Background Severe atherosclerotic internal carotid artery stenosis may progress to complete internal carotid artery occlusion (ICAO). Therefore, ICAO represents an advanced form of carotid artery disease. We sought to investigate the association between ICAO with atherosclerotic disease in other arterial beds and vascular risk factors and to identify the patient implications of the diagnosis of ICAO. Methods Using the term “Internal carotid artery occlusion,” a search of PubMed/MEDLINE, Scopus, and Embase between 1980 and 2025 revealed 10,588 results. After exclusion of case reports, letters to the Editor and Editorials, 5771 reports were identified. Following meticulous screening of the identified reports, 28 studies specifically addressing patient with ICAO cohorts were included in the final analysis. A quantitative and qualitative synthesis analysis was performed. A questionnaire was subsequently developed and sent out to 63 participants from the United States (n = 21) and several European countries (n = 42), aiming to achieve consensus regarding the optimal management of patients with ICAO. Three participants did not respond. The Consensus Coordinator abstained from voting to avoid introducing bias, resulting in a final voting panel of 60 participants. Results Across included studies, the proportion of patients with ICAO presenting with neurologic symptoms varied widely, ranging from 38% to 100%, whereas approximately 24% to 27% of patients were asymptomatic at the time of diagnosis. Consensus (≥75%) was achieved in 11 of the 17 (64.7%) prespecified statements. Most participants agreed that atherosclerotic ICAO represents a systemic manifestation of advanced atherosclerosis rather than isolated cerebrovascular pathology (56/60; 93.3%). Duplex ultrasound study should be used as the first-line diagnostic tool for suspected ICAO, with computed tomography angiography or magnetic resonance angiography confirmation if necessary (59/60; 98.3%). Optimal medical therapy (including antiplatelet, antihypertensives, statins, and glycemic control) remains the cornerstone of ICAO management (59/60; 98.3%). Lifestyle and metabolic risk factor optimization, smoking cessation, optimizing body weight, a healthy diet and exercise, should be strongly advised in all patients with ICAO (60/60; 100%). Most participants concurred that ICAO revascularization should be centralized in specialized vascular-neuro centers equipped for intraoperative neuromonitoring and advanced hemodynamic control (57/60; 95.0%). Finally, most participants agreed that current evidence for ICAO intervention is insufficient and that a global registry should be created to record outcomes and guide future trials (56/60; 93.3%). Conclusions This international, multispecialty consensus highlights ICAO as a marker of advanced, systemic atherosclerosis. Management should emphasize comprehensive evaluation for multisystem vascular disease and aggressive modification of cardiovascular risk factors. Best medical therapy remains the cornerstone of the management of patients with ICAO, with conservative or invasive interventions considered selectively based on symptom status, anatomic considerations, procedural risk, and institutional expertise, to reduce the overall cardiovascular disease burden.

Background: Groin incision wound complications (WC) are common among vascular surgery patients. Obesity is a known risk factor, but there is no consensus on the best way to prevent WC in obese patients after vascular procedures. The objective of this study was to identify risk factors for WC and strategies to prevent these complications specifically in obese patients. Methods: All patients who had longitudinal groin incisions at a single institution from 20212022 were included. The medical records were reviewed and all groin-related WC were identified. WC were stratified into major and minor WC where major WC were those requiring reoperation or hospital readmission. Patients were stratified into obese (body mass index > 30 kg/ Results: A total of 238 groin incisions were included. There were 46 (19.3%) obese and 192 (80.7%) nonobese patients. One hundred fifty six (65.5%) were closed with nylon, 49 (20.6%) were closed in a subcuticular fashion, and 32 (13.4%) were closed with staples. There were 45 (18.9%) WC: 15 (33.3%) major and 30 (66.7%) minor. Obesity was associated with a higher WC rate (39.1% vs. 14.1%, P < 0.001), which was driven by minor WC (32.6% vs. 7.8%, P < 0.001) rather than major WC (6.5% vs. 5.7%, P - 0.873). On multivariable analysis, obesity remained a predictor for overall (odds ratio [OR] 4.953, P < 0.001) and minor WC (OR 7.389, P < 0.001). Additionally, female sex was associated with a higher rate of WC on unadjusted (27.6% vs. 12.8%, P - 0.016) and adjusted analysis (OR 2.411, P - 0.014). Among obese patients, subcuticular closure was associated with higher rates of minor complications (OR 8.454, P - 0.044). Obese patients with major complications less frequently had close follow-up including rehab disposition, discharge with visiting nurse, or frequent office wound checks than those with minor complications (33.33% vs. 86.67%, P - 0.043). Conclusions: Groin WC are more common in obese and female patients. Among obese patients, this difference is driven primarily by minor WC. Avoiding a subcuticular skin closure may reduce the risk of minor WC in obese patients. In addition, close postoperative follow-up using rehab, visiting nurse services, and frequent office wound checks may prevent minor complications from escalating to major complications.

