BACKGROUND:While carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the long-term risk of stroke, patients with a short life expectancy or multiple medical comorbidities, including end-stage renal disease (ESRD), may not derive significant benefit from these interventions. The benefits of intervention are especially questionable for patients with asymptomatic carotid artery disease. We assessed the outcomes of stroke and mortality following carotid intervention in a real-world ESRD population. METHODS:This multicenter retrospective cohort study utilized the TriNetX US Collaborative Network, a global federated database, to identify individuals with and without ESRD who underwent CEA or CAS for asymptomatic carotid artery disease between January 2014 and August 2024. Patients were 1:1 propensity score matched based on preoperative covariates, including demographics, comorbidities, and medications. Thirty-day, 3-year, and 5-year rates of stroke and all-cause mortality were compared between the 2 cohorts, using odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS:This study identified 332 ESRD patients and 28,369 non-ESRD patients who underwent carotid intervention for asymptomatic carotid artery disease. Propensity-score matching yielded 329 patients. 53.0% were male with a mean age of 67.3 ± 8.7 years. The mean follow-up was 958 days. Outcomes at 30 days resulted in comparable rates for stroke and mortality. At 3 years, patients with ESRD had greater rates of stroke (15.8% vs. 10.0%; OR, 1.65; 95% CI, 1.05-2.61). Mortality was significantly higher in the ESRD group at both 3 years (23.5% vs. 11.8%; OR, 2.31; 95% CI, 1.51-3.53) and 5 years (32.2% vs. 15.5%; OR, 2.59; 95% CI, 1.78-3.78). Subgroup analysis comparing CEA versus CAS demonstrated similar stroke rates at all time points. Notably, the 5-year stroke rate was 19.4% for CEA versus 14.0% for CAS (P = 0.33). Mortality was comparable at all time points, with 5-year rates of 33.3% for CEA versus 30.1% for CAS (P = 0.64). CONCLUSION:ESRD patients exhibited nearly 2-fold long-term mortality after carotid intervention compared with non-ESRD patients, whereas neurologic outcomes remained comparable. Within ESRD patients, long-term neurologic complications and mortality remained statistically similar. This study highlights the poor prognosis of ESRD patients undergoing carotid intervention. Carotid intervention remains a reasonable option for selected ESRD patients, particularly those with a lower comorbidity burden.

OBJECTIVE:The optimal clinical management of isolated distal deep venous thrombosis (IDDVT) remains controversial as the benefits of routine anticoagulant therapy are not clearly defined amid the risk of bleeding events. Our study aimed to compare clinical outcomes between patients with IDDVT treated with anticoagulation vs those managed conservatively. METHODS:We performed a retrospective analysis of adults (≥18 years old) with IDDVT identified in the TriNetX Research Network from January 1, 2014, to January 1, 2024. Patients who received anticoagulation therapy within 1 week of diagnosis were compared with patients without anticoagulation therapy. Patients were 1:1 propensity score matched for baseline covariates, including demographics and various comorbidities. We calculated and compared odds ratios with 95% confidence intervals of pulmonary embolism (PE), gastrointestinal bleeding, intracranial bleeding at 6 months, and all-cause mortality at both 6 months and 1 year. RESULTS:Propensity score matching resulted in 4085 patients in each group after matching. The incidence of PE and intracranial bleeding were not significantly different between anticoagulated or nonanticoagulated patients. The risk of gastrointestinal bleeding was significantly higher in patients receiving anticoagulation at 6 months. All-cause mortality was also significantly higher at both 6 months (4.94% vs 2.09%; P < .01) and 1 year (5.85% vs 2.82; P < .01). CONCLUSIONS:In patients with IDDVT, anticoagulation therapy did not decrease the incidence of PE. These findings suggest a more selective approach to IDDVT management rather than routine anticoagulation.

