Endovascular aortic repair has been increasingly used to treat a multitude of thoracic aorticpathologies. When placement of a thoracic endograft necessitates coverage of one or more of the great vessels, in situ laser fenestration is a safe and effective option for supra-aortic trunk revascularization. Certain anatomic factors may render laser fenestration more technically challenging, particularly depending on aortic arch type and branch vessel characteristics. Short-term and mid-term outcomes have shown promising results for mortality, stroke, and complication rates. Future developments may extend the utility of this approach and allow it to be applied to a more widespread set of patients with challenging anatomy.

Arteriovenous fistulas (AVF) can be created percutaneously or surgically. The 2022 national average for Medicare payment of outpatient access creation is $16,402 for endovascular (endoAVF) approach and $2924 for surgical creation (sAVF). This study compared the costs of creating autogenous fistulas using an endoAVF method with the cost of sAVF in a single integrated health care network. A retrospective review was performed of all patients who underwent a successful endoAVF procedure between January 2015 and May 2021. Using propensity scoring, a comparative sAVF group was created. Cost and budgetary data were obtained through collaboration with Sentara Vascular Service Line Department. For the surgical cohort, the cost of operating room use (nursing staff, hospital cost of anesthesia) was derived from the cost per minute of anesthesia and nursing staff at each phase of care, calculated per patient and then averaged for the cohort. For the endoAVF patients, the cost of the procedure performed in an angiography suite (staff, moderate sedation, phases of care), was similarly derived with their accompanying cost per minute. Cost of disposables was calculated per patient itemized costs. Several financial assumptions were made in this calculation; the cost of anesthesia for the surgical group was based on an average at a single facility; the cost of nursing staff at each phase of care was based on a blended hourly rate of the nursing to patient care ratio. All statistical tests were performed in SPSS v.24. Between January 2015 and May 2021, 1805 sAVF procedures and 18 endoAVF procedures were identified using Current Procedural Terminology codes. Using baseline demographics, the cohorts were 1:1 matched and statistical analysis showed P values of greater than .05. All 18 endoAVF and 18 sAVF patients had patent fistulas at the end of the procedures. The average cost for the disposables used for the surgical group was $295 (range, $170-$403) and endoAVF group was $9555 ($9127-$10,019). The average cost of using the operating room was $886.81 ($559-1107.18). The average cost of providing patient care in the outpatient angiography suite was $138.03 ($53.40-198.40). The total costs associated with performing the sAVF was $1182 ($380-$1392) and $9693 ($9127-$10,164) for the endoAVF. EndoAVF costs significantly more than sAVF owing to the higher costs of disposables. However, Medicare reimbursement for this procedure takes this into account and removes a financial barrier for centers to offer endoAVF. This option may help address the large population of patients needing permanent access to be treated in a more timely fashion.

Endovascular treatment has become an accepted method in the treatment of aortoiliac occlusive disease. Bare metal stents have been used in the treatment of aortoiliac disease since the early 1990s. More recently, the use of covered stent grafts in the aortoiliac segment has shown clinical benefit in terms of patency, freedom from reintervention and quality of life. The VBX FLEX study evaluated the safety and efficacy of the Gore VBX stent graft for use in the aortoiliac segment. The early and mid-term data on the Gore VBX stent graft have shown it to be a safe device for use in the treatment of aortoiliac occlusive disease. This review examines the use of stents in aortoiliac occlusive disease with specific focus on the VBX FLEX Study.