OBJECTIVE:Although the Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia trial demonstrated superiority of bypass with single-segment great saphenous vein for chronic limb-threatening ischemia (CLTI), an endovascular-first approach remains appropriate for patients lacking single-segment great saphenous vein, those who are high risk for open surgery, and most patients with Global Limb Anatomic Staging System stage I disease. Isolated popliteal artery disease is an anatomically challenging disease pattern for which evidence to drive operative decisions is lacking. The objective of this study was to compare endovascular therapies (EVTs) for isolated popliteal artery disease with CLTI. METHODS:All isolated popliteal EVT performed for CLTI were identified within the Vascular Quality Initiative database from 2017 to 2022 and those with available long-term follow-up data were included. The main exposure was type of EVT and the primary end point was limb salvage. RESULTS:There were 3330 EVT isolated to the popliteal segment, of which 881 (26.5%) were plain balloon angioplasty, 927 (27.8%) were special balloon angioplasty (drug coated, cutting, lithotripsy), 835 (25.1%) included stents, and 687 (20.6%) included atherectomy. Atherectomy as part of the endovascular treatment strategy was associated with higher 1-year freedom from major amputation when compared against all other interventions combined (94.7% vs 89.2%; adjusted hazard ratio [HR] for amputation, 0.632; P = .022), as well as plain balloon angioplasty alone (94.7% vs 88.3%; adjusted HR for amputation, 0.502; P = .003) and special balloon angioplasty alone (94.7% vs 87.4%; adjusted HR for amputation, 0.456; P < .001). Although including atherectomy and stent as part of the endovascular treatment resulted in equivalent 1-year freedom from major amputation (94.7% vs 92.1%; P = .201), this result was driven by greater use of atherectomy in patients with diabetes. When selecting only for patients with diabetes, atherectomy with or without other EVTs demonstrated greater 1-year freedom from major amputation than stenting (univariate, 93.4% vs 86.1%; adjusted HR for amputation, 0.541; P = .019). CONCLUSIONS:Atherectomy as a part of an endovascular treatment strategy may be associated with improved limb salvage compared with other EVTs among patients with CLTI requiring interventions limited to the popliteal artery.

OBJECTIVES:Chronic Limb Threatening Ischemia (CLTI) involving the crural arteries is clinically and anatomically challenging. The BASIL-2 trial and a subanalysis of the BEST-CLI trial examined the efficacy of endovascular therapy (EVT) versus surgical bypass (BP) among this cohort, but arrived at differing conclusions. This study aimed to compare the outcomes of EVT and surgical bypass among patients with CLTI requiring infra-popliteal interventions in a real-world registry. METHODS:All infra-popliteal procedures performed for CLTI were identified in the peripheral vascular intervention and infra-inguinal bypass registries of the Vascular Quality Initiative (VQI) from 2017 to 2022. Patients were identified with significantly different risk profiles (19,505 EVT and 9,185 BP). Propensity score-matched cohorts were constructed to compare EVT versus BP, BP with autologous vein (BPAV), and BP with prosthetic conduit (BPPC). Amputation-free survival (AFS), overall survival (OS), and freedom from major amputation were examined. RESULTS:5,236 well-matched pairs of EVT versus BP, 3,892 well-matched pairs of EVT versus BPAV, and 1,971 well-matched pairs of EVT versus BPPC were included. BP and EVT demonstrated equivalent AFS (2-year AFS: 50.3% vs. 49.0%, HR amputation/death: 0.947 [0.876-1.024], P = 0.229), which was due to superior OS in the BP group (2-year OS: 79.7% vs. 75.6%, HR all-cause mortality: 0.841 [0.761-0.928] P = 0.002) matched by inferior limb salvage in the BP group (2-year freedom from major amputation: 71.4% vs. 81.4%, HR major amputation: 1.432 [1.266-1.620], P < 0.001). BPAV, composed primarily (91%) of great saphenous vein bypass (GSV BP), was associated with significantly greater AFS than EVT (2-year AFS: 53.9% vs. 52.5%, HR amputation/death: 0.854 [0.778-0.938], P < 0.001), which was driven by greater OS (2-year OS: 81.1% vs. 77.4%, HR all-cause mortality: 0.872 [0.776-0.980], P = 0.015) with equivalent limb salvage (2-year freedom from major amputation: 76.0% vs. 81.4%, HR major amputation: 1.102 [0.951-1.278], P = 0.353). However, BPPC was associated with significantly lower AFS than EVT (2-year AFS: 44.1% vs. 46.9%, HR amputation/death: 1.279 [1.126-1.452], P = 0.001), which was driven inferior limb salvage in the BPPC group (2-year freedom from major amputation: 63.3% vs. 77.5%, HR major amputation: 2.165 [1.780-2.633], P < 0.001) despite higher OS in the BPPC group (2-year OS: 78.8% vs. 75.8%, HR all-cause mortality: 0.837 [0.706-0.992], P = 0.012). CONCLUSION:When feasible, BPAV (particularly with GSV) should be considered over EVT due to superior AFS and OS with equivalent limb salvage. However, when autologous vein is unavailable, an aggressive approach to EVT may be warranted due to superior AFS and limb salvage despite slightly higher OS in the BPPC group.

