Background: Major vascular involvement is often considered a contraindication to resection of malignant tumors, but in highly selected patients, it can be performed safely, with results that are highly dependent upon the tumor biology. Resection of both the aorta and inferior vena cava (IVC) is a rare undertaking, requiring both favorable tumor biology and a patient fit for a substan-tial surgical insult; nevertheless, it provides the possibility of a cure. Methods: Patients requiring resection and reconstruction of both the aorta and IVC from 2009 through 2019 at 2 university medical centers were included. Patient characteristics, operative technique, and outcomes were retrospectively collected.Results: We identified 9 patients, all with infrarenal reconstruction or repair of the aorta and IVC. All cases were performed with systemic heparinization and required simultaneous aortic and caval cross-clamping for tumor resection. No temporary venous or arterial bypass was used. Since arterial reperfusion with the IVC clamped was poorly tolerated in 1 patient, venous reconstruction was typically completed first. Primary repair was performed in 1 patient, while 8 required replacements. In 2 patients, aortic homograft was used for replacement of both the aor-toiliac and iliocaval segments in contaminated surgical fields. In the remaining 6, Dacron was used for arterial replacement; either Dacron (n = 2) or polytetrafluoroethylene (n = 4) were used for venous replacement. Patients were discharged after a median stay of 8 days (range: 5-16). At median follow-up of 17 months (range 3-79 months), 2 patients with paraganglioma and 1 patient with Leydig cell carcinoma had cancer recurrences. Venous reconstructions occluded in 3 patients (38%), although symptoms were minimal. One patient presented acutely with a thrombosed iliac artery limb and bilateral common iliac artery anastomotic stenoses, treated successfully with thrombolysis and stenting.Conclusions: Patients with tumor involving both the aorta and IVC can be successfully treated with resection and reconstruction. En bloc tumor resection, restoration of venous return before arterial reconstruction, and most importantly, careful patient selection, all contribute to positive outcomes in this otherwise incurable population.

Background: The "crescent sign" is a hyperattenuating crescent-shaped region on CT within the mural thrombus or wall of an aortic aneurysm. Although it has previously been associated with aneurysm instability or impending rupture, the literature is largely based on retrospective analyses of urgently repaired aneurysms. We strove to more rigorously assess the association between an isolated "crescent sign" and risk of impending aortic rupture. Methods: Patients were identified by querying a single health system PACS database for radiology reports noting a crescent sign. Adult patients with a CT demonstrating a descending thoracic, thoracoabdominal, or abdominal aortic aneurysm and "crescent sign" between 2004 and 2019 were included, with exclusion of those showing definitive signs of aortic rupture on imaging. Results: A total of 82 patients were identified. Aneurysm size was 7.1 +/- 2.0 cm. Thirty patients had emergent or urgent repairs during their index admission (37%), 19 had elective repairs at a later date (23%), and 33 patients had no intervention due to either patient choice or prohibitive medical comorbidities (40%). Patients without intervention had a median follow up of 275 days before death or loss to follow up. In patients undergoing elective intervention, 6,968 patient-days elapsed between presentation and repair, with zero episodes of acute rupture (median 105 days). Patients undergoing elective repair had smaller aneurysms compared to those who underwent emergent/urgent repair (6.2 +/- 1.3 vs. 7.7 +/- 2.1 cm, P = 0.008). No surgical candidate with an aneurysm smaller than 8 cm ruptured. There were 31 patients with previous axial imaging within 2 years prior to presentation with a "crescent sign," with mean aneurysm growth rate of 0.85 +/- 0.62 cm per 6 months [median 0.65, range 0-2.6]. Those with aneurysms sized below 5.5 cm displayed decreased aneurysm growth compared to patients with aneurysm's sized 5.5-6.5 cm or patients with aneurysms greater than 6.5 cm (0.12 vs. 0.64 vs. 1.16 cm per 6 months, P= 0.002). Conclusions: The finding of an isolated radiographic "crescent sign" without other signs of definitive aortic rupture (i.e., hemothorax, aortic wall disruption, retroperitoneal bleeding) is not necessarily an indicator of impending aortic rupture, but may be found in the setting of rapid aneurysm growth. Many factors, including other associated radiographic findings, aneurysm size and growth rate, and patient symptomatology, should guide aneurysm management in these patients. We found that patients with minimal symptoms, aneurysm sizes below 6.5 cm, and no further imaging findings of aneurysm instability, such as periaortic fat stranding, can be successfully managed with elective intervention after optimization of comorbid factors with no evidence of adverse outcomes.