We sought to evaluate perioperative and short-term outcomes between transcarotid artery revascularization (TCAR) procedures compliant with manufacturer’s instructions for use (IFU) versus procedures in violation of IFU. We retrospectively evaluated patients undergoing TCAR within a single multispecialty group between December 2015 and February 2020. Patients without adequate preoperative imaging were excluded. IFU criteria include common carotid artery (CCA) diameter of ≥6 mm, ICA diameter of 4 to 9 mm, femoral venous access, carotid bifurcation to clavicle length of ≥5 cm, and absence of severe CCA disease at the puncture site. Patient selection warnings (PSW) included extensive lesion calcification, intraluminal thrombus, and ICA/CCA tortuosity. Primary end points included perioperative (30-day) major adverse events (ipsilateral stroke, transient ischemic attack, death, or myocardial infarction) and perioperative complications. Secondary end points included ipsilateral restenosis, neurologic events, and reinterventions. Two hundred seventeen procedures (85 symptomatic, 132 asymptomatic) were performed on 209 patients. One hundred ninety-eight procedures were IFU compliant, and 19 (8.8%) had IFU violation(s). Of 198 within IFU patients, 69 (35%) had PSW violation(s). IFU violations included length from clavicle to bifurcation (n = 6), distal ICA diameter (n = 5), CCA puncture site disease (n = 5), and other (n = 4). The IFU violation group had higher incidences of urgent or emergent procedures (26% vs 15%; P = .004) and prior ipsilateral CEA (42% vs 16%; P = .006). The perioperative major adverse event rate was 3.2% (n = 7), 3.0% within IFU (n = 6; three strokes, two transient ischemic attacks, one death) and 5.3% outside IFU (n = 1 death), (P = .63). There was one conversion to endarterectomy in each group (P < .05). There were no differences in other perioperative outcomes. Follow-up data >30 days was available for 196 of 217 procedures. Average follow-up time was 1.2 ± 1.0 years. Ipsilateral reintervention rates within 2 years were significantly higher off IFU (log-rank P = .04) (Fig). Other outcomes (stroke, transient ischemic attack, myocardial infarction, and in-stent restenosis) were equivalent. PSW infringement had no differences in early or late outcomes. TCAR in patients with anatomy outside of the manufacturer’s IFU can be safely performed, but leads to higher rates of carotid reintervention. Larger sample size and long-term follow-up data is needed to identify risks of specific anatomic violations as well as long-term outcomes.

An open surgical repair is a gold standard for the treatment of aortic arch pathologies. It requires cardiopulmonary bypass, hypothermia. and circulatory arrest and is associated with considerable morbidity and mortality. In prohibitive surgical risk patients, the hybrid approach of supra-aortic debranching, followed by stent-graft deployment, is a valuable alternative. It avoids circulatory arrest and cardiopulmonary bypass. Total endovascular aortic arch repair has emerged as an exciting option in this critically ill patient population with acceptable risk profile but technology is still in infancy and is not available outside a few centers of excellence. The total endovascular aortic arch repair could improve the outcomes of these patients. In this comprehensive overview; we present the current management of the aortic arch pathologies including open, hybrid, and total endovascular arch replacement that includes fenestrated endovascular endograft, multibranched thoracic endografts, and physician-modified fenestration endograft as alternative options.

Mycotic aneurysms and prosthetic graft infections are traditionally treated with excision of the infected tissue or graft, often requiring anatomical or extraanatomical bypass, carrying significant morbidity and mortality. Currently, the role of endovascular repair without excision in this setting has yet to be defined. We present 2 case scenarios, whereby mycotic pseudoaneurysms were successfully treated with endovascular stent-graft coverage and to present an in-depth review of endovascular in situ revascularization in the treatment of arterial and graft infections. There are data to support the use of stent grafting in mycotic aortic and iliac aneurysms, lower and upper extremity native arterial infections, lower extremity prosthetic bypass infections, and infections of carotid artery aneurysms. It is our belief that this technique may be utilized as primary therapy if there is no significant contamination and certainly serves an essential role in acute rupture or hemorrhage. In situations where there is significant tissue infection, stent grafting should be considered as a bridge if traditional excision is warranted.