Background: The optimal management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis is controversial and includes intensive medical management (i.e., best medical therapy [BMT]) with/without an additional carotid revascularization procedure (i.e., carotid endarterectomy [CEA], transfemoral carotid artery stenting [TFCAS] or TransCarotid Artery Revascularization [TCAR]). The aim of this international, expert-based, multispecialty Delphi Consensus document was to reconcile the conflicting views regarding the optimal management of AsxCS and SxCS patients. Methods: A three-round Delphi Consensus process was performed including 63 experts from Europe (n=37) and the United States (n=26). A total of 6 different clinical scenarios were identified involving patients with either AsxCS or SxCS. For each scenario, 5 treatment options were available: (i) BMT alone, (ii) BMT plus CEA, (iii) BMT plus TFCAS, (iv) BMT plus TCAR, or (v) BMT plus CEA/TFCAS/TCAR. Consensus was achieved when >70% of the Delphi Consensus participants agreed on a therapeutic approach. Results: Most participants concurred that BMT alone is not adequate for the management of a 70-year-old fit male or female patient with 80-99% AsxCS (52/63; 82.5% and 45/63; 71.5%, respectively). In contrast, most panelists would opt for BMT alone for an 80-year-old male AsxCS patient with several co-morbidities (48/63; 76.2%). The majority of participants would opt for BMT plus a carotid revascularization procedure for an 80-year-old male SxCS patient with a recent ipsilateral cerebrovascular event, an ipsilateral 70-99% SxCS and a 5-year predicted risk of ipsilateral ischemic event of 10% (54/63; 85.7%), 15% (59/63; 93.6%), or 20% (63/63; 100%). The opinion of U.S.-based participants varied from that of Europe-based respondents in some scenarios. Conclusions: The present Delphi Consensus document showed that a "one-size-fits-all" approach is not appropriate for patients with either AsxCS or SxCS. Patients should be stratified according to their future stroke risk and should be treated accordingly. ### Competing Interest Statement Dr. Michael C. Stoner has a Consultant agreement with Boston Scientific. Dr. Mahmoud B. Malas is a Consultant to Cordis and Bard. Dr. Peter A. Schneider is a Consultant to Surmodics, Medtronic, Boston Scientific, Cagent, Acotec, Abbott, Endologix, Shockwave, Healthcare Inroads, Inari and BD. Dr. Mark K. Eskandari is a paid consultant for W.L. Gore and Silkroad Medical (Boston Scientific). Dr. Meghan Dermody is a Consultant/speaker for Boston Scientific Vascular and Medtronic Aortic. Dr. Marc L. Schermerhorn is PI for Medtronic, Boston Scientific and Shape clinical trials. He also does research with Cook, Terumo and Gore. Dr. Gary Roubin is the Chair of the Interventional Management Committee of CREST-2. He is also InspireMD Inc. Director and stock holder. Dr. Sean P. Lyden is a Consultant for BD, Boston Scientific, Contego Medical, Cordis, Endologix, Inspire MD, Medtronic, Rapid Medical, Shockwave, Penumbra, Vivasure and Nectero. He has stock options in Inspire MD, Reva Medical and Centerline Biomedical. He is a Board Member for VIVA Physicians. He has performed Research Studies for Abbott, Endologix, Surmodics, W.L. Gore, Terumo Aortic, NIH, Boston Scientific, Merit, Contego Medical, Inspire MD, Reva Medical, Penumbra, Medalliance and Nectero. The other authors have no conflicts of interest. ### Funding Statement This work did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Not applicable I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data is available by Dr. Kosmas I. Paraskevas