Operative expenses compose one-third of the rising health care costs in the United States. Therefore, novel strategies for mitigating cost in the vascular surgery space are warranted. Our institution implemented a cost reduction strategy in 2017 by simply showing surgeons the costs of their implants and disposable supplies at the end of each case in order to increase surgeon financial awareness and reduce costs. We performed a retrospective analysis of recorded supply and implant costs for vascular procedures from 2015 to 2018 at a single institution. Total operative cost was defined as the accumulated implant and supply cost during a procedure. We assessed total implant and disposable supply cost, supply cost alone, and cost per time. Cost was analyzed over two periods: the 24 months prior (PRE) to the tool implementation and 24 months following (POST) with a 1-month washout. Medians and interquartile ranges were calculated for each parameter and compared using the Mann-Whitney U test. We analyzed a total of 1372 procedures performed over the time period studied. Total supply and implant cost (–17.5%; P = .008), supply cost (–1.99%; P = .049) and cost per minute (–28.24%; P = .015) all saw significant reductions across the composite of open procedures from the PRE to POST time point (Table). Largest supply cost reductions were seen in common femoral artery endarterectomy (–42%; P < .001). The total operative cost/time was most significantly reduced for carotid endarterectomy (–8.89%; P = .001), abdominal aortic aneurysm repair (–16.21; P = .019), carotid-subclavian bypass (–9.94%; P = .032), and common femoral endarterectomy (–41.16%; P = .06), with nonsignificant cost reductions in arteriovenous grafting and rib resection. Relative price increases of 31%, 8%, and 3% were calculated for temporal artery biopsy, vein transposition, and distal bypass, respectively. The composite of all endovascular procedures saw large implant cost increases with minimal change in supply cost. We demonstrate that a low-cost, highly implemenTable cost sheet is effective at reducing cost in vascular surgery. Further investigations should assess how and why surgeons choose supplies and implants in order to target further intraoperative cost savings.TableCost trends before and after implementation of a cost sheet across multiple vascular surgery proceduresProcedureTotal operative cost (supply + implant), $Supply cost, $Total cost/time (supply + implant), $/minutePREPOST% ΔP valuePREPOST% ΔP valuePREPOST% ΔP valueCarotid endarterectomy504.3 (411.5-664)452.6 (409.5-525.7)–10.25.012250.3 (238.5-277)249.1 (235-276.1)–0.45.35344.86 (4.05-6.09)4.43 (3.77-5.25)–8.89.001AAA repair1686 (1268-2041)1399 (1257-1717)–17.01.037542.5 (432-602.5)536.8 (456.6-621.8)–1.052.81857.59 (5.67-9.49)6.36 (1.65-8.13)–16.21.019Carotid-subclavian bypass681 (609.1-805.4)682.6 (641-771.6)0.23.953272.3 (245.8-385.7)259.9 (245.1-290)–4.54.36155.49 (4.52-6.36)4.85 (1.39-5.76)–9.94.032Common femoral endarterectomy3102 (1107-5232)971.3 (532.5-4309)–68.69.0107662.4 (441.3-886.1)382.8 (237.8-566.8)–42.21<.000114.35 (6.32-14.35)8.45 (3.81-8.45)–41.16.061Arteriovenous graft181.8 (130.8-189.2)183.3 (123.8-223.1)0.822.5425113.8 (108.3-132.4)112.5 (106.7-125.9)1.0865.54112.07 (1.39-10.57)1.70 (1.48-2.67)–17.65.14Rib resection119.7 (115.8-124.6)116.6 (112.2-149.2)–2.577.8662120.3 (117.8-123)114.6 (109.7-138.3)–4.738.05621.46 (1.25-2.06)1.39 (1.02-2.11)–4.46.56Temporal artery biopsy45.25 ( 34.41-73.4)90.26 (47.84-121.4)99.49.000345.25 (34.41-73.4)90.55 (48.17-121.4)100.01.00041.38 (0.79-1.79)1.81 (1.25-3.05)30.92.0099Upper extremity vein transposition181.9 (125.1-249)187.7 (132.2-269.2)3.16.5116127.2 (113-145.7)114.9 (101.3-121.1)–9.669.00081.89 (1.02-2.84)2.05 (1.39-2.56)8.68.53Distal bypass831.7 (491.8-2315)767.6 (480-2987)–7.69.8428308.8 (244.9-382.6)377.9 (242.4-572)22.36.08172.64 (1.87-7.98)2.72 (1.59-8.29)3.26.94All endovascular (EVAR + TEVAR)17653 (12890-24376)22524 (15366-29092)27.59.00022031 (1581-2588)2022 (1559-2597)0.437.8103180.3 (11.4-262.1)163.2 (97.84-271.4)–9.48.6396All open549 (275.1-1115)452.7 (209.3-782.4)–17.54.0078250.3 (141.1-411.1)245.3 (121.5-343.2)1.99.04935.237 (2.039-11.03)3.758 (1.86-7.241)–28.24.015AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair; POST, the 24 months following tool implementation; PRE, The 24 months prior to the tool implementation; TEVAR, thoracic endovascular aneurysm repair.Values are median (interquartile range). Open table in a new tab

During pancreatic head resection (Whipple procedure), the portal vein (PV) and mesenteric veins must often be resected or repaired. Grafts or patches for mesenteric venous reconstruction—homograft, internal jugular vein, or bovine pericardium—can take time to thaw or to be harvested. Therefore, temporary procedural shunting of the mesenteric venous circulation during reconstruction can mitigate bowel edema and ischemia resulting from procedural venous occlusion (Fig). Patient health information was harvested retrospectively from a prospectively maintained database. Data were summarized using standard statistical techniques. Twenty-one patients, 12 women and 9 men, underwent temporary PV shunting during oncologic resection and PV reconstruction from 2010 to 2020. Average age was 64 years. All patients had either pancreatic cancer (95%) or cholangiocarcinoma (5%) and underwent Whipple procedure (81%) or pancreatectomy and splenectomy (19%). Reconstructions consisted of interposition grafting (52% cadaveric aortic homograft and 5% internal jugular vein) or patch angioplasty (38% bovine pericardium and 5% internal jugular vein). No. 12 and No. 14 Argyle shunts were used. In all but two patients, the shunt was easily placed into the superior mesenteric vein (SMV) caudally and the PV cranially. One patient was shunted caudally into the splenic vein as his SMV had chronic nonocclusive thrombus that precluded shunt placement. The other patient lacked sufficient length of the SMV stump to clamp around the shunt, so only the second anastomosis (on the liver side) was performed with the shunt in place. Technical success of the PV reconstruction was 100%, and no intraoperative complications resulted from shunt placement. Postoperatively, one PV reconstruction thrombosed before discharge on day 7, which was managed nonoperatively with anticoagulation. During a mean follow-up of 13.6 months (range, 0.2-112 months), three additional reconstructions occluded (two early at 0.5 month and 1.5 months in patients with aggressive recurrent cancer and one late at 28 months after adjuvant radiation therapy). No other complications, including pseudoaneurysm or graft infection, were noted. Shunting is a well-established technique with which most vascular surgeons are comfortable in practice. Applying it as an adjunct in a novel context for PV reconstruction is safe, is technically straightforward, and may mitigate the deleterious effects of temporary mesenteric venous occlusion required for mesenteric venous reconstruction during oncologic resection.