Purpose Thoracic endovascular aortic aneurysm repair (TEVAR) has become a mainstay of therapy for aneurysms and other disorders of the thoracic aorta. The purpose of this narrative review article is to summarize the current literature on the risk factors for and pathophysiology of spinal cord injury (SCI) following TEVAR, and to discuss various intraoperative monitoring and treatment strategies. Source The articles considered in this review were identified through PubMed using the following search terms: thoracic aortic aneurysm, TEVAR, paralysis+TEVAR, risk factors+TEVAR, spinal cord ischemia+TEVAR, neuromonitoring+thoracic aortic aneurysm, spinal drain, cerebrospinal fluid drainage, treatment of spinal cord ischemia. Principal findings Spinal cord injury continues to be a challenging complication after TEVAR. Its incidence after TEVAR is not significantly reduced when compared with open thoracoabdominal aortic aneurysm repair. Nevertheless, compared with open procedures, delayed paralysis/paresis is the predominant presentation of SCI after TEVAR. The pathophysiology of SCI is complex and not fully understood, though the evolving concept of the importance of the spinal cord’s collateral blood supply network and its imbalance after TEVAR is emerging as a leading factor in the development of SCI. Cerebrospinal fluid drainage, optimal blood pressure management, and newer surgical techniques are important components of the most up-to-date strategies for spinal cord protection. Conclusion Further experimental and clinical research is needed to aid in the discovery of novel neuroprotective strategies for the protection and treatment of SCI following TEVAR.

ObjectiveEndografts (eg, aortic aneurysm device or covered stent) are increasingly being used to temporize or treat arterial and graft infections in inaccessible areas, in patients with compromised anatomy, or in the presence of active bleeding or rupture. This summary examines the evidence for "in situ" endografting in the treatment these conditions.MethodsA two-level search strategy of the literature (MEDLINE, PubMed, Google Scholar, and The Cochrane Library) was performed for relevant articles listed between January 2000 and December 2015. The review was confined to patients with primary and secondary bacterial or viral arterial infections, with or without fistulization and infection of bypass grafts and arteriovenous accesses. For the purposes of this summary, endografts can be considered to be an aortic aneurysm device or a covered stent.ResultsThere are no societal guidelines. Endografts have been successfully applied to mycotic arterial aneurysms, aortoenteric, aortobronchial, and arterioureteric fistulae, and to anastomotic bleeds secondary to infection. Multiple reports indicate success at the control of hemorrhage in all locations. Short-term outcomes are good, but fatal infection-related complications, especially if antibiotic therapy is halted, are well reported and necessitate a more definitive plan for the long term.ConclusionsStent grafts remain an important and viable option for the treatment of mycotic aneurysms, aortoesophageal and aortobronchial fistulae, and infected pseudoaneurysms in anatomically or technically inaccessible locations. In patients with a short life span (<6 months), no further intervention is generally required. In patients with a predicted life span >6 months, careful consideration should be given to a more definitive procedure. Life-long appropriate antibiotic therapy is strongly recommended for any patient receiving an endograft in an infected field.

Objective Systemic anticoagulation remains the standard for acute lower extremity (LE) deep venous thrombosis (DVT), but growing interest in catheter-directed thrombolysis (CDT) and its potential to reduce the incidence of post-thrombotic syndrome (PTS) has led to advent of ultrasound-accelerated CDT (US-CDT). Few studies to date have examined the outcomes of US-CDT against traditional CDT (T-CDT). Methods This is a retrospective, single-center review of all patients treated for acute LE DVT over a five-year period with either US- and T-CDT. Patients were stratified based on demographics, presentation, co-morbidities, risk factors, and peri-procedural data. Results Seventy-six limbs in 67 patients were treated; 51 limbs in 42 patients were treated with US-CDT, and 25 limbs in 25 patients were treated with T-CDT. Adjuncts include: pharmacomechanical thrombolysis ( n = 28 vs. 20, p = 0.04), angioplasty ( n = 22 vs. 18, p = 0.11), stenting ( n = 30 vs. 6, p ≤ 0.001), and IVC filter insertion ( n = 5 vs. 0, p = 0.07). Mean lysis times were 21 ± 1.7 and 24 ± 1.8 h for US- and T-CDT, respectively ( p = 0.26). Thirty (25 ultrasound, 5 traditional) limbs had complete lysis. Thirty-one (22 ultrasound, 9 traditional) limbs had incomplete lysis. Fifteen (4 ultrasound, 11 traditional) limbs had ineffective lysis ( p = 0.002 in favor of ultrasound). Four patients (3 US-CDT, 1 T-CDT) had recurrent ipsilateral thrombosis within 30 days ( p = 0.60). By Kaplan-Meier analysis, there were no significant difference between primary patency, primary-assisted patency, secondary patency, re-thrombosis, and recurrent symptoms at 6, 12, and 24 months. Conclusion US-CDT does not significantly improve mid-term patencies but results in greater acute clot burden reduction in patients with acute LE DVTs compared to T-CDT, which may be beneficial in reducing the long-term incidence of PTS.