Objective Cancer patients in general are thought to be poor candidates for lower extremity revascularization procedures due to hypercoagulability, potential need for chemotherapy, or multiple other cancer-related co-morbidities. While vascular surgeons may shy away from these patients, only one previous study we found has assessed the effect of this relationship on lower extremity bypass patency, and substantially worse outcomes were documented. Our study aims to quantify the risk of poor outcomes for lower extremity revascularization in a large sample of cancer patients, utilizing the TriNetX database.Methods Within the US cohort of 55 healthcare organizations in the TriNetX database, we identified 1419 patients diagnosed with either breast, prostate, colon, or non-small cell lung cancer of any stage and 60 609 patients without diagnosis of those cancers who had undergone either an open infra-inguinal bypass of any graft type or endovascular intervention on the infra-inguinal arteries from September 3, 2004 to September 3, 2024. Propensity score matching was conducted, which yielded 1413 patients analyzed in each group, and incidence of arterial thrombectomy, bypass revision, amputation, and arteriogram were recorded for each group at 30-day and 1-year time points. Secondary subgroup analyses were conducted within the cancer cohort to determine whether rates of the same outcomes listed above varied between open versus endovascular interventions.Results In the primary analysis, there was no significant difference in any of the 4 outcomes between cancer patients and non-cancer patients. In the subgroup analysis, open bypass was found to have a significantly lower incidence of repeat arteriogram within 30 days as compared to endovascular intervention (3.62% vs 7.97%; risk ratio [RR], 0.455, P = 0.029) and 1 year (18.84% vs 28.62%; risk ratio [RR], 0.658, P = 0.007). All other outcomes in both the 30-day and 1-year follow-up periods for the subgroup analysis did not vary significantly between the 2 groups.Conclusion It is possible that patients with a recent diagnosis of cancer may not have worse outcomes for lower extremity bypass compared to patients without a cancer diagnosis. Cancer patients undergoing endovascular interventions, in contrast, did require more repeat interventions which may suggest that open interventions are preferable in this population. We would, however, caution that overall limb salvage was reasonable in this patient population and results were not markedly worse with any intervention strategy. Cancer diagnosis should not necessarily be seen as a contraindication to a lower extremity revascularization and should be considered on a case-by-case basis.

Open thoracoabdominal aortic aneurysm (TAAA) repair remains the gold standard for patients with connective tissue disorders. Traditionally, repair of these aneurysms is conducted through a single thoracotomy often requiring rib resection or excessive retraction and resulting in postoperative pain and complications. This report presents the case of a 47-year-old woman with Loeys-Dietz syndrome who required an extent V TAAA repair. A single-incision double-thoracotomy approach was performed. This technique is believed to improve outcomes with less postoperative pain and to provide better exposure with a more expeditious procedure overall.

BACKGROUND:The Hemodialysis Reliable Outflow (HeRO) graft combines an arteriovenous graft with a central venous stent, allowing for hemodialysis access in patients with end-stage renal disease limited by central venous stenosis. The impact of anticoagulation (AC) and antiplatelet (AP) medications on HeRO graft patency is unknown. METHODS:Institutional medical records were retrospectively queried for all HeRO graft procedures performed from 2014 to 2023. Data were collected on demographics, medical comorbidities, operative details, and perioperative AC/AP medication use. The Cox proportional hazards model was used to identify risk factors for loss of primary patency. RESULTS:A total of 232 patients with end-stage renal disease underwent HeRO graft implantation across 3 hospitals, with a median follow-up of 1.5 years. Perioperative AC/AP strategies included mono-antiplatelet therapy (MAPT, n = 38 [16.4%]), dual-antiplatelet therapy (DAPT, n = 57 [24.6%]), AC only (n = 38 [16.4%]), MAPT with AC (n = 66 [28.4%]), DAPT with AC (n = 28 [12.1%]), and none (n = 5 [2.2%]). Direct oral anticoagulants were used in 85 patients (36.6%). There were no differences in bleeding or thrombotic complications between groups (symptomatic hematoma, P = 0.96; pulmonary embolism, P = 0.45). One-year primary patency rates were highest among patients on AP therapy (16.7 ± 6.2% [no AP] vs. 40.2 ± 5.4% [MAPT] vs 33.7 ± 5.6% [DAPT], log-rank P = 0.016). There was no difference with AC use (38.6 ± 5.4% [no AC] vs. 28.8 ± 4.3% [AC], log-rank P = 0.11). After adjusting for patient factors, MAPT (hazard ratio [HR] 0.54, 95% confidence interval [CI] 0.35-0.83, P = 0.005) and DAPT (HR 0.64, 95% CI 0.41-1.01, P = 0.05) were protective of loss of primary patency, whereas AC (HR 1.07, 95% CI 0.76-1.50, P = 0.70) did not impact primary patency rates. CONCLUSION:Among patients undergoing HeRO graft implantation, the use of antiplatelet medications was associated with improved primary patency rates.