Background: Chronic limb-threatening ischemia (CLTI) is associated with high morbidity and mortality. As such, close follow-up is recommended to ensure patency of revascularization, limb viability, and optimization of cardiovascular risk factors. This study aimed to test the association between follow-up adherence and mortality, and to identify risk factors for nonadherence with recommended vascular follow-up. Methods: All patients hospitalized from 2019 to 2023 with infrainguinal CLTI and at least 30 days of posthospitalization survival were included. Patients were stratified based on adherence with any outpatient vascular follow-up within 1 year defined as any outpatient visit conducted after the index hospitalization in which CLTI of the index limb was addressed. The primary endpoint was 1-year mortality and risk factors for follow-up nonadherence were assessed to identify targets for improvement. Multivariable models adjusted for other relevant contributors to mortality including age, clinical comorbidities, medical therapies, and anatomic/clinical limb severity among others. Additional sensitivity analyses were conducted using various definitions of follow-up adherence to enhance reliability of the findings. Results: A total of 131 patients with a median age of 73 years were included. A majority had tissue loss (97, 74.1%), 118 (90.1%) underwent index revascularization and 13 (9.9%) received no intervention due to nonsalvageable disease or patient preference. The overall 1-year mortality rate was 19.8% and follow-up adherence was 83.2%. Nonadherence with vascular follow-up was associated with greater 1-year mortality (40.9% vs. 15.6%, odds ratio (OR) 6.67, P = 0.005), a finding which persisted when all definitions of follow-up were tested. Risk factors for follow-up nonadherence include transfer from another institution (30.2% vs. 10.2%, OR 3.704, P = 0.014) and lack of a primary care provider (66.7% vs. 11.8%, OR 14.603, P < 0.001). Conclusions: Nonadherence with vascular follow-up is associated with higher 1-year mortality among patients with CLTI. Improved referral of CLTI patients to a vascular surgeon in the outpatient setting before the need for urgent interhospital transfer as well as care coordination through a primary care provider may help improve adherence with vascular follow-up.

OBJECTIVE:Centralized aortic hubs frequently exist in competitive markets, which have at times demonstrated inferior surgical outcomes. Here we evaluate the impact of local market competition specifically on complex aortic surgical outcomes. METHODS:A retrospective review included all Vascular Quality Initiative (VQI) patients between 2013 and 2022 undergoing index complex endovascular aortic repair, thoracic endovascular aortic repair, or open aortic repair. Market competition was defined by the Herfindahl-Hirschman index (HHI), using surgeon-level market share within blinded VQI regions or metropolitan statistical areas (MSAs). A higher HHI indicates lower competition. Multivariable logistic 30-day mortality models and Cox survival models were used to examine the association between HHI and outcomes. A sensitivity analysis further adjusted for complexity among all complex and routine aortic surgical patients in the Vascular Implant Surveillance and Interventional Outcomes Network from 2017 to 2019, using generalized estimating equations with MSA-level clustering. RESULTS:The VQI contained 10,868 complex aortic surgical patients, with 4372 additional patients in MSA-based Vascular Implant Surveillance and Interventional Outcomes Network sensitivity analysis. The median patient age was 75 years. Of these patients, 68.4% were male, with a greater number of patients in high competition regions (51.3%) and MSAs (34.6%) vs medium and low competition locales. Comorbidities and aneurysm diameter were broadly similar across HHI intervals. Lower 30-day mortality was observed in high competition regions (high, 23.7%; medium, 25.9%; low, 25.9%; P = .03). In multivariable logistic models, medium regional competition was associated with greater 30-day mortality odds vs high competition (odds ratio [OR], 1.39; 95% CI, 1.21-1.60; P < .001), with a trend toward increased mortality for low competition (OR, 1.20; 95% CI, 0.98-1.45; P = .07). MSA-based sensitivity analyses demonstrated a similar trend for medium competition MSAs (OR, 1.25; 95% CI, 0.98-1.58; P = .07), without significant relationship for low-competition MSAs. Regional interval was not associated with any long-term mortality difference. CONCLUSIONS:More competitive regions demonstrate lower 30-day mortality after complex aortic surgery but equivalent long-term survival. Further efforts should focus on drivers of this difference to widen access to high-quality complex aortic care.