The aim of this study was to evaluate practice patterns of antiplatelet therapy after complex endovascular aortic surgery and to investigate the effects of antiplatelet therapy on 1-year outcomes. A review of all complex endovascular aortic aneurysm procedures involving visceral vessel treatment with stent, fenestration, scallop, snorkel, or side arm branch in the national Vascular Quality Initiative database from 2014 to 2018 was performed. Cohorts based on antiplatelet regimen at discharge were formed: aspirin vs dual antiplatelet (DAPT). Multivariable logistic regression analysis evaluated those variables associated with DAPT. Immediate postoperative and 1-year outcomes separated by antiplatelet regimen were evaluated. A total of 1291 patients accounting for 3552 visceral vessel treatments (9.8% celiac, 24.5% superior mesenteric artery [SMA], 32.9% right renal, 32.8% left renal) met inclusion criteria. Stenting and side arm branch treatment represented the most common intervention (77.6%), followed by scallop/fenestration (14.1%) and snorkel (8.3%). Preoperatively, 13.9% of patients were receiving DAPT. Postoperatively, 52.1% of patients were discharged on DAPT, a proportion that increased from 49.1% in 2014 to 63.1% in 2018 (P = .02; Fig 1). At 1-year follow-up, 32.7% of patients were maintained on DAPT. Patients discharged on DAPT were younger (73.0 vs 74.9 years; P < .001), were more often male (80% vs 74.9%; P = .04), and had a higher prevalence of cardiovascular comorbidities: coronary artery disease (36.7% vs 27.5%; P < .001) and prior coronary artery bypass graft or percutaneous coronary intervention (45.2% vs 34.3%; P < .001). Intraoperatively, the DAPT cohort had the same average number of visceral vessels treated (2.8 vs 2.7; P = .09) but had a higher frequency of SMA involvement (70.4% vs 64.0%; P = .02) with a higher proportion of SMA interventions involving snorkels (10.6% vs 7.0%; P = .01). Immediate postoperative outcomes were similar between the two antiplatelet regimens. At 1-year follow-up, the two cohorts did not differ in aneurysm size, disease extent, or overall reintervention rate. The DAPT cohort had similar visceral vessel reintervention compared with the aspirin cohort (4.2% vs 3.5%; P = .54). Snorkel treatment and increased number of visceral vessels treated were associated with discharge on DAPT. Increasing age, American Society of Anesthesiologists class 4 or class 5, and discharge on anticoagulation were all associated with decreased likelihood of discharge on DAPT (Table). These results show an increase in use of DAPT after complex endovascular aortic aneurysm surgery involving visceral vessels. DAPT is used more with snorkel technique and with increased numbers of visceral vessels treated. One-year outcomes including aneurysm size change, need for reintervention, and vessel-specific reintervention do not differ on the basis of the antiplatelet regimen at discharge.TableVariables associated with discharge on DAPT therapyOR (95% CI)P valueDischarge on anticoagulation0.25 (0.15-0.43)<.001ASA 4 or 50.75 (0.57-0.98).04Age0.98 (0.96-0.99).005Preop aspirin therapy1.63 (1.22-2.08).001Number of visceral vessels treated (relative to one vessel treatment) Two1.93 (1.18-3.13).008 Three2.98 (1.85-4.79)<.001 Four2.1 (1.25-3.51).005Any snorkel therapy2.28 (1.50-3.46)<.001Preop antiplatelet therapy (other than aspirin)3.87 (2.60-5.76)<.001 Open table in a new tab

Active smoking is often a deterrent for vascular surgeons to offer invasive therapies for patients with athero-occlusive disease due to concerns over perioperative outcomes and long-term durability of the intervention. We aimed to examine the impact of smoking status on perioperative outcomes, stroke, and mortality in patients undergoing carotid endarterectomy (CEA). All patients in the Vascular Quality Initiative CEA dataset between 2003 and 2019 who had recorded follow-up data of a minimum of 1 year were included. Patient demographics were compared in patients who were either active smokers (AS), former smokers (FS) or never smokers (NS). Cox regression was used to assess long-term survival and freedom from transient ischemic attack (TIA)/stroke. We included 77,625 patients: 20,351 (26.2%) were AS, and 38,128 (49.1%) were FS, comprising the largest group in this cohort. Patients in the AS group were younger (mean age, 65.1 years vs 71.9 years [FS] and 73.0 years [NS]; P < .01), and had a lower burden of most documented comorbidities (hypertension, diabetes, chronic kidney disease, and congestive heart failure), except frequency of chronic obstructive pulmonary disease, which was significantly more prevalent among active smokers (35.2% vs 22.5% [FS] and 7.3% [NS]; P < .01). On univariate analysis, perioperative TIA/stroke were similar between all groups (1.6% [AS] vs 1.6% [FS] vs 1.7% [NS]; P = .61), however, in long-term follow-up, TIA/stroke was highest among active smokers (2.6% vs 2.0% [FS] and 1.9% [NS]; P < .01) (Table). Multivariable analysis showed that both active smoking (hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.10–1.35; P < .01) and former smoking (HR 1.10; 95% CI, 1.01-1.99; P = .03) were independently associated with a higher combined end point of TIA/stroke/death at 2 years compared with the NS group. These patterns held true for asymptomatic patients, where active smoking was associated with a higher rate of TIA/stroke/death (HR 1.21; 95% CI, 1.04-1.42; P = .02), as was former smoking (HR 1.14; 95% CI, 1.01-1.30; P = .04) at 2 years (Figure 1). Importantly, active smoking was associated with a higher rate of TIA/stroke/death (HR 1.09; 95% CI, 1.00-1.19; P = .04) above that seen in the former smoker group in the overall cohort. Our adjusted analysis demonstrates that both active and former smokers had a significantly elevated risk of TIA/stroke/death at 2 years following CEA. FS did not suffer from as high a rate of TIA/stroke/death compared to AS. These data suggest that smoking cessation should be encouraged in patients undergoing CEA, as it will improve long-term outcomes.TablePatient demographics, operative factors and outcomes in patients undergoing carotid endarterectomy (CEA) based on smoking statusPatient demographicsAS n = 20,351FS n = 38,128NS n = 20,351P valueAge, years, mean ± SD65.1 ± 8.771.9 ± 8.573.0 ± 9.2<.01Female sex43.0%34.1%45.9%<.01White race92.2%93.4%89.6%<.01Ipsilateral TIA/stroke41.4%36.9%39.9%<.01History of contralateral CEA/CAS15.3%16.8%11.8%<.01Insured90.0%97.2%96.8%<.01Hypertension86.5%90.6%88.5%<.01Diabetes29.7%36.9%36.4%<.01Creatinine >1.84.7%7.0%6.2%<.01Coronary artery disease26.4%30.4%24.1%<.01Hx of PCI19.3%24.2%19.2%<.01Hx of CABG11.0%19.4%17.2%<.01Congestive heart failure8.5%11.8%9.4%<.01COPD35.2%22.5%7.3%<.01PAD7.6%6.9%2.7%<.01Preoperative ASA82.9%84.7%83.6%<.01Preoperative statin79.4%82.9%80.1%<.01Preoperative anticoagulation6.9%10.7%10.7%<.01Operative factors Operative time, minutes120.0 (51.3)120.2 (51.1)116.7 (49.9)<.01 General anesthesia92.6%91.3%91.1%<.01 Conventional88.1%87.3%85.6%<.01 Shunt54.8%51.2%52.3%<.01Perioperative outcomes TIA/stroke1.6%1.6%1.7%.61 MI0.4%0.5%0.3%.02 CNI2.3%2.4%2.4%.58 Return to OR1.8%1.9%1.7%.13Long-term follow-up TIA/stroke2.6%2.0%1.9%<.01 MI1.3%1.4%1.2%.26 Restenosis >70%3.0%3.4%2.8%<.01 Occlusion0.7%0.5%0.6%.11AS, Active smoker; ASA, American Society of Anesthesiologists; CABG, coronary artery bypass grafting; CAS, carotid artery stenting; CNI, cranial nerve injury; COPD, chronic obstructive pulmonary disease; FS, former smoker; Hx, history; MI, myocardial infarction; NS, nonsmoker; OR, operating room; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; SD, standard deviation; TIA, transient ischemic attack. Open table in a new tab