Acute type A aortic dissection (ATAAD) with cerebral malperfusion presents a significant surgical challenge. This report describes a novel approach involving initial right carotid artery repair with interposition grafting and selective cerebral perfusion, followed by total aortic arch replacement using deep hypothermic circulatory arrest. This strategy optimized cerebral perfusion and facilitated successful aortic repair. The patient experienced partial neurologic recovery despite an initial ischemic stroke with hemorrhagic conversion. This case highlights the importance of a tailored, multidisciplinary approach in patients with complex ATAAD.

BACKGROUND:Hemodialysis Reliable Outflow (HeRO) graft implantation is performed as a last resort option for hemodialysis access in patients limited by central venous stenosis or occlusion. In this single-center series, we examined the incidence, risk factors, and long-term outcomes of patients with a HeRO graft infection. METHODS:Institutional medical records were retrospectively reviewed for all HeRO graft procedures performed from 2014 to 2023. Only index procedures were included in this analysis. The primary outcome of interest was HeRO graft infection. Data were analyzed using Kaplan-Meier, univariable, and multivariate analyses. RESULTS:Over the 10-year study period, 232 patients underwent index HeRO graft surgery with a median follow-up period of 18.5 months. A total of 57 patients (24.6%) were diagnosed with a HeRO graft infection. The estimated 1- and 3-year incidences of graft infection were 14.9% ± 2.6% and 34.2 ± 4.3%, respectively. The median interval from operation to infection was 0.93 years (interquartile range, 0.16-1.88 years). Patients with graft infection were more frequently female (63.2% vs 46.3%; P = .03). Most patients were treated with complete graft resection and intravenous antibiotics (n = 54 [94.7%]). After the infected graft is removed, a nontunneled catheter is used until the infection has been adequately treated. The most common pathogens were Staphylococcus aureus (n = 12 [21.1%]), polymicrobial cultures (n = 11 [19.3%]), and Staphylococcus epidermidis (n = 8 [14.0%]). Primary patency rates were similar between the groups (1 year, 23.8 ± 5.7% vs 37.1 ± 4.1%; log-rank P = .15). However, secondary patency rates were significantly lower among patients with graft infection at 1 year (47.0 ± 6.7% vs 78.6 ± 3.7%) and 3 years (13.8 ± 4.7% vs 59.1 ± 5.4%) (log-rank P < .0001). The median survival after diagnosis of graft infection was 0.95 years (interquartile range, 0.50-2.18 years). On multivariate analysis, only female sex (hazard ratio, 1.89; 95% CI, 1.08-3.31; P = .026) was independently associated with HeRO graft infection. CONCLUSIONS:The incidence of HeRO graft infection is high and persists for years after the index operation. Patients undergoing HeRO graft implantation should be counseled on the risks and consequences of this complication.