Objective In October 2023, Centers for Medicare & Medicaid Services (CMS) approved transfemoral carotid artery stenting (tfCAS) for standard-risk patients. Thus, we sought to compare outcomes among tfCAS, transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) in standard-risk and high-risk patients. Methods All carotid revascularization procedures in the Vascular Quality Initiative after the CMS decision (October 2023-March 2025) were analyzed. Patients were classified as standard-risk or high-risk per CMS criteria and stratified by symptom status. The primary outcome was perioperative stroke/death. Inverse probability of treatment weighting was performed to mitigate selection bias in high-risk patients and included demographics, comorbidities, physician volume, and operative characteristics. Inverse probability of treatment weighting was also applied to symptomatic standard-risk patients to account for the large proportion of tfCAS cases performed outside of Society for Vascular Surgery guidelines. Results Overall, 57,843 patients underwent revascularization (9123 tfCAS, 21,814 TCAR, and 26,906 CEA). Before weighting, tfCAS patients were more often symptomatic (standard-risk: tfCAS: 45% vs TCAR: 25% vs CEA: 31%, P < .01; high-risk: 35% vs 24% vs 28%, P < .01), more frequently had a modified Rankin score of 4 or 5 (standard-risk: 7.7% vs 2.4% vs 1.7%; high-risk: 6.6% vs 2.6% vs 2.4%, P < .01), and more frequently underwent urgent or emergent surgery (standard-risk: 33% vs 11% vs 16%, high-risk: 28% vs 12% vs 17%, P < .01). Standard-risk asymptomatic patients undergoing tfCAS had the highest rates of perioperative stroke/death (1.6% vs 1.2% vs 1.0%, P = .01), as did symptomatic patients (2.9% vs 1.9% vs 1.7%, P = .01). tfCAS was associated with higher overall odds of stroke/death compared with CEA (odds ratio [OR]: 1.89 [1.43, 2.48], P < .01) and TCAR (OR: 1.59 [1.15, 2.18], P < .01). Compared with CEA, tfCAS was associated with higher odds of stroke/death in both asymptomatic (OR: 1.71 [1.12, 2.55], P = .01) and symptomatic patients (adjusted OR [aOR]: 1.78 [1.21, 2.56], P < .01). After weighting, there were no significant differences in perioperative stroke/death overall for either tfCAS or TCAR compared with CEA in standard-risk symptomatic patients. In high-risk patients, TCAR was associated with lower odds of perioperative stroke/death overall compared with CEA (1.5% vs 2.1%, aOR: 0.75 [0.59, 0.94], P = .01), whereas tfCAS had higher odds of stroke/death compared with TCAR (1.5% vs 2.4%, aOR: 1.57 [1.25, 1.98], P < .01). Conclusions In this retrospective analysis, there were higher odds of perioperative stroke/death when comparing tfCAS with CEA overall and among asymptomatic and symptomatic standard-risk patients, as well as overall compared with TCAR. In high-risk patients, TCAR performed better with lower odds of stroke/death compared with both CEA and tfCAS.

OBJECTIVE:In 2023, the Centers for Medicare and Medicaid Services expanded coverage for transfemoral carotid artery stenting (tfCAS) to include standard-risk patients. Given this shift, we sought to identify predictors of postoperative stroke in patients undergoing tfCAS. METHODS:We analyzed Vascular Quality Initiative data from 2011 to 2024, identifying tfCAS patients treated for atherosclerosis or restenosis. We excluded patients with interventions outside the internal carotid artery or bifurcation and procedures with concurrent intracranial treatment. We then stratified patients based on in-hospital postoperative stroke status. Baseline characteristics and outcomes were compared using χ2 tests, and factors associated with stroke risk were compared using logistic regression. Ten-fold cross-validation was used to identify predictors of stroke, and a point system was developed to predict the risk of in-hospital postoperative stroke. RESULTS:In our cohort of 35,346 tfCAS cases, 693 patients (2%) had an in-hospital post-procedure stroke. Patients who had a post-procedure stroke were older, more likely to be female, non-White, and had a higher overall comorbidity burden. After 10-fold cross-validation using the original logistic regression model, the factors most strongly associated with increased odds of stroke included uncontrolled hypertension (23% vs 14%; adjusted odds ratio [aOR], 2.66; 95% confidence interval [CI], 1.94-3.71; P < .001), emergent surgery (41% vs 32%; aOR, 2.39; 95% CI, 1.74-3.27; P < .001), severe distal tortuosity (13% vs 8%; aOR, 1.62; 95% CI, 1.25-2.27; P < .001), age greater than 75 years (41% vs 32%; aOR, 1.53; 95% CI, 1.23-1.92; P < .001), preoperative stroke (44% vs 29%; aOR, 1.57; 95% CI, 1.30-1.90; P < .001), prior carotid endarterectomy (14% vs 12%; aOR, 1.44; 95% CI, 1.14-1.81; P = .002), type III arch (7.1% vs 5.5%; aOR, 1.45; 95% CI, 1.02-2.03; P = .03), and circumferential or protruding calcification (3.3% vs 1.7%; aOR, 1.43; 95% CI, 1.04-1.93; P = .02). Dual antiplatelet therapy and having a high-volume physician or center were associated with lower odds of stroke. Based on variable importance, a simplified point system was developed to predict postoperative stroke (receiver operating characteristic area under the curve = 0.68). CONCLUSIONS:The identified mediators of stroke risk after tfCAS offer the opportunity to improve patient selection. These data highlight the importance of managing modifiable factors preoperatively, such as hypertension and antiplatelet therapy. The timing of surgery also emerged as a strong predictor of stroke, suggesting the need for careful consideration of the need for emergent or urgent surgery. Anatomic considerations such as vessel tortuosity, arch type, and calcification should also prompt consideration for an alternate revascularization strategy.