The aim of this study was to explore current practice patents for prescribing single versus dual antiplatelet therapy after lower extremity endovascular interventions and to explore the effects of various antiplatelet therapy regimens on 1-year patency and reintervention rates. All lower extremity endovascular interventions performed for occlusive disease and entered into the national Vascular Quality Initiative database from 2010 to 2018 were investigated. Two cohorts were created based on antiplatelet regimen at discharge: aspirin vs dual antiplatelet therapy (DAPT). Multivariable logistic regression evaluated predictors of discharge on DAPT. Controlling for preoperative demographics and operatic characteristics (lesion and treatment variables), Cox regression analyzed 1-year vessel patency and reintervention rates. During the study period, 65,956 patients met inclusion criteria. Treated lesions involved the following distributions: 37.9% iliac, 60.1% femoral/popliteal, and 22.6% infrapopliteal. Of the interventions, 84.7% involved percutaneous transluminal angioplasty, 60.6% stenting, and 14.9% atherectomy. Of the patients, 27.9% were on DAPT preoperatively, rising to 57.54% at discharge, and dropping to 44.0% at the 1-year follow-up. Discharge on anticoagulation (odds ratio [OR], 0.19; 95% confidence interval [CI], 0.17-0.20; P < .001), advancing age (OR, 0.98; 95% CI, 0.98-0.99; P < .001), and iliac treatment (OR, 0.81; 95% CI, 0.75-0.87; P < .001) were the strongest predictors of discharge on aspirin only, while prior coronary artery bypass grafting/percutaneous coronary intervention (OR, 1.52; 95% CI, 1.43-1.62; P < .001), stenting as intervention (OR, 1.73; 95% CI, 1.63-1.84; P < .001), femoral/popliteal lesion location (OR, 1.32; 95% CI, 1.23-1.42; P < .001), and increasing TransAtlantic Inter-Society Consensus (TASC) lesion grade (TASC D, OR, 1.51; 95% CI, 1.37-1.68; P < .001) were the strongest predictors of discharge on DAPT (Table). Cox regression found no effect of DAPT on 1-year vessel patency (hazard ratio [HR], 0.95; 95% CI, 0.85-1.07; P = .42) or vessel reintervention rate (HR, 0.96; 95% CI, 0.89-1.03; P = .21) (Figure). Cox regression was repeated on a more selective, higher risk vascular disease cohort (stenting intervention, TASC grade C or D, femoral/popliteal or infrapopliteal lesion location) and again no effect on 1-year vessel patency (HR, 0.93; 95% CI, 0.75-1.16; P = .524) or reintervention (HR, 1.01; 95% CI, 0.86-1.19; P = .89) was found. Dual antiplatelet therapy is prescribed after the majority of lower extremity endovascular interventions and is most often used in more complex and higher risk patients with higher TASC lesion classifications, femoral and popliteal lesion locations, and interventions requiring stenting. Despite its widespread use, no beneficial effect of DAPT therapy on 1-year reintervention or vessel patency was found.Table IMultivariable logistic regression predicting variables associated with discharge on dual antiplatelet therapy (DAPT)Variables associated with discharge on DAPT therapyOR95% CIP valueDischarge on anticoagulation0.19(0.17-0.20)<.001Treated lesion location Iliac0.81(0.75-0.87)<.001 Femoral/popliteal1.32(1.23-1.42)<.001 Infrapopliteal1.10(1.02-1.18)0.02 Creatinine >1.8 mg/dL0.82(0.76-0.89)<.001Symptoms (compared to claudication)<.001 Rest pain0.80(0.75-0.84)<.001 Tissue loss/acute limb ischemia0.77(0.68-0.88)<.001Age0.98(0.98-0.99)<.001Non-white race1.09(1.02-1.17)0.01Hypertension1.16(1.08-1.24)<.001Atherectomy1.19(1.10-1.28)<.001Prior lower extremity intervention1.20(1.14-1.26)<.001Coronary artery disease1.23(1.16-1.31)<.001Prior carotid stent or endarterectomy1.32(1.13-1.53)0.001TASC lesion (compared to A)<.001 B1.13(1.07-1.20)<.001 C1.19(1.12-1.27)<.001 D1.51(1.36-1.68)<.001Prior CABG or PCI1.52(1.43-1.62)<.001Stent (compared to angioplasty alone)1.73(1.63-1.84)<.001CABG, Coronary artery bypass grafting; CI, confidence interval; OR, odds ratio; PCI, percutaneous coronary intervention; TASC, TransAtlantic Inter-Society Consensus. Open table in a new tab

The aim of this study was to investigate trends in surveillance carotid artery duplex ultrasound examination after carotid artery stenting (CAS) and to investigate the association between postoperative duplex ultrasound restenosis and long-term ipsilateral stroke or transient ischemic attack (TIA). All CAS procedures entered into the national Vascular Quality Initiative database from 2012 to 2018 were investigated. Only patients for whom follow-up surveillance carotid ultrasound data were captured were included in the analysis. Multivariable logistic regression analysis investigated factors associated with absence of postoperative surveillance duplex ultrasound as well as the association between postoperative restenosis (>70%) or occlusion and follow-up ipsilateral stroke or TIA. During the study period, 10,537 patients met inclusion criteria. Postoperative carotid duplex ultrasound surveillance rate was 82.9%. Rates of surveillance duplex ultrasound decreased throughout the years of the study from 100% in 2012 to 64.4% in 2018 (P = .002; Fig). On multivariable logistic regression, more recent year of operation was found to be the strongest predictor of lack of postoperative duplex ultrasound (odds ratio [OR], 2.43; 95% confidence interval [CI], 2.27-2.60; P < .001; Table). Femoral access (OR, 2.04; 95% CI, 1.67-2.463; P < .001), discharge to facility (OR, 1.66; 95% CI, 1.32-2.08; P < .001), and symptomatic status (OR, 1.28; 95% CI, 1.12-1.48; P < .001) were also associated with absence of postoperative carotid surveillance. In contrast, higher center volume (OR, 0.53; 95% CI, 0.45-0.63; P < .001) was the strongest predictor of postoperative carotid surveillance. Prior carotid endarterectomy or CAS (OR, 0.66; 95% CI, 0.56-0.77; P < .001), insured status (OR, 0.68; 95% CI, 0.52-0.91; P = .01), and higher surgeon volume (OR, 0.83; 95% CI, 0.72-0.97; P < .001) were all associated with postoperative carotid surveillance. The overall rate of restenosis (>70%) or occlusion at the 1-year surveillance duplex ultrasound was 5.8%. The overall rate of ipsilateral stroke or TIA was 1.7%, with these patients having higher rates of restenosis or occlusion compared with those without neurologic events (13.1% vs 5.6%; P < .001). On multivariable logistic regression, surveillance duplex ultrasound restenosis or occlusion was independently associated with follow-up ipsilateral TIA or stroke (OR, 2.17; 95% CI, 1.25-3.75; P = .01). These results show a dramatic decrease in use of postoperative CAS surveillance duplex ultrasound during the past 7 years. Higher surgeon and center volume along with carotid access were independently associated with higher rates of post-CAS carotid surveillance. Surveillance restenosis or occlusion was significantly associated with ipsilateral TIA or stroke at follow-up. These data suggest that increasing surveillance duplex ultrasound rates may decrease post-CAS neurologic events.TableMultivariable logistic regression predicting variables associated with lack of post CAS carotid surveillance duplex examinationVariables associated with lack of post CAS surveillance duplexOR (95% CI)P valueMore recent year of surgery2.43 (2.27-2.60)<.001Femoral access (compared to carotid access)2.04 (1.69-2.46)<.001Discharge to facility1.66 (1.32-2.08)<.001Symptomatic status1.28 (1.12-1.48)<.001Higher Surgeon volume (compared to lower 50%)0.83 (0.72-0.97).02Insured0.68 (0.52-0.91).01Prior CEA or CAS0.66 (0.56-0.77)<.001Higher Center volume (compared to lower 50%)0.53 (0.45-0.63)<.001 Open table in a new tab