Background: Development of recalcitrant stenotic lesions of the cephalic arch is a significant cause of dysfunction of brachiocephalic access arteriovenous fistulas (AVFs). Endovascular and surgical therapy can be used to treat cephalic arch stenosis. The aim of this study was to evaluate the outcomes of endovascular and surgical interventions for cephalic arch stenosis. Methods: A retrospective review of all patients during a 16-year period with a compromised but not occluded brachiocephalic AVF due to cephalic arch stenosis was undertaken. Patency, reintervention, infection, and functional dialysis rates were examined. Results: From January 2000 to December 2015, 219 patients (67% female; mean age, 58 6 20 years) with a failing brachiocephalic AVF underwent intervention at the cephalic arch. These interventions included angioplasty, primary stent placement, transposition, and bypass. The average time to intervention for cephalic arch stenosis was 1.7 years after primary access placement. The average number of percutaneous interventions before the decision to intervene surgically on the cephalic arch was three (range, two to six). Technical success was superior in the surgical groups (70% and 80% compared with 96% and 100% for balloon angioplasty, stenting, transposition, and bypass, respectively; P = .02). Major adverse cardiovascular events were overall low but significantly higher in the surgical groups (1%, 1%, 0.3%, and 0.3% for transposition, bypass, balloon angioplasty, and stenting, respectively; P = .02). Both surgical options carried significantly superior patency rates at 2 years for transposition, bypass, balloon angioplasty, and stenting, respectively (63%, 59%, 90%, and 92%; P = .04). There was a lower rate of interventions per person-year of follow-up in the surgical groups compared with the endovascular groups (1.9, 1.4, 3.5, and 3.1 for transposition, bypass, balloon angioplasty, and stenting, respectively; P = .04). Functional dialysis durations were significantly superior in the surgical groups compared with the endovascular group (P = .03). Conclusions: Cephalic arch stenosis is a significant cause of brachiocephalic AVF malfunction. Surgical options offer superior long-term patency and functional results and should be considered earlier in the treatment of this disease.

Background: Endovascular revascularization is an established approach for limb salvage in the setting of critical limb ischemia. However, failure rate of antegrade recanalization in complex femoropopliteal to infrapopliteal occlusions is as high as 20%. We report a series of 21 patients who underwent retrograde pedal access and recanalization of below-the-knee chronic total occlusions after failed antegrade attempts.Methods: This is a retrospective review of prospectively maintained data for all patients who underwent ultrasound-guided percutaneous pedal access for retrograde endovascular treatment of advanced tibial vessel disease between 2011 and 2014. All patients had undergone prior unsuccessful attempts at antegrade revascularization. Pedal vessel access was followed by angioplasty with selective stenting and completion angiogram. Patients were followed up with duplex ultrasound to evaluate for patency. Time-dependent outcomes were determined by Kaplan-Meier survival analyses. Median follow-up was 9 months.Results: A total of 21 patients (17 men, 4 women, mean age 68) underwent retrograde tibial recanalization. Eighty-one percent of the patients presented with Rutherford category 4, 5, or 6 critical limb ischemia. The average Prevent Ill amputation risk score was 7.0 +/- 2.9. Eighteen patients (86%) were medium or high risk (Prevent Ill amputation risk score >= 4). Retrograde pedal access was successful in 95% of the patients (dorsalis pedis = 11, posterior tibial = 5, anterior tibial = 4). Retrograde revascularization was achieved in 14 patients (67%) using balloon angioplasty (n = 14) and additional stent placement (n = 2). Revascularization failed in 7 patients (33%). There were no pedal access site complications. Forty-eight percent of the patients experienced improvement or resolution of their symptoms. The 30-day major adverse cardiac events (MACE), major adverse limb events (MALE), and amputations were all 5%. At 1 year, limb salvage was 88 +/- 8% with amputation-free survival of 61 +/- 12% and freedom from MALE of 81 +/- 10%. Primary assisted and secondary patencies were both 84 +/- 10% at 1 year.Conclusions: Early outcomes for ultrasound-guided retrograde pedal access show that it is safe, with low 30-day mortality, and a low rate of MACE. Freedom from MALE and limb salvage are both high at 1-year follow-up. This technique expands revascularization options after failed conventional endovascular antegrade approaches.