OBJECTIVE:The optimal management of patients with asymptomatic carotid stenosis (AsxCS) and symptomatic carotid stenosis (SxCS) is controversial and includes intensive medical management (ie, best medical therapy [BMT]) with or without an additional carotid revascularization procedure (ie, carotid endarterectomy [CEA], transfemoral carotid artery stenting [TFCAS] or transcarotid artery revascularization [TCAR]). The aim of this international, expert-based, multispecialty Delphi consensus document was to reconcile the conflicting views regarding the optimal management of AsxCS and SxCS patients. METHODS:A three-round Delphi consensus process was performed including 63 experts from Europe (n = 37) and the United States (n = 26). A total of six different clinical scenarios were identified involving patients with either AsxCS or SxCS. For each scenario, five treatment options were available: (i) BMT alone, (ii) BMT plus CEA, (iii) BMT plus TFCAS, (iv) BMT plus TCAR, and (v) BMT plus CEA/TFCAS/TCAR. Differences in treatment preferences between US and European participants were assessed using Fisher's exact test, and odds ratios were used to quantify the magnitude and direction of association. Consensus was achieved when >70% of the Delphi consensus participants agreed on a therapeutic approach. RESULTS:Most participants concurred that BMT alone is not adequate for the management of a 70-year-old fit male or female patient with 80% to 99% AsxCS (52/63 [82.5%] and 45/63 [71.5%], respectively). In contrast, most panelists would opt for BMT alone for an 80-year-old male AsxCS patient with several comorbidities (48/63 [76.2%]). The majority of participants would opt for BMT plus a carotid revascularization procedure for an 80-year-old male SxCS patient with a recent ipsilateral cerebrovascular event, an ipsilateral 70% to 99% SxCS, and a 5-year predicted risk of ipsilateral ischemic event of 10% (54/63 [85.7%]), 15% (59/63 [93.6%]), or 20% (63/63 [100%]). The opinion of US-based participants varied from that of Europe-based respondents in some scenarios. CONCLUSIONS:The panel agreed that BMT alone is insufficient for most patients with SxCS, and that select subgroups of AsxCS patients may also benefit from revascularization, especially when high-risk features are present. Patients should be stratified according to their predicted stroke risk, as well as their individual clinical, anatomical, and imaging features and should be treated accordingly.

OBJECTIVE:Most surgeons employ an endovascular-first approach to the treatment of peripheral arterial disease (PAD), but controversy remains regarding the ideal interventions for the management of isolated popliteal artery disease (IPAD). Indeed, there are a paucity of data that compare outcomes of popliteal stents vs other peripheral vascular interventions (PVIs). The goal of this study was to evaluate outcomes of PVIs in IPAD. METHODS:The Vascular Study Group of New England database was queried for all IPAD PVIs performed for atherosclerotic occlusive disease from 2010 to 2021. Those with at least 1 year of follow-up data available were included for analysis. The primary endpoint was 1-year freedom from a composite target lesion (TL) treatment failure that included restenosis >50% on duplex, reintervention, or ipsilateral major amputation. RESULTS:We included 689 procedures performed on 634 patients. Of these, 250 (36.3%) were treated with plain balloons (POBA), 215 (31.2%) had stents, 170 (24.7%) had special balloons (drug-coated, cutting, or lithotripsy), and 54 (7.8%) atherectomies were performed. Stent placement was associated with lower freedom from TL treatment failure (72.6%) than special balloon (81.2%; P = .048) and atherectomy (88.9%; P = .012), but not POBA (76.8%; P = .293). On multivariable logistic regression, stents (odds ratio, 0.637; P = .021) and preoperative P2Y12 inhibitor therapy (odds ratio, 0.683; P = .048) were both associated with lower freedom from intervention failure. CONCLUSIONS:Popliteal stent placement is associated with a higher rate of TL treatment failure at 1 year when compared with other PVIs including special balloon angioplasty and atherectomy, but not POBA, and should therefore be avoided in favor of special balloons or atherectomy whenever feasible.

Background: Chronic kidney disease (CKD) increases morbidity and mortality in most vascular procedures. However, a binary classification of estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, which is often used in both modeling and clinical trials, may not be optimal for predicting clinical outcomes. Objective: Determine the optimal eGFR cutoff for use in risk stratification and prediction models. Methods: Vascular Quality Initiative (VQI) data for non-emergent, first-time OAR, EVAR, TEVAR, CEA, CAS, PVI, Supra- and infra-inguinal bypass were analyzed from to 2013-2023 and divided into cohorts based on eGFR (≥60, 45-59, 30-44, <30, and preoperative dialysis). χ2 and logistic regression were used to evaluate perioperative outcomes. Results: Compared to patients with eGFR ≥60, those with eGFR 45-59 had similar odds of mortality following all procedures, except TEVAR. Driven by this group, the combined cohort showed a slight increase in the odds of mortality for eGFR 45-59 (0.6% vs. 0.7%, aOR 1.16, P=0.002). Those in the 30-44 group demonstrated increased odds of mortality both overall and in the individual procedure groups (0.6% vs. 1.2%, aOR 1.78, P<0.001). The odds of mortality continued to increase with worsening eGFR. The overall rate of new permanent dialysis was low for all eGFR cohorts, with a 0.02% difference between those with eGFR >60 and those in the 45-59 cohort (0.04% vs. 0.06%; a OR 1.65, P<0.001). The odds of permanent dialysis likewise continued to increase with decreasing eGFR. Conclusions Rather than a binary eGFR cutoff of ≥60 and <60 to stratify patient risk, better risk stratification may be achieved by using five groups of ≥60, 45-59, 30-44, <30, and preoperative dialysis.