OBJECTIVE:The Hemodialysis Reliable Outflow (HeRO) graft offers hemodialysis access options for patients who have developed central venous stenosis or occlusion. In this single-center study, we report our perioperative and long-term outcomes after HeRO graft placement, and investigate the impact of conduit type and configuration on patency rates. METHODS:We retrospectively reviewed all HeRO graft procedures performed from January 2014 to December 2023 across three hospitals. Data were collected on patient demographics, operative details, postoperative outcomes, and patency. Only index HeRO graft procedures were included, and any subsequent or reoperative HeRO operations were excluded from analysis. Cox proportional hazards model was used to derive risk factors for loss of graft patency. RESULTS:A total of 232 index HeRO implantations were performed over the 10-year study period. These included 49 primary procedures (23.1%) and 183 staged procedures (78.9%). Postoperative complications included wound infection (n = 18; 7.8%), symptomatic hematoma (n = 23; 9.9%), steal syndrome (n = 23; 9.9%), myocardial infarction (n = 3; 1.3%), and pulmonary embolism (n = 7; 3.0%). Overall primary patency was 33.0% ± 3.4% at 1 year, 6.4% ± 2.1% at 3 years, and 4.3% ± 1.9% at 5 years post-implantation. Secondary patency was 69.4% ± 3.4% at 1 year, 41.9% ± 4.4% at 3 years, and 28.0% ± 4.9% at 5 years post-implantation. Primary and secondary patency rates did not differ between primary and staged procedures (log-rank P = .46 and .73, respectively). On multivariate analysis, the use of a tapered 4- to 6-mm (hazard ratio [HR], 2.89; 95% confidence interval [CI], 1.11-7.49; P = .029) or tapered 4- to 7-mm conduit (HR, 1.82; 95% CI, 1.15-2.87; P = .011) was independently associated with loss of primary patency, compared with a non-tapered 6-mm graft. Tapered conduits were also associated with loss of secondary patency (4- to 6-mm tapered: HR, 3.68; 95% CI, 1.07-12.63; P = .039; 4- to 7-mm tapered: HR, 1.85; 95% CI, 1.01-3.37; P = .044). Neither graft type (standard vs early cannulation) nor procedure (primary vs staged) were associated with loss of primary or secondary patency. CONCLUSIONS:Among patients with limited hemodialysis access options, HeRO graft implantation is associated with limited primary patency but acceptable secondary graft patency rates. In our experience, staged procedures and early cannulation grafts did not impact patency rates; however, the use of a tapered conduit was associated with loss of patency and should be considered with caution in this patient population.

OBJECTIVE:Catheter-based therapies (CBTs) have become established treatments for high-risk pulmonary embolism (PE). Anecdotally, these therapies are increasingly used in lower-risk patients despite unclear efficacy. We evaluated the use of CBT for PE in an intermediate-low risk stratified population vs anticoagulation (AC) only and systemic thrombolysis (ST). METHODS:In this multicenter retrospective cohort study, three intermediate-low-risk PE cohorts were identified using the TriNetX database, defined as normotensive PE patients with evidence of right heart strain on echocardiography, but without elevated cardiac biomarkers from December 2010 to December 2024. The treatment cohorts were AC, ST, or catheter-based therapy (CBT), including catheter-directed thrombolysis and mechanical thrombectomy. Cohorts were 1:1 propensity score matched based on demographics and comorbidities. Study outcomes included mortality, bleeding complications, and pulmonary hypertension on periprocedural (30-day) and long-term (3-year) timeframes, using odds ratio (OR) with 95% confidence interval (CI). RESULTS:AC, ST, and CBT cohorts included 52,141, 3277, and 2378 patients, respectively. The incidence of CBT increased markedly during the study period (387%). Of patients undergoing CBT procedures, 45.5% received catheter-directed thrombolysis and 52.0% received mechanical thrombectomy. When comparing CBT with AC, there was no mortality difference at any timeframe. The 30-day intracranial hemorrhage (ICH) rates were greater in CBT (OR, 2.12; 95% CI, 1.00-4.50; P = .047), although the 3-year rates were comparable. Conversely, the rate of gastrointestinal (GI) bleeding was significantly lower with CBT at 3 years (OR, 1.45; 95% CI, 1.06-2.00; P = .02), but this difference was insignificant in a subgroup analysis of patients treated with direct oral anticoagulants. The 3-year pulmonary hypertension rates were low in all cohorts (0.73%-1.81%). ST carried universally high mortality in all timeframes (vs AC at 3 years: OR, 2.95; 95% CI, 2.54-3.41; P < .01; vs CBT at 3 years: OR, 3.27; 95% CI, 2.54-4.22; P < .01). Periprocedural bleeding complication rates were higher vs AC for both ICH (OR, 3.34; 95% CI, 1.99-5.60; P < .01) and GI bleeding (OR, 1.38; 95% CI, 0.90-2.13; P = .14), but comparable vs CBT. CONCLUSIONS:Despite a marked increase in the use of CBT in an intermediate-low-risk PE population, CBT offers minimal benefit in mortality, GI bleeding, or pulmonary hypertension over AC, with a greater perioperative ICH risk. ST carries unacceptably high mortality and bleeding complication rates compared with AC. More granular data are needed to optimize patient selection and treatment modality for intermediate-low-risk PE patients.

