Demographics, comorbidities, anatomic features, and outcomes were analyzed for patients receiving devices with active fixation. Outcomes of using active fixation in necks with <15-mm neck lengths, >60-degree infrarenal neck angle (β), >30-mm infrarenal neck diameter, severe aortic neck calcification or thrombus, and nonstraight neck morphology were evaluated. Of the 340 patients, ...
Objectives: Proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR) can b... more Objectives: Proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR) can be associated with late endoleaks and migration. This study was designed to identify predictors of early AND in patients undergoing EVAR. Methods: The study group comprised 267 prospectively enrolled consecutive patients undergoing EVAR with EndoAnchor implantation at 39 sites in the ANCHOR Registry. Aortic diameter was measured 20 mm proximal to the lowest main renal artery and at three levels within the proximal neck (0 mm, 5 mm, and 10 mm distal to the lowest main renal artery). Dilatation was expressed as the difference between the baseline and the post-EVAR diameters, measured a mean of 6 6 6 months after EVAR. Multivariable analyses were performed to identify independent predictors of early AND at each level. Results: The mean AND was 0.6 6 2.0 mm, 1.1 6 2.3 mm, and 1.4 6 1.6 mm at 0 mm, 5 mm, and 10 mm below the lowest renal artery, and 0.0 6 1.6 mm at the suprarenal level. When a 4-mm threshold was used, dilatation occurred in 4.1%, 10.6%, and 15.6% of patients at the three infrarenal levels, respectively, and in 0.9% of patients at the suprarenal level. No patients had AND beyond the nominal diameter of the endograft. Regression models identified the presence of a suprarenal stent as a risk factor for dilatation at all four levels (Table). Additional predictors of dilatation at the lowest renal artery included increased baseline suprarenal aortic diameter (risk factor), infrarenal diameter (protective), and endograft oversizing (risk factor). Conclusions: Within the first 6 months after EVAR, up to 15.6% of all patients exhibit significant ($4 mm) AND of the infrarenal neck, likely due to the combined effects of endograft radial force and to a lesser extent, aortic dilatation. Aggressive endograft oversizing and use of endografts with suprarenal stents are independent risk factors for AND. Dilatation of the aortic neck was more common in aneurysms with smaller aortic diameter at the lowest renal artery and in those with larger suprarenal diameter before EVAR. Long-term follow-up of these patients will provide information on the efficacy of EndoAnchors in preventing AND beyond the nominal endograft diameter, endograft migration, and late type IA endoleak.
imaging, carotid duplex ultrasound criteria, and ultimately, threshold for surgery. We sought to ... more imaging, carotid duplex ultrasound criteria, and ultimately, threshold for surgery. We sought to identify national variation in preoperative imaging, duplex ultrasound criteria, and surgical intervention threshold for asymptomatic CEA. Methods: The Society for Vascular Surgery Vascular Quality Initiative (VQI) database was used to identify all CEA procedures performed for asymptomatic carotid artery stenosis between 2003 and 2014. VQI currently captures 100% of CEA procedures performed at >270 centers by >2000 physicians nationwide. Three analyses were performed to quantify the variation in 1) preoperative imaging modality, 2) duplex ultrasound criteria, and 3) degree of stenosis threshold used for CEA. Results: Of 35,695 CEA procedures in 33,488 patients, 19,610 (55%) were performed for asymptomatic disease. The preoperative imaging modality varied widely, with 53% of patients receiving a single imaging study (duplex ultrasound, 41%; computed tomography angiography, 8.3%; magnetic resonance angiography, 2.5%; cerebral angiography, 1.1%) and 47% receiving multiple preoperative imaging studies. Of the 16,997 asymptomatic patients (87%) who underwent a preoperative duplex ultrasound study, there was significant variability between centers in the degree of stenosis (50%-69%, 70%-79%, 80%-99%) designated for a given peak-systolic velocity, end-diastolic velocity, and internal carotid artery/common carotid artery ratio. Although asymptomatic CEA procedures were performed in 68% of patients for an 80% to 99% stenosis, 26% were for a 70% to 79% stenosis, and 4.1% were for a 50% to 69% stenosis. At the center level, institutions range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis from 2.8% to 86%. At the surgeon level, surgeons ranged from 0.6% to 88% in the percentages of CEA procedures performed for a <80% asymptomatic carotid artery stenosis from 0.6% to 88%. Conclusions: Despite CEA being an extremely common procedure, there is widespread variation in the three primary determinantsdpreoperative imaging, duplex ultrasound criteria, and treatment thresholddof whether CEA is performed for asymptomatic carotid stenosis. The observed variation likely has significant downstream effects that influence health care quality and health care costs, which may be improved with increased standardization of care.