Objective Despite level 1 evidence demonstrating the benefit of carotid endarterectomy for the prevention of stroke in patients with severe asymptomatic carotid stenosis (ACS), there has been a trend toward recommending optimal medical therapy (OMT) alone. This recommendation has been promulgated based on the observation that modern advances in OMT reduce the overall stroke risk in the general population, but the success of this treatment strategy is dependent on patient and provider adherence. In current practice, patients with moderate ACS are nearly all treated with OMT alone. The objective of this study was to evaluate adherence to OMT in a cohort of patients with moderate ACS undergoing treatment with OMT alone. Methods Consecutive carotid duplex ultrasound examinations were reviewed for the years 2019 and 2020. Those with moderate (50%-69%) ACS based on Society for Vascular Surgery guidelines were included in the study. Patients were assessed for OMT at the time of the index duplex, the first follow-up visit, and at each subsequent follow-up visit until the end of the study. OMT was defined as abstinence from smoking, aspirin or other antiplatelet use, and statin or other lipid-lowering therapy. Patients were stratified based on their ability to achieve OMT, and each component was evaluated to identify shortfalls in therapy. Results A total of 323 duplex ultrasound examinations with moderate ACS in 255 patients were identified. Of the 255 patients, 143 (56.1%) were on OMT at the time of the first duplex; that number increased to 163 (63.9%) by the first follow-up visit and 175 (68.6%) by the completion of the study. There were 112 (43.9%) patients who were not on OMT at the time of the index duplex, 43 (38.4%) of whom achieved OMT over a median follow-up time of 2.7 years. By the end of follow-up, 86 (76.8%) were taking aspirin or another antiplatelet medication, 93 (83.0%) were on statin or other lipid-lowering therapy, and 74 (66.1%) were abstinent from smoking. Pre-duplex smoking was independently associated with failure to achieve OMT (hazard ratio: 0.452, P = .017). Conclusions Among patients with moderate ACS who were not previously on OMT, the rate of OMT achievement is poor. Although advances in lipid management through statin therapy have been praised for their role in improving the effectiveness of OMT, smoking cessation represents an important target for improving uptake and as a result effectiveness of OMT.

The Best-CLI trial confirmed the superiority of infra-inguinal bypass with single-segment great saphenous vein (ssGSV) over an endovascular-first approach for chronic limb-threatening ischemia (CLTI). However, for patients without suitable ssGSV conduit, and those who are not appropriate surgical candidates, an endovascular-first approach is preferred. Despite the voluminous literature regarding percutaneous interventions in the lower extremity, there is a paucity of data evaluating endovascular therapies in patients with isolated popliteal disease. The objective of this study was to examine outcomes of endovascular therapies for isolated popliteal CLTI. The Vascular Quality Initiative (VQI) database was queried for all isolated popliteal artery endovascular interventions performed for CLTI in 2017-2021. Patients who survived the index hospitalization with available long-term follow-up data were included. The primary endpoint was freedom from above-ankle amputation. Procedures were also stratified by presenting symptom and intervention. A total of 2978 procedures were included. Of these, 778 (26.1%) were plain balloons (POBA), 799 (26.8%) were special balloons (drug-coated, cutting, or lithotripsy), 825 (29.5%) were stents, and 501 (16.9%) were atherectomy. Overall, 2219 (74.5%) interventions were for wounds or tissue loss (TL), and there were 217 (7.3%) major amputations. Patients treated with stents (95.0% vs 93.4%; P = .003) and atherectomy (95.2% vs 92.2%; P = .011) had higher freedom from amputation than the remaining cohort (Table 1). The superiority of the stent group was driven primarily by lower utilization of stents in patients with TL (67.8% tissue loss in the stent group vs 77.1% tissue loss in the non-stent group; P < .001). When stratifying for presenting symptom, atherectomy was associated with higher freedom from amputation among patients with TL on both univariate (95.6% vs 90.9%; P = .001) (Table 1; Fig1) and multivariable analysis (HR, 0.497; P = .026) (Table 3), but stents were not (93.7% vs 91.0%; P = .059) (Table 2). Stents and atherectomy were associated with a higher freedom from amputation among patients with CLTI than balloon therapy alone, but stents were more often used in patients presenting with rest pain, which likely contributes to their favorable outcome. When selecting for TL specifically, atherectomy is associated with higher freedom from amputation than all other interventions. Table IAbove-ankle amputation among all patients with CLTI (n = 2978)AmputationNo AmputationTotalP-valueStent41 (5.0%)784 (95.0%)825.003Atherectomy24 (4.8%)478 (95.2%)502.011POBA64 (8.2%)714 (91.8%)778.180Special balloon74 (9.3%)725 (90.7%)799.023Total217 (7.3%)2761 (92.7%)2978 Open table in a new tab Table IIAbove-ankle amputation among patients with wounds or tissue loss (n=2219)AmputationNo AmputationTotalP-valueStent35 (6.3%)524 (93.7%)559.059Atherectomy17 (4.4%)368 (95.6%)385.001POBA53 (8.7%)559 (91.3%)612.650Special balloon66 (11.0%)536 (89.0%)602.009Total184 (8.3%)2035 (91.7%)2219 Open table in a new tab Table IIICox proportional hazards model for above-ankle amputation among patients with wounds or tissue loss (n = 2219)HR95% CIP-valueAge0.9900.980 – 1.010.220Male0.7950.560 – 1.127.201Caucasian0.7260.507 – 1.041.081CHF1.2710.896 – 1.822.179Diabetes1.3630.852 – 2.160.194ESRD2.0961.433 – 3.004< .001Anticoagulation1.3360.914 – 1.935.131Re-do intervention1.6651.185 – 2.340.004Runoff0.6000.423 – 0.844.003Treatment length0.9900.970 – 1.010.347Atherectomy0.4970.273 – 0.923.026 Open table in a new tab