Introduction The outcome of a ruptured abdominal aortic aneurysm (AAA) without any interventions is close to uniformly fatal. The Society for Vascular Surgery suggests a door-to-intervention time of less than 90 minutes in a patient with a ruptured AAA. Admission factors associated with poor outcomes in ruptured AAAs include hypotension, renal insufficiency, severe anemia, advanced age, and cardiac arrest. Patients who are particularly at high risk for open AAA repair may be candidates for endovascular repair, which may decrease mortality. This study aimed to assess the relationship between systolic blood pressure (SBP) and serum bicarbonate levels in predicting mortality in patients with ruptured AAAs. Methods This retrospective study was performed using the United States Collaborative Network of 57 academic medical centers/healthcare organizations in the TriNetX database. A total of 4,226 patients with ruptured AAAs were identified. Patients were categorized based on SBP of ≤90 mmHg, any SBP, or >90 mmHg and further stratified by bicarbonate levels. Rounded cutoffs of the bicarbonate ranges (<10, 10.01-15; 15.01-20, >20.01) were chosen for interpretative purposes. Mortality outcome was assessed within 90 days after presentation for the ruptured AAA. Results After exclusions, 4,174 patients presented with ruptured AAA between September 30, 2003, and September 30, 2023, in the database. Overall, 90-day mortality in any SPB cohort was 28%. Patients who presented with a ruptured AAA with an SBP ≤ 90 had a 46.3% mortality. Those who presented with a SBP > 90 had a 20.1% mortality. Additionally, as bicarbonate levels decreased, mortality increased within each SBP group. Conclusions Early recognition and intervention are critical for survival in patients with ruptured AAAs. Metabolic acidosis is an important marker of the severity of hemorrhage in these patients. In this large cohort study of ruptured AAAs, mortality increases significantly with hypotension and metabolic acidosis, represented by lower bicarbonate levels. Abnormalities in the serum bicarbonate may be seen before severe changes in vital signs in hemorrhaging patients. Early recognition of metabolic acidosis may lead to earlier life-saving interventions in patients with ruptured AAAs.

Locally advanced cutaneous squamous cell carcinoma can erode into blood vessels, leading to vascular blowout, requiring emergent surgical intervention. We describe a first case of this disease complication which was effectively managed with endovascular stenting as a bridge to effective systemic and regional therapy. We discuss the efficacy of this staged approach which is novel and timely in a clinical environment of increasingly effective systemic therapies.

Objective Thrombolytic therapy has been a mainstay of treatment for massive or sub-massive pulmonary embolism (PE), a common and highly morbid pathology. New percutaneous mechanical thrombectomy devices have recently become widely available and have been increasingly utilized for the treatment of acute PE, but evidence demonstrating its efficacy over standard catheter-directed lytic protocol remains limited. Methods Using TriNetX Data Network, a global federated database of over 250 million patients, we conducted a retrospective cohort study of patients from January 2017 to August 2023 with a diagnosis of PE, treated with either percutaneous mechanical thrombectomy (PMT) or catheter-directed thrombolysis (CDT). Eligible patients were 1:1 propensity score-matched for preoperative co-variates including demographics and comorbidities. We calculated and compared the 30-day outcomes of all-cause mortality, bleeding complications (blood transfusion, gastrointestinal (GI) bleed, and intracranial hemorrhage (ICH)), diagnosis of acute respiratory failure (RF), myocardial infarction (MI), and pulmonary hypertension (PH) using odds ratio (OR) with 95% confidence interval (CI). Also, the 5-year outcomes of all-cause mortality, a composite outcome of chronic PH (chronic PE, chronic cor pulmonale, chronic thromboembolic PH (CTEPH)), right heart failure (RHF), RF, and emergency department (ED) visits, were compared using hazard ratio (HR) with 95% CI. Results We identified 2,978 patients treated with PMT and 1,137 patients treated with CDT. After matching, we compared 1,102 patients in each cohort. For 30-day outcomes, all-cause mortality, acute RF, and blood transfusion were similar between the two groups. However, compared to CDT, PMT was associated with a better safety profile, including lower bleeding risk for both ICH (OR [95% CI] = 0.46 [0.24-0.890]) and GI bleed (OR [95% CI] = 0.42 [0.28-0.63]). PMT also demonstrated better immediate functional outcomes, with less PH (OR [95% CI] = 0.53 [0.41-0.68]) and MI (OR [95% CI] = 0.54 [0.41-0.76]). At 5 years, the all-cause mortality and RF for both procedures were similar, but PMT was associated with lower rates of chronic PH (HR [95%CI] = 0.70 [0.55-0.90]), RHF (HR [95% CI] = 0.49 [0.37-0.65]), and ED visits (348 for PMT versus 426 for CDT, p<0.01). Conclusions In patients undergoing catheter-based therapy for PE, PMT has an improved procedural safety profile versus CDT and results in significantly fewer 30-day postoperative complications, with fewer bleeding events, and is also associated with less periprocedural MI and acute PH. Perhaps, more importantly, PMT also demonstrated improved long-term outcomes with significantly fewer chronic PH and RHF diagnoses with fewer ED visits.