001). Metformin use (hazard ratio, 0.7 [0.5-0.9]; P ¼ .008) was an independent factor associated ... more 001). Metformin use (hazard ratio, 0.7 [0.5-0.9]; P ¼ .008) was an independent factor associated with survival (Fig). Conclusions: Metformin is not associated with improved patency or limb salvage rates but is independently associated with improved survival and decreased MACEs in patients with PAD. Limb salvage was similar in nondiabetics and patients taking metformin and other OHs. Insulin use was associated with increase limb loss. Fig. Overall survival: Kaplan-Meier and Cox regression analysis.
INTRODUCTION This study analyzes sex-based differences in the risk of discharge to a nonhome faci... more INTRODUCTION This study analyzes sex-based differences in the risk of discharge to a nonhome facility (loss of independence) after lower extremity revascularization and resultant outcomes. METHODS Data from the NSQIP database for years 2015-2017 was utilized to assess sex-based differences in loss of independence and associated unplanned readmission and 30-day amputation using chi-square, student t-test, and multivariate logistic regression analyses where appropriate. RESULTS There was increased loss of independence in women (34.9% vs. 26.1 %, p < .01) and associated increase in unplanned readmission (18.4% vs. 13.6 %, p = .01) and length of stay (12.1 days vs 6.5 days, p < .01). Endovascular revascularization was associated with decreased likelihood of loss of independence (OR 0.43, CI 0.36-0.50). CONCLUSION Loss of independence after lower extremity bypass surgery affects women more than men and it is associated with worse postoperative outcomes.
Background: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava ... more Background: This study retrospectively reviewed results of simultaneous (SIM) inferior vena cava (IVC) filter and separate (SEP) IVC filter placement with open pulmonary thromboembolectomy (PTE) in pulmonary embolism and its clinical outcomes. Materials and Methods: From November 2006 to May 2014, 23 patients (14 females and 9 males; median age 58 years; range, 21–88 years) underwent emergent PTE for submassive (12) or massive (11) pulmonary embolism (PE). All had a preoperative computed tomography (CT) scan and echocardiography consistent with right ventricular (RV) strain. Mean cardiopulmonary bypass times and temperatures; chest tube outputs; length of stay; perioperative complications; and survival were compared between groups. Results: There were 13 patients in the SIM group and 10 in the SEP group. PE consisted of 14 acute (60.9%) and nine acute on chronic (39.1%). There were seven deaths (30.4%). Median follow up was 44 days (range, 2–2204 days). Follow up was 81% complete in...
This literature review discusses the current evidence on acute limb ischemia (ALI) in patients wi... more This literature review discusses the current evidence on acute limb ischemia (ALI) in patients with COVID-19. Throughout the pandemic, these patients have been at increased risk of arterial thrombotic events and subsequent mortality as a result of a hypercoagulable state. The exact mechanism of thrombosis is unknown; however arterial thrombosis may be due to invasion of endothelial cells via angiotensin-converting enzyme 2 (ACE2) receptors, endothelial injury from inflammation, or even free-floating aortic thrombus. Multiple studies have been performed evaluating the medical and surgical management of these patients; the decision to proceed with operative intervention is dependent on the patient’s clinical status as it relates to COVID-19 and morbidity of that disease. The interventions afforded typically include anticoagulation in patients undergoing palliation; alternatively, thrombectomy (endovascular and open) is utilized in other patients. There is a high risk of rethrombosis, despite anticoagulation, given persistent endothelial injury from the virus. Postoperative mortality can be high in these patients.
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