BACKGROUND:Visceral artery aneurysms have an array of presentations and management strategies. Pancreaticoduodenal artery aneurysms (PDAAs) are rare, potentially lethal, and necessitate treatment. We present the case of a PDAA in a patient with a congenitally hypoplastic celiac artery treated by open surgical reconstruction. CASE REPORT:A 60-year-old female presented with an incidental 2-cm proximal inferior PDAA. Significantly, her celiac trunk was hypoplastic and all flow to the hepatic, gastric, and splenic arteries stemmed from a dilated superior mesenteric artery. The PDAA was located 1 cm from the origin of the pancreaticoduodenal artery at the superior mesenteric artery and was adhered to the fourth portion of the duodenum. Considering her anatomy, open repair with reconstruction of the pancreaticoduodenal artery was pursued via a midline laparotomy, resection of the PDAA, and primary end-to-side pancreaticoduodenal artery to superior mesenteric artery reconstruction. There was an excellent flow into the pancreaticoduodenal artery, gastroduodenal artery, and their emanating branches intraoperatively and on postoperative imaging. The patient progressed well and was discharged home on postoperative day 5. Liver function tests were serially checked and were within normal limits upon discharge. CONCLUSIONS:We demonstrate a safe and successful surgical option for patients with PDAA who required preserved gastroduodenal aneurysm flow.

Objective The evaluation of perioperative and long term outcomes for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) using anatomic (unibody) and proximal neck fixated (docking limbs) endografts across consecutive time cohorts. Design This study compares the outcomes of EVAR in Medicare patients stratified by mode of fixation. Methods All patients who underwent EVAR between 2012 and 2018 were identified in the Medicare database. Anatomic fixation (AF) and proximal fixation (PF) grafts were differentiated using Current Procedural Terminology (CPT) codes. The AF population was divided into three-time cohorts based on iterative changes in graft design: Cohort 1: (01/01/2012-20/07/2014); Cohort 2: (21/07/2014-09/05/2016); and Cohort 3: (10/05/2016-31/12/2017). The PF cohort was similarly divided into these three periods. Outcomes were evaluated through 31/12/2020 and included all-cause mortality, aortic rupture, and aortic-related reintervention. Results 32,031 patients underwent EVAR during the study period; 4729 were AF and 27,302 were PF. There were more women (p < .001) and patients with peripheral vascular disease (PVD) (p < .001) in the AF group. There were no group differences in perioperative outcomes. In Cohort 1, there was a higher rate of reintervention (11.9% vs 7.6%; p < .001) and aortic rupture (5.3% vs 4.0%; p = .019) in the AF group compared to the PF group. In Cohort 2, reintervention, aortic rupture, and reintervention rates were similar between the two groups (p = NS). In Cohort 3, the reintervention and aortic rupture rates were similar between the two groups (p = NS). Conclusion The higher rates of aortic rupture and reintervention seen in the AF group in Cohort 1 when compared with the PF group did not persist in Cohorts 2 and 3. This suggests that improvements in graft design may have led to durability which is similar to that of PF grafts. However, late aneurysm related complications are inherent risks after EVAR and long-term surveillance remains necessary.