Introduction: Current evidence suggests that dual antiplatelet therapy (DAPT) reduces perioperative stroke, but increases bleeding after carotid endarterectomy (CEA). The long term effects of antiplatelet therapy after CEA have yet to be studied. Methods: A retrospective review of patients undergoing CEA in the national Vascular Quality Initiative database (2003-2018) was performed. Based on antiplatelet regimen at discharge, patients were propensity score matched on aspirin monotherapy vs. DAPT. Multivariable logistic regression and Kaplan-Meier analyses were used to investigate the long term effects of antiplatelet regimen on mortality and stroke/TIA. Results: Of the 72,122 patients undergoing CEA, 64.6% were discharged on aspirin, and 35.4% on DAPT. The DAPT group had higher frequencies of comorbidities (COPD, HTN, CHF, smoking, diabetes) as well as atherosclerotic diseases (PAD, CAD, prior PCI, prior CABG). After propensity score matching, two groups of 8,722 patients with comparable comorbidities were formed. While unmatched Kaplan-Meier analysis showed the DAPT cohort to have higher mortality (p=0.001), this difference dissipated after matching. The resultant matched DAPT cohort did not differ from the aspirin group in one year stroke/TIA (1.7% vs. 1.6%, p=0.70), or mortality (3.1% vs. 3.3%, p=0.55). At 5 years, however, patients treated with DAPT did exhibit a mortality benefit (6.4% vs. 7.3%, p=0.02) with multivariable logistic regression identifying DAPT as an independent predictor of reduced mortality (OR 0.94, 95% CI 0.88-0.99, p=0.04). Conclusions: Patients discharged on DAPT after CEA represent a significantly different cohort than those discharged on aspirin monotherapy. After propensity score matching, there was no difference at one year stroke/TIA or mortality outcomes, but DAPT was found to be protective against long-term mortality. Further study is warranted to investigate this finding.

Current guidelines recommend dual antiplatelet therapy (DAPT) for at least one month after Carotid Artery Stenting (CAS). The effects of maintained dual antiplatelet therapy after CAS have yet to be examined.

BACKGROUND:The characteristics of and indications for open abdominal aortic aneurysm (AAA) repair have evolved over time. We evaluated these trends through the experience at a tertiary care academic center. METHODS:A retrospective review was conducted for patients undergoing open AAA repair (inclusive of type IV thoracoabdominal aortic aneurysms) from 2005 to 2018 at an academic institution. Trends over time were evaluated using the Spearman test; Cox regression was used to determine predictors of mortality and to generate adjusted survival curves. RESULTS:There were 628 patients (71.5% male; 88.2% white) with a mean age of 70.5 ± 9.4 years who underwent open AAA repair with a mean aneurysm diameter of 6.2 ± 1.5 cm. The median length of stay was 10 days, and the median intensive care unit length of stay was 3 days. Urgent repair was undertaken in 21.1%; 22.3% were type IV thoracoabdominal aortic aneurysm repairs, and 9.9% were performed for explantation. Our series favored a retroperitoneal approach in the majority of cases (82.5%). The proximal clamp sites were supraceliac (46.1%), suprarenal (29.1%), and infrarenal (24.8%), with approximately a third requiring renal artery reimplantation. The average cross-clamp time was 25.5 ± 14.9 minutes; the mean renal ischemia time for supraceliac and suprarenal clamp sites was 28.4 ± 12.3 minutes and 23.5 ± 12.7 minutes, respectively. Postoperative renal dysfunction occurred in 19.6% of the overall cohort, with 6.2% requiring hemodialysis. Of those requiring postoperative hemodialysis, the majority (75%) received an urgent repair. The in-hospital mortality was 2.3% for elective cases vs 20.9% for urgent repair, and 29.8% of patients were discharged to rehabilitation, with an overall 30-day readmission rate of 7.9%. Over time, there were trends of increased aneurysm repair complexity, with decreasing infrarenal clamp sites, increasing supraceliac clamp sites, increasing proportion of explantations, and increasing need for bifurcated grafts. The acuity of aneurysm repair likewise changed, with the proportion of urgent repairs increasing over time, largely attributable to the rise in explantations. Clamp site influenced the frequency of perioperative complications. Urgent repairs and age at operation were associated with mortality, whereas mortality was not associated with need for explantation and clamp location. CONCLUSIONS:Aneurysm repair reflected increasing complexity over time, with the need for explantation among urgent repairs significantly on the rise. Urgency and clamp location independently predicted long-term mortality, even after adjustment for age. These findings underscore the changing landscape of open AAA repair in the current era.

Background: Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. Methods: Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. Results: Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. Conclusions: This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.

Improvements in chemoradiotherapy have rendered complex pancreatic cancers involving the portal vein (PV) amenable to resection. PV reconstruction (PVR) is an essential component. Various conduits have been proposed; however, the optimal choice remains unknown. Fourteen patients underwent PVR with a cadaveric descending thoracic aortic homograft from 2014 to 2020. The primary diagnosis was pancreatic cancer. The splenic vein was ligated in seven patients (50%). The 30-day and 3-, 12-, and 24-month primary patency rates were 100%, 86%, 76%, and 76%, respectively. We found a cadaveric descending thoracic aortic homograft is an excellent conduit for PVR, given the optimal size, rapidly availability, favorable risk profile, and absence of harvest site complications.