BACKGROUND:We present 6 patients who had operative repair of symptomatic popliteal cystic adventitial disease (pCAD). Developmental theories for pCAD and surgical alternatives are presented.METHODS:All patients who had repair of pCAD over the past 3 years are included.RESULTS:Three patients had cyst excision alone, whereas the remaining 3 had cyst and artery excision with interposition vein grafting. Cyst recurrence occurred in 2 patients who had cyst excision alone. Four of the patients had a patent communication between the cyst and the joint capsule.CONCLUSIONS:Our small series suggests that the articular (synovial) theory of development may be the most likely and that cyst and artery excision with interposition vein grafting may be preferred over cyst excision alone.

Acute pulmonary embolism (PE) continues to carry a high mortality if not recognized early and treated aggressively. Rapid recognition and diagnosis remains the mainstay of all efforts. Risk stratification early is paramount to guide therapy and achieve successful outcomes. Pulmonary emboli can generally be classified as massive, submassive, or stable. Fibrinolysis and/or surgical embolectomy are recommended for the treatment of the patient with massive PE to rescue the patient and restore hemodynamic stability. Current trials support an aggressive approach. In submassive PE, determination of right ventricular (RV) strain by echocardiography and biomarker assessment (troponin and B-type natriuretic peptide) identify patients who can benefit from catheter-directed therapy with the therapeutic intent of achieving a rapid reduction of RV afterload, prevention of impending hemodynamic collapse and prolonged in-hospital and outpatient survival. Current trials have not shown long-term benefit for this approach to date, and thus, this therapy should only be offered to select patients. Stable PE can be treated using both an inpatient and an outpatient approach, based on the available infrastructure. Therapy for PE continues to evolve and stratification of risks and benefits remain the key to implementation of invasive strategies.

PURPOSE:To describe the use of the Hybrid vascular graft in disadvantaged anatomy for hemodialysis access creation and compare outcomes to standard-wall polytetrafluoroethylene (PTFE) grafts.METHODS:In a retrospective analysis, 25 patients (mean age 65±14 years; 13 men) who received the Hybrid graft were compared with 35 contemporaneous patients (mean age 63±12 years; 20 men) who received a standard PTFE graft for hemodialysis access over a 2-year period. Criteria for Hybrid graft placement were (1) exhausted or inadequate peripheral veins for arteriovenous fistula (AVF) creation and concomitant small target veins that precluded conventional PTFE graft placement, (2) previous graft anastomosis or a stent in the venous target at the level of the axilla, or (3) failed brachial-basilic or brachial-brachial upper arm transposition AVF with a small target vein at the axilla. Efficacy, anatomic and clinical considerations, and technique were reviewed; patency rates, complications, and reinterventions were examined.RESULTS:Technical success was achieved in all cases, and all grafts were usable for hemodialysis. Seven of 25 Hybrid patients required stent-graft extensions and 3 patients required angioplasty to improve venous outflow at the time of Hybrid graft insertion. Three of 35 standard PTFE graft patients required angioplasty to improve venous outflow at the time of graft insertion. There was no perioperative mortality or procedure-related morbidity in either group. Median follow-up was 21 months. The patient survival estimate was 66% at 2 years. Estimated primary patency (24% vs 18%, p>0.05), assisted primary patency (34% vs 28%; p>0.05), and secondary patency rates (40% vs 38%, p≥0.05) at 24 months were equivalent for Hybrid vs PTFE grafts, respectively. Venous hypertension was not a complication following Hybrid graft implantation but was seen in 2 patients with the standard PTFE graft.CONCLUSION:The Hybrid graft offers a safe, technically effective alternative for patients with disadvantaged anatomy requiring hemodialysis access and has comparable outcomes to standard PTFE grafts. Further clinical experience and long-term data are required for determining the proper utility of this device in chronic dialysis-dependent patients.