Aortic graft and endograft infections remain a significant source of morbidity and mortality after abdominal aortic aneurysm repair. With graft excision and extra-anatomic bypass, an infrarenal aortic stump remains which can have suture line dehiscence and catastrophic stump blowout. Treatment of this is extremely challenging, especially for severely co-morbid patients who cannot undergo major surgery, or in patients with a hostile abdomen. We present a case study of a 74-year-old male found to have an aortoenteric fistula (AEF). This case broadens operative options for this type of patient population by demonstrating an endovascular technique for addressing aortic stump blowout by parallel grafting and coil embolization of the visceral aorta.

Multi-visceral transplantation (MVT) is a complex surgical procedure involving the transplantation of multiple abdominal organs as a single unit, typically used as bailout treatment of patients with devastating abdominal pathologies. Due to the complexity of the procedure, major and even life-threatening complications can happen. Vascular complications, including anastomotic breakdowns or pseudoaneurysms due to infections, can be universally lethal. Open surgical repair is often not an option due to the hostile operative field. We report a case of endovascular salvage of multi-visceral aortic conduit blowout utilizing parallel stent grafts and coils without sacrifice of the transplanted viscera. This combination can successfully control bleeding and maintain graft perfusion in this rare but devastating complication.

IntroductionTranscarotid artery revascularization (TCAR) is a hybrid technique with excellent initial outcomes. The technical success and safety of TCAR is heavily dependent on an anatomically suitable common carotid artery (CCA). Many patients do not meet anatomic criteria and therefore are not eligible for this therapy. We sought to extend the eligibility of TCAR to patients with unfavorable CCA anatomy via the adoption of a prosthetic arterial conduit.MethodsA single center retrospective study of patients with critical carotid artery stenosis who underwent TCAR via a prosthetic conduit between June 2019 and October 2021 was performed. All patients in the study were considered high-risk for carotid endarterectomy (CEA) based on anatomic features, such as restenosis post-CEA and neck radiation. Unfavorable CCA anatomy was defined as a clavicle to carotid bifurcation distance < 5 cm, a CCA diameter < 6 mm, and/or significant atherosclerotic disease at the intended arterial access site. The primary outcome of interest was technical success. Secondary outcomes included perioperative complications, intermediate and long-term patency, intermediate and long-term stroke and/or mortality and in-hospital length of stay. Follow-up ranged from 1-29 months.ResultsEight patients underwent ten TCAR procedures via a prosthetic conduit. A total of two procedures (20%) were performed on female patients and eight procedures (75%) were performed on male patients. The mean age was 65 years old (standard deviation (SD) 11 years). Technical success was 100%. The 30-day ipsilateral stroke rate was 0%. The 30-day patency was 90%. There was no re-exploration for hemorrhage and 30 day mortality was 0%.ConclusionsTCAR is an excellent option for carotid artery revascularization. Unfavorable CCA anatomy has limited its applicability. TCAR via a prosthetic conduit has the potential to expand eligibility for this promising therapy.