The aim of this study was to develop a model predicting likelihood of progression to a higher level of amputation after transmetatarsal amputation (TMA). All transmetatarsal amputations entered into the national Vascular Quality Initiative database from 2013 to 2019 were investigated. Planned staged amputations were excluded from analysis. Two cohorts were created based on 1-year reamputation at a higher level status. A model for TMA progression was created based on a multivariable logistic regression analysis predicting reamputation at a higher level. The model was validated graphically (depicting predicted vs actual reamputation rates) and statistically utilizing bootstrapping with 1000 repetitions with replacement. During the study period, 781 TMAs were performed, with a 1-year reamputation rate of 27.3% (72.7% below knee amputation, 27.3% above knee amputation). Indications for reamputation included nonhealing wound (58.0%), infection (25.5%), and vascular disease progression (16.6%). The reamputation cohort was less Caucasian (48.8% vs 62.1%; P < .001), less ambulatory preoperatively (81.7% vs 88.5%; P = .01), had higher rates of ankle-brachial index (ABI) <0.7 (43.6% vs 35.6. P = .002), lower rates of ABI >1.4 (24.5% vs 42.96%; P = .002), and were less likely ambulatory at discharge (62.4% vs 72.0%; P = .01). Neuropathic ulcer indication (compared to infection and ischemic disease) and preoperative ambulatory status were protective against reamputation (Table). Active smoking, ABI <0.7 or >1.4, non-Caucasian race, and Hispanic ethnicity were associated with increased reamputation (Table). The TMA progression model was created from the aforementioned variables, with five risk group categories created based on quintile distribution of summed amputation progression scores (1 [lowest risk; score <0], 2 [score 0-1], 3 [score 2], 4 [score 3-4], 5 [highest risk; score >4]). The model displayed good fit with bootstrap validated area under the curve of 0.67 (95% confidence interval, 0.61-0.72) and appropriate Hosmer-Lemeshow goodness of fit testing with a P value of .88. As expected, Kaplan-Meier analysis for reamputation showed corresponding increasing 1 -year reamputation rates based on risk quintile (1 = 9.3%, 2 = 16.0%, 3 = 20.1%, 4 = 36.4%, 5 = 42.7%; P < .001) (Figure). Using six readily obtained preoperative variables (indication for amputation, ambulatory status, smoking status, ABI, race, ethnicity), we created the TMA progression model which accurately predicts 1-year reamputation rates at a higher level. This model can be utilized by physicians in determining the appropriate level of initial amputation in patients presenting with foot and toe wounds without options for revascularization.TableMultivariable logistic regression predicting variables associated with reamputation at a higher levelaVariables associated with reamputation at a higher levelBeta coefficient95% CIP valueScore valueNeuropathic ulcer as indication–1.04(–2.15 to 0.07).07–3Ambulatory preoperatively–0.73(–1.43 to –0.04).04–2Active smoker0.62(0.03 to 1.21).042ABI (compared to reference group 0.7-1.4)0 <0.70.8(0.19 to 1.41).013 >1.40.91(0.25 to 1.57).013Non-Caucasian race0.9(0.38 to 1.41)<.0013Hispanic ethnicity0.93(–0.07 to 1.93).073ABI, Ankle-brachial index.aScore values are attributed to each variable based on beta coefficient value. Each patient’s summed score value was utilized to create an overall transmetatarsal amputation progression score. Open table in a new tab

Recent literature has shown the growing complexity of open abdominal aortic aneurysm (AAA) repair over time. Limited data exist on the trends in open AAA repair in the context of operative volume. We evaluated data from the open AAA registry in the Vascular Quality Initiative from 2003 to 2019. Centers were separated by the average number of open AAA repairs submitted per year into four volume categories based on the 25th (<8 cases), 50th (>8-16 cases), 75th (>16-33 cases), and >75th (>33 cases) percentiles. Analysis of variance and χ2 analysis were used to compare continuous and categorical variables; Cox regression analysis was used to assess in-hospital and overall mortality. Between 2003 and 2019, 13,984 patients underwent open AAA repair. In the lower quartile centers, ruptures represented a greater proportion of the overall volume (20.0%, 18.0%, 16.5%, 14.1%; P < .001), whereas the proportion of transfers was highest in the top three quartiles (14.5%, 19.5%, 17.8%, 17.8%; P < .001). There was a higher proportion of endograft explantations (5.4%, 6.0%, 5.5%, 8.5%; P < .001) in the highest quartile centers. Supraceliac clamp was most prevalent in the second-quartile centers (8.6%, 12.4%, 8.4%, 9.8%; P < .001). Median renal ischemia time (33, 30, 29, 26 minutes; P < .001) and median procedure time (229, 227, 242, 211 minutes; P = .001) were lowest in the highest quartile group. Postoperative complications including congestive heart failure (5.8%, 5.6%, 4.1%, 2.9%; P < .001), reintubation (13.7%, 10.9%, 11.1%, 9.6%; P < .001), and dialysis (3.8%, 3.7%, 3.7%, 2.0%; P < .001) were most common in the lower volume quartiles. In-hospital reinterventions were more frequent (13.2%, 12.6%, 10.6%, 10.5%; P < .001) and in-hospital mortality was highest (12.3%, 8.8%, 7.8%, 5.3%; P < .001) at the lower volume centers. Multivariable analysis demonstrated that higher center volume was independently protective against in-hospital mortality (Fig 1; P < .001). Furthermore, patients undergoing explantation (P = .007) and transferred (P < .001) to higher volume centers had decreased operative mortality. Despite these findings, the proportion of cases being performed at the highest quartile centers decreased over time from 41.0% in 2003 to 16.9% in 2019 (P < .001; Fig 2). In contrast, center case volume was associated with increased mortality in the long term (P = .014). Higher center volume was independently associated with a lower in-hospital mortality after open AAA repair. Despite these findings, the proportion of open AAA repairs being performed at lower volume centers is increasing over time. Interestingly, higher center volume was associated with increased long-term mortality. Further discussions regarding the feasibility and benefits of regionalization of open AAA repair should be explored.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Treatment of Paget-Schroetter syndrome (PSS) involves first rib resection and division of the anterior scalene muscle (FRR). This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram and lysis, percutaneous mechanical thrombectomy, and angioplasty (henceforth, venography, and percutaneous treatment [VPT]), followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients underwent VPT before FRR; if the vein could not be crossed and opened during VPT then the patient was not offered FRR. The experience was divided into early (before 2012, n = 50) and late periods. Mean patient age was 28 years (range, 12-68 years). Of the cohort, 33 were high-level competitive athletes, 13 presented with pulmonary embolism in addition to local symptoms, and 3 had a cervical rib. Patients underwent FRR between 4 days and 18 years after their initial symptoms (median, 50 days), and between 1 day and 9 months (median, 22 days) after VPT. Postoperative VPT was required in 23 patients, and performed 1 to 137 days postoperatively (median, 5 days); in 19 of these patients, postoperative VPT was required for postoperative rethrombosis, whereas in 4 patients postoperative VPT was planned before FRR owing to vein stenosis or residual thrombus. No operative venous reconstruction or bypass was performed. Last follow-up was at 1 to 89 months (median, 8 months) after FRR; at that time, 123 of 125 axillosubclavian veins were patent by duplex ultrasound examination (98.4%) and all those patients were asymptomatic with respect to symptoms of PSS. Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early rethrombosis or follow-up patency, as summarized in the Table. This large experience demonstrates excellent Results with standard preoperative VPT, transaxillary FRR, and postoperative endovascular reintervention only in cases with persistent symptoms, stenosis, or rethrombosis. Patients presenting with both acute and chronic PSS did equally well; surgical venous reconstruction was never used. In the later experience, patients have frequently not been anticoagulated postoperatively. Advantages of this algorithm include (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) elimination of the risk and inconvenience of postoperative anticoagulation.TableEarly rethrombosis and follow-up patencyNo.Postoperative anticoagulationEarly rethrombosisClinical and duplex vein patency at last follow-upOverall experience12586 (69)19 (15)123 (98.4)Early experience5047 (94)9 (18)49 (98)Late experience7539 (52)a10 (13)b74 (98.7)cValues are number (%) unless otherwise indicated.aP < .005 comparing use of postoperative anticoagulation during early and late experiences, by Fisher Exact test.bP = .32 comparing rate of early rethrombosis during early and late experiences, by Fisher Exact test (one tailed).cNot significant comparing vein patency at last follow-up during early and late experiences, by Fisher exact test. Open table in a new tab