BACKGROUND:The number of patients maintained on hemodialysis is rising. There are limited data on the outcomes of femoropopliteal interventions, both open and endovascular, in this population. This report examines the anatomic and clinical outcomes in this population.METHODS:A database of patients undergoing open (OPEN) and endoluminal (ENDO) intervention for femoropopliteal disease (2000 to 2010) was retrospectively queried. Patients on hemodialysis with critical ischemia at the time of surgery or intervention were selected. Patients who underwent tibial bypass or had concomitant tibial interventions were excluded. Kaplan-Meier analyses were performed to assess time-dependent outcomes. Factor analyses were performed for time-dependent variables.RESULTS:One hundred sixty-one hemodialysis-dependent patients underwent either OPEN or ENDO procedures for critical ischemia. Of these, 70 patients were treated with OPEN procedures and 91 with ENDO procedures. ENDO patients were more likely to present with a higher cardiac risk index (P = 0.0001), metabolic syndrome (P = 0.02), cerebrovascular disease (P = 0.01), and a dependent living status preoperatively (P = 0.04). ENDO patients presented with more rest pain and tissue loss (P = 0.03). OPEN patients presented with more advanced lesions (P = 0.04). Combined morbidity was higher in the OPEN group (P = 0.05). Cumulative patency (P = 0.04) and clinical efficacy (P = 0.05) were higher in the OPEN group compared to those in the ENDO group.CONCLUSIONS:Hemodialysis patients undergoing femoral-popliteal endovascular interventions for symptomatic disease have a low cumulative patency and clinical efficacy. Although open surgical revascularization has higher perioperative morbidity and a trend toward higher perioperative mortality, it provides a superior 5-year cumulative patency and clinical efficacy and should be considered in this population subgroup.

Objective: During the last decade, primary endoluminal therapy for critical limb ischemia (CLI), assessed as rest pain and tissue loss of the lower extremity, has significantly increased. Reporting of patient-centered outcomes using the new Society for Vascular Surgery objective performance goals (OPGs) has been limited. This study examined the OPGs for infrainguinal endovascular management of CLI.Methods: A prospective database of patients undergoing endovascular treatment of the lower extremity for CLI between 2000 and 2011 was queried. Evaluated were clinical efficacy (absence of recurrent symptoms, maintenance of ambulation and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (MALEs; above-ankle amputation of the index limb or major reintervention - new bypass graft, jump/interposition graft revision).Results: A total of 728 patients (60% male; age, 68 +/- 14 years) underwent lower extremity interventions for CLI (66% tissue loss); of these, 39% had superficial femoral artery and tibial interventions. Diabetes mellitus was present in 71%, hyperlipidemia in 64%, and chronic renal insufficiency in 37%. Technical success was 96%. The overall rate at 30 days of major adverse cardiovascular events (MACEs) was 3% and MALEs was 12%. At 5 years, clinical efficacy was (mean +/- standard error of the mean) 42% +/- 5%, amputation-free survival was 41% +/- 7%, and freedom from MALEs was 51% +/- 4%. Clinical efficacy was significantly different in those presenting with rest pain and tissue loss and in the anatomic high-risk group compared with the clinical high-risk group, and both were worse compared with the group without clinical or high-risk criteria.Conclusions: Endoluminal therapy for CLI is associated with early low MACE rates but high MALE rates. When the key outcome of amputation free survival is considered, predictors of a better outcome were absence of current smoking, a lower modified Edifoligide for the Prevention of Infrainguinal Vein Graft Failure (PREVENT III) amputation risk score, better preoperative ambulation status, lower MACEs, and discharge disposition to home. The presence of tissue loss and anatomic risk factors negatively affect outcomes. Longer-term outcomes after endovascular intervention for CLI remain relatively poor, with <40% success in objective performance outcomes at 5 years.