Objective: Intravascular ultrasound (IVUS) examination is an integral technique used for treating type B aortic dissection (TBAD) because it verifies true lumen access. The purpose of this study was to evaluate the use of IVUS, to determine factors associated with IVUS use, and to investigate the potential survival benefit associated with IVUS in the treatment of TBAD. Methods: A retrospective review of TEVARs performed for TBAD in the national Vascular Quality Initiative was performed from January 2010 to August 2018. Data collected included demographics, intraoperative and postoperative variables, and long-term mortality. Multivariable logistic regression evaluated variables associated with IVUS the use and mortality, and Cox regression was performed for adjusted survival analysis. Results: In this study of 2686 patients, the average age was 60.4 years, 69.3% were male, and IVUS examination was used in 74.6% of cases. IVUS patients were younger (60.0 years vs 61.7 years; P = .004), more often male (72.1% vs 61.3%; P < .001), exhibited less coronary disease, but had higher preoperative creatinine (1.27 +/- 0.89 mg/dL vs 1.14 +/- 0.68 mg/dL; P < .001) and were more often treated in the acute setting (55.2% vs 49.7%; P = .03). Interestingly, there were no differences in contrast use (117.4 +/- 77.6 mL vs 123.0 +/- 81.90.1 mL; P = .11) or fluoroscopy time (20.3 +/- 16.5 minutes vs 19.0 +/- 22.1 minutes; P = .10). However, IVUS cases had a greater number of devices implanted (1.84 vs 1.65; P < .001), higher rates of Zone 0 to 2 proximal seal (43.9% vs 30.7%; P < .001), higher rates of distal seal zones beyond the diaphragm (53.9% vs 37.4%; P = .001), and larger proximal and distal graft diameters, with no differences in postoperative renal function. IVUS patients notably also had higher rates of follow-up imaging (61.3% vs 54.8%; P = .003), larger maximum aortic diameters at follow-up, and more reinterventions over time. The number of aortic devices (odds ratio [OR] 1.56; 95% confidence interval [CI], 1.24-1.97; P < .001), malperfusion indication (OR, 1.68; 95% CI, 1.17-2.42; P = .005) and distal seal zone beyond the diaphragm (OR, 1.64; 95% CI, 1.30-2.07; P < .001) were independently associated with IVUS use, whereas female gender showed a trend towards less IVUS use (OR, 0.79; 95% CI, 0.62-1.01; P = .063). Even after controlling for age, preoperative comorbidities, and postoperative complications like spinal cord ischemia, IVUS was associated with a 61% decrease in the odds of mortality (OR, 0.39; 95% CI, 0.20-0.78; P = .008), with a clear survival advantage shown in adjusted survival curves. Conclusions: IVUS examination was used in the majority of TBAD, although not universally. IVUS examination was used more often in acute TBAD and more complex aortic repairs, and was independently associated with improved long-term survival. Further study is needed to understand these patterns.

The aim of this study was to evaluate patterns of inferior vena cava (IVC) filter insertion and retrieval in a granular, national data set. A review of all IVC filter procedures entered into the national Vascular Quality Initiative registry between January 2012 and August 2018 was performed. Data collected included demographics, venous thromboembolism risk factors, indications for filter placement, and presence and timing of retrieval. Trend analysis and multivariable logistic regression were performed to evaluate factors associated with failure to retrieve the filter. During the study period, 8050 IVC filters were inserted. The mean age was 62.6 ± 16.7 years, and 52.2% were male; 59.5% were placed for major indications, 14.8% were placed for relative indications, and 25.7% were placed for prophylaxis. The overall filter retrieval rate was 34.5%. The clinically relevant retrieval rate (excluding those filters placed with permanent intent or patients who died before follow-up) was 57.1%. Trends in filter placement and retrieval are represented in the Fig. The total number of filter placements and retrievals increased from 2013 to 2015. However, beginning in 2015, there was a significant decline in filter placement (P = .009), whereas the number of filter retrievals remained relatively stable (P = .243). Importantly, the clinically relevant filter retrieval rate significantly increased throughout the years of the study from 36.2% in 2013 to 78.4% in 2018 (P = .004). The average time to filter retrieval also decreased from 138.5 ± 126.7 days in 2015 to 90.9 ± 50.9 days in 2018 (P < .001). The independent predictors for failure to retrieve the filter are represented in the Table. In addition to age and baseline medical comorbidities (congestive heart failure, chronic obstructive pulmonary disease, diabetes, malignant disease, smoking), recent trauma (odds ratio [OR], 2.41; 95% confidence interval [CI], 1.62-3.58), new follow-up deep venous thrombosis (OR, 2.34; 95% CI, 1.67-3.28), and long-term filter complications (OR, 2.30; 95% CI, 1.62-3.27) all predicted failure to retrieve the filter. Factors found to be protective from filter nonretrieval were discharge home after filter placement (OR, 0.50; 95% CI, 0.42-0.59), use of anticoagulation at follow-up (OR, 0.60; 95% CI, 0.52-0.69), and relative (OR, 0.81; 95% CI, 0.68-0.98) or prophylactic indication for filter placement (OR, 0.53; 95% CI, 0.30-0.94). These results show a decline in overall IVC filter placement in 2015 with a steady and significant rise in clinically relevant filter retrieval rate from 2013 to 2018. These data reflect a change in practice nationally with a more conservative stance toward filter placement and more aggressive approach for filter retrieval.TableMultivariate logistic regression analysis predicting failure to retrieve filterOR (95% CI)P valueRecent trauma2.41 (1.62-3.58)<.001Follow-up DVT2.34 (1.67-3.28)<.001Long-term filter complication2.30 (1.62-3.27)<.001CHF1.35 (1.04-1.76).024Malignant disease1.29 (1.08-1.54).004COPD1.28 (1.06-1.55).01Diabetes1.20 (1.01-1.42).038Smoking1.18 (1.03-1.35).019Age1.01 (1.01-1.02)<.001Relative indication (compared with major indication)0.81 (0.68-0.98).026Follow-up anticoagulant use0.60 (0.52-0.69)<.001Prophylactic indication (compared with major indication)0.53 (0.30-0.94).029Discharge home after filter placement0.50 (0.42-0.59)<.001CHF, Congestive heart failure; CI, confidence interval; COPD, chronic obstructive pulmonary disease; DVT, deep venous thrombosis; OR, odds ratio. Open table in a new tab

Major vascular involvement is often considered a contraindication to resection of malignant tumors, but in highly selected patients, it can be performed with mixed oncologic results that are highly dependent on the tumor’s biology. Resection of both the aorta and inferior vena cava (IVC) is a rare undertaking, requiring both favorable tumor biology and a patient fit for a substantial surgical insult; nevertheless, it provides the possibility of a cure. Patients requiring resection and reconstruction of both the aorta and IVC from 2009 through 2018 at a single university medical center were included. Patients’ characteristics, operative technique, and outcomes were retrospectively collected. We identified seven patients, all with infrarenal reconstruction or repair of the aorta and IVC. Patients’ characteristics are detailed in the Table. All cases were performed with systemic heparinization and required simultaneous aortic and caval cross-clamping for tumor resection. No temporary venous or arterial bypass was used. Because arterial reperfusion with the IVC clamped was poorly tolerated in one patient, venous reconstruction was typically completed first. Primary repair was performed in one patient, whereas six required replacement. In two patients, aortic homograft was used for replacement of both the aortoiliac and iliocaval segments in contaminated surgical fields. In the remaining four, Dacron was used for arterial replacement; either Dacron (n = 2) or polytetrafluoroethylene (n = 2) was used for venous replacement. Patients were discharged after a median stay of 8 days (range, 6-16 days). At median follow-up of 16 months (range, 1-79 months), there were no deaths. Two patients with paraganglioma had cancer recurrences. Venous reconstructions occluded in three patients (50%), although symptoms were minimal. One patient presented acutely with a thrombosed iliac artery limb and bilateral common iliac artery anastomotic stenoses, treated successfully with thrombolysis and stenting. Patients with tumor involving both the aorta and IVC can be successfully treated with resection and reconstruction. En bloc tumor resection, restoration of venous return before arterial reconstruction, and most important, careful selection of patients contribute to positive outcomes in this otherwise incurable population.TablePatients’ characteristics and oncologic outcomePatient’s age, years, and sexDiagnosisVenous involvementVenous reconstructionArterial involvementArterial reconstructionEBL, LAntithrombotic therapyRecurrence1. 28 FParagangliomaIVC, obliterated left CIVIVC only (Dacron)Aortic bifurcationAortoiliac (Dacron)2.5WarfarinNone2. 51 FParagangliomaIVCIVC only (ringed PTFE)AortaAortic tube graft (Dacron)3NoneNone3. 50 MParagangliomaIVCPrimary repairAortaPrimary repair1.8Aspirin 325 mgSpine4. 71 FParagangliomaIVC, bilateral CIVsIliocaval (ringed PTFE)Aorta, bilateral CIAsAortoiliac (Dacron)6Aspirin 81mgSpine, LNs5. 26 MMixed germ cell tumorThrombosed IVCIVC only (thoracic aorta homograft)Aortic bifurcationAortoiliac (aortoiliac homograft)3.5Aspirin 81 mgNone6. 36 MMixed germ cell tumorIVC, bilateral CIVsIliocaval (aortoiliac homograft)Aorta, bilateral CIAsAortoiliac (aortoiliac homograft)3Aspirin 81 mgNone7. 21 MMixed germ cell tumorIVC, thrombosed bilateral CIVsIliocaval (Dacron)Aortic bifurcationAortoiliac (Dacron)5RivaroxabanNoneCIAs, Common iliac arteries; CIVs, common iliac veins; EBL, estimated blood loss; IVC, inferior vena cava; LNs, lymph nodes; PTFE, polytetrafluoroethylene. Open table in a new tab

OBJECTIVE:The aim of this study was to examine practice patterns of inferior vena cava (IVC) filter insertion and retrieval at a tertiary care institution. METHODS:A retrospective review of all IVC filter procedures performed at the University of Pennsylvania and entered into the Penn cohort of the Vascular Quality Initiative registry between January 2013 and September 2017 was performed. Data collected included demographics, venous thromboembolism risk factors, indications for filter placement, and presence and timing of retrieval. Trend analysis and multivariable logistic regression were performed to evaluate factors associated with failure to retrieve the filter. RESULTS:During the study period, 627 IVC filters were inserted. The mean age was 52.8 ± 16.9 years, and 49.3% were male; 39.2% were placed for a major indication, whereas 58.1% were placed for prophylaxis. There was a significant decline in overall frequency of filter placement during the period observed, with a 33% decrease from 2015 to 2016 and a 26% decrease from 2016 to 2017 (P < .001), with an overall retrieval rate of 44.9%. In contrast, there was a corresponding increase in filter retrieval, with a 20% increase in 2015 and a 68% increase in 2016 (P = .02). In evaluating trends separated by indication, there was a significant decline in prophylactic filter placement (P < .001) and a trend toward an increase in retrieval of prophylactic filters (P = .09). Whereas there was not a significant change in number of filter insertions for major indication (P = .06), filter retrievals for major indication filters increased (P = .01). Multivariable regression analysis revealed that longer time to follow-up (odds ratio [OR], 1.08; P < .001) and discharge to rehabilitation facility (OR, 6.14; P < .001) were predictive of failure to retrieve the filter. In contrast, filter placement at a later date within our study period (OR, 0.90; P < .001) and prophylactic indication for filter placement (OR, 0.36; P < .001) were protective from filter nonretrieval. CONCLUSIONS:These results show both a decline in overall IVC filter placement and an increase in overall IVC filter retrieval at our institution. These trends are predominantly due to a decrease in prophylactic filter placement as well as an overall increase in filter retrieval. Further study should be dedicated to increasing the retrieval rate in this population